essay on nursing a profession of excellence

Importance of Nursing Excellence in Healthcare Essay

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Excellence in nursing is owed to the availability of infrastructure that has enhanced the nursing fraternity. This excellence has also been aided by the favorable working conditions that are provided to the nurses to enable them to provide satisfactory services. In fact, without excellence in nursing, it would be difficult for healthcare providers to achieve their mission.

According to Kirkley, Johnson, and Anderson (2004), four approaches have been used in achieving excellence in nursing, and they are: practice, career advancement, research, and education. In this case, the mentioned approaches are explained as examples of excellence attributed to VA hospital in the outpatient department of home mental health. Practice excellence is manifested through the introduction of new improvements. In addition, new delivery strategies have been put in place at VA hospital as an indicator of excellence in nursing. The service that is provided in nursing is based on the evidence of practice, which aims at analyzing how nurses relate with their patients.

Career development in nursing has been exercised through the introduction of certifications that are issued by oversight boards. These certifications are issued to nursing institutions that offer high quality services that meet international standards. Career development is a very demanding approach because it is broad. The other contribution to excellence in nursing is perceived to be the registration of nurses from VA hospital with professional organizations such as National League for Nursing.

Education is also used to enhance excellence in nursing because it is the only sure way of maintaining the excellence that has been achieved. At times, nurses are chosen at random and sponsored to go through training programs that are meant to keep them updated about the emerging trends in nursing. Besides, VA hospital has integrated scholars in nursing institutions to help in carrying out research that is meant to come up with better approaches of achieving excellence in nursing.

Malloch and Porter-O’Grady (2009) argue that most of the initiatives towards excellence in nursing have been made possible through the availability of money provided by the US federal government to the healthcare department. Without reliable source of money, the mentioned initiatives would not have been possible. Of all the approaches, board certification is the most preferred strategy in the US because it is easily integrated with the other approaches, including education, practice, and career advancement.

This is because through the board certifications, nurses get better pay thus advancing in career. Moreover, certification amounts to education because the nurses have to go through training programs before being awarded the certification.

Additionally, the excellence that has been achieved in nursing is owed to the integration of information technology in the VA hospital. This means that information technology has been incorporated with nursing practice which has helped in improving the performance of nurses. Information Technology has played a major role as far as nursing practice is concerned because the nurses have used it as a platform to exchange ideas and carry out their research schedules.

In this regard, the above mentioned approaches are related to healthcare systems in different ways. For instance, the board certifications make sure that nurses who are in nursing practice are very knowledgeable in their profession. The boards that issue certifications have ethics that are to be adhered to internationally and thus, if any professional in the nursing goes against them, the certification is cancelled. Furthermore, the education part of it is used to determine who climbs up the clinical ladder in nursing.

In addition, the board certifications make the caregivers have a common regulation. Likewise, the integration of Information Technology has made it possible for the processes that are involved in completing the tasks in nursing to be finished faster than usual. The excellence in nursing has resulted in many patients being contented. In essence, there has been a decline in patients who die in hospitals, or under the care of nurses.

Kirkley, D., Johnson, A. P., & Anderson, M. A. (2004). Technology Support of Nursing Excellence: The Magnet Connection . Medscape News. Web.

Malloch, K. & Porter-O’Grady, T. (2009). Introduction to Evidence-Based Practice in Nursing and Healthcare . Canada: Jones & Bartlett Learning.

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30 Examples of How to Demonstrate Professionalism in Nursing

Whether you are a nursing student or a nurse with several years of experience, you know that professionalism is a significant trait all nurses should have. While nurses are referred to as healthcare professionals, many do not understand the concept of what true professionalism encompasses. Maybe you have asked yourself, "What is professionalism in nursing?” In this article, you will find information about nursing professionalism, including 30 examples of how to demonstrate professionalism in nursing. As you continue reading, keep in mind that each nurse is responsible for developing professional characteristics and implementing those characteristics into daily practice.

What is Professionalism in Nursing?

Who determines the standards of professionalism in nursing, 10 reasons why professionalism is so important in nursing, what are the 7 key elements of professionalism in nursing, 1. leadership:, 2. professional values:, 3. professional development:, 4. basic care competency:, 5. altruism:, 6. social justice:, 7. human dignity:, how to demonstrate professionalism in nursing, example #1: learn effective communication, how to demonstrate it in nursing practice:, why is it important in nursing:, example #2: show compassion, example #3: participate in interdisciplinary collaboration, example #4: be accountable, example #5: never stop learning, example #6: have a positive attitude, example #7: provide high-quality patient care, example #8: dress the part, example #9: be ethical, example #10: practice cultural awareness, example #11: have a “patients first” mindset, example #12: mentor other nurses, example #13: practice integrity, example #14: be detail-oriented, example #15: become a critical-thinker, example #16: help resolve conflicts, example #17: be adaptable, example #18: lead by example, example #19: make yourself a priority by practicing self-care, example #20: show respect and appreciation to your co-workers, example #21: be a faithful patient advocate, example #22: show up for work, example #23: promote safe nursing practices, example #24: pursue personal growth and development, example #25: be willing to show empathy, example #26: be sympathetic to others, example #27: practice resilience, example #28: exercise your right to practice autonomously, example #29: be confident in your abilities, example #30: be willing to accept constructive criticism and advice, what are some examples of unprofessionalism in nursing, 1. participating in or causing conflict among team members:, 2. missing work unnecessarily:, 3. not protecting patient privacy and confidentiality:, 4. taking credit for someone else’s work:, 5. avoiding responsibilities:, 6. providing misleading or false information:, 7. abandoning patient care:, 8. accepting an unsafe patient assignment:, 9. failure to maintain professional boundaries with clients or their families:, 10. using unsafe practices:, consequences of unprofessional conduct in nursing, 1. increased absenteeism:, 2. hostility among staff:, 3. disciplinary action:, 4. loss of license:, 5. damaged professional reputation:, 5 most-common challenges to professionalism in nursing practice and how to overcome them, challenge #1: maintaining positive relationships with unprofessional peers, what is it:, how to overcome:, challenge #2: knowing where to draw the line with nurse-patient relationships, challenge #3: dealing with rude patients, challenge #4: unprofessional work environment, challenge #5: emotionally charged situations, 5 tips to enhance professionalism with patients in nursing practice, 1. make patient care a priority., 2. take time to hear what your patient needs to say., 3. speak up on your patient’s behalf., 4. protect your patient’s privacy., 5. demonstrate high standards of care., 5 tips to enhance professionalism with co-workers in nursing practice, 1. be honest with yourself., 2. encourage and participate in team collaboration., 3. recognize the accomplishments and contributions of your co-workers., 4. be accountable to your team members., 5. invite co-workers to join professional nursing associations with you., bonus useful resources to learn more about professionalism in nursing, blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. does nursing require a higher level of professionalism compared to other healthcare careers, 2. what are professional boundaries in nursing, 3. why nurses should set boundaries to maintain professionalism in nursing, 4. what is professional presence in nursing, 5. what is professional misconduct in nursing, 6. what is personal and professional development in nursing, 7. what is professional caring in nursing, 8. what is professional communication in nursing, 9. what is professional competence in nursing, 10. what is professional advocacy in nursing, 11.what is professional accountability in nursing, 12.what is professional socialization in nursing, 13.how does professionalism in nursing influence health policy, 14.how complaining in the nursing profession hurts professionalism, 15.how should professionalism be evaluated in nursing, 16.how do nursing schools teach professionalism, 17.what are the top 3 professional goals every nursing student should aim for.

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Nursing MSN & DNP

| 16 June 2020

The Importance of Professionalism in Nursing

Part of being a great nurse is the ability to demonstrate professionalism. Regardless of their level of nursing , a successful nurse is someone who exhibits compassion, empathy, and commitment—and who dedicates their career to personal growth and professional development. This post defines professional values in nursing, discusses how you can best demonstrate it, and explores ways you can expand and strengthen your core professional qualities .

What Is Professionalism in Nursing?

Professionalism in nursing means providing top-quality care to patients, while also upholding the values of accountability, respect, and integrity. ((Hernandez, Ronald, et al., “Digital Health in a Post-COVID World,” December 2022: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9902819/ ))

As defined by the American Nurses Association , “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” In essence, nursing professionalism is about demonstrating an unwavering commitment to the vocation and the willingness to continuously deliver the highest-quality care to patients.

When nurses exhibit professional behaviors, patients receive better care, team communication is improved, there is increased accountability among all practitioners, and the overall clinical environment is more positive. (( Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/ ))  All stakeholders benefit—including patients, other members of the healthcare team, and support staff.

6 Ways to Demonstrate Professionalism in Nursing

There are several ways that you can show you are dedicated to providing quality, safe, and evidence-based care. You should work to uphold the six standards of conduct outlined below in order to best demonstrate professionalism in nursing. (( Nursing and Midwifery Council, “The Code,” Jan. 29, 2015: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ))

1. Put patients first

It’s important not only to uphold patients’ rights—but also to care about how patients feel. Treat them with kindness, respect, and compassion, and listen to their particular concerns and preferences. Be sure to act in the best interests of your patients at all times, and be prepared to serve as an advocate for them when their health needs diverge from their family’s expectations.

2. Communicate effectively

Nursing professionals should communicate clearly and effectively at all times. When speaking with patients and their caregivers, use terms they can easily understand. Also, be willing to take reasonable steps to meet an individual’s language and communication needs (e.g., bring in a translator). Communicating effectively also means keeping clear and accurate patient records and practicing good interprofessional teamwork and handoff skills.

3. Collaborate with and mentor others

Working as a nurse means acting as part of a team, so it’s important to have a collaborative attitude and value the contributions of others. You should be open to receiving advice and constructive criticism, and you should also feel comfortable offering your colleagues both praise and constructive feedback on their work. Sharing knowledge and insights with your peers creates a more educated and effective team. Offering to mentor a colleague or student can also deepen the bonds within a team and serve as a professional growth experience for all.

4. Maintain a positive attitude

To succeed as a nurse, it’s important to maintain a positive attitude. Patients look to you not only for excellent care, but also for emotional support. You will face many challenges on the job, and you won’t do everything perfectly—no one can. But don’t get weighed down by negative self-talk , as this can take a toll on your mental health and your ability to best help patients.

5. Uphold the standard of care

Of course, you must always deliver evidence-based care by keeping your knowledge and skills up to date. You can help prevent medical errors by tapping into a wide knowledge base and making sure that any care you deliver or advice you offer is informed by research. You can also expand your understanding of your specialty area by joining a nursing association or investing in advanced education .

6. Be accountable and honest

It’s important for those in the nursing profession to maintain their integrity by taking personal responsibility and holding themselves accountable for any mistakes. Not only should you stay actively engaged in the care process—you also need to recognize your own limitations and ask for help when you need it. When you make a mistake, offer solutions for correcting it. For example, if you realize you’ve made an error on a patient record, it’s important that you tell the necessary personnel and have it corrected.

How to Develop Professionalism in Nursing

For anyone, becoming an exemplary nurse involves both personal and professional development. To exhibit professionalism in nursing, focus on these skills:

• Conflict resolution . You can help two parties, such as a patient and physician, find a reasonable and peaceful solution to a disagreement.
• Critical thinking . You make decisions based on evidence and objective analysis. For example, you offer lifestyle advice to patients—such as changing their diet and exercising more frequently—based on scientific evidence and not personal opinion.
• Attention to detail. You strictly follow each directive in the nursing care plan and keep meticulous, clear notes in the patient record. Double-checking your work will help you and others avoid mistakes that could affect patient care.
• Adaptability . You are able to alter your approach when the situation calls for it. For example, when a patient has an infectious disease, you implement different safety protocols.
• Leadership . You can motivate yourself or a group to work toward achieving a specific goal. For example, you stay current with the latest research on a patient health condition, and you share this information with team members.
• Ability to grow . Taking time to work on personal growth can help you better understand your goals, strengths, and weaknesses. One way to do this is by practicing self-discovery .

You can also enhance your qualifications and skills by pursuing nurse leadership and management roles . The role of the nurse leader or nurse manager requires you to be proficient with the skills described above, as well as with decision making, organization, delegation, and overcoming obstacles. Or you may choose to become a member of one of the top healthcare administrator organizations .

Depending on your background, you may need additional education to qualify for nurse leader and nurse manager positions. Requirements vary by employer and role, but you will need at least a Bachelor of Science in Nursing (BSN). Graduate degree programs, such as a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP), provide coursework and practice experience specific to leadership and management.

The University of St. Augustine for Health Sciences (USAHS) offers Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions* and an annual interprofessional trip abroad. Role specialties include Family Nurse Practitioner (FNP), Nurse Educator,** and Nurse Executive. The MSN has several options to accelerate your time to degree completion. Complete coursework when and where you want—and earn your advanced nursing degree while keeping your work and life in balance.

*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum. **The Nurse Educator role specialty is not available for the DNP program.

Additional Sources:

Regis College, “What Is Professionalism in Nursing?” https://online.regiscollege.edu/blog/what-is-professionalism-in-nursing/

Registered Nurses’ Association of Ontario, “Healthy Work Environments Best Practice Guidelines,” March 2007: https://rnao.ca/sites/rnao-ca/files/Professionalism_in_Nursing.pdf

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Characteristics of nursing excellence

What’s behind Magnet®-recognized organizations?

By Lillee Gelinas, MSN, RN, CPPS, FAAN

I’ve learned a lot through the years about the characteristics of healthcare organizations whose nursing excellence is evident, even palpable. As I sat in the 2016 American Nurses Credentialing Center (ANCC) National Magnet Conference ® and connected with organizations that have earned their third, fourth, and fifth Magnet recognitions, my interest in nursing excellence sustainability grew even more. Fewer than 9% of all hospitals in the United States achieve Magnet recognition, and an even smaller number achieve it three or more times. Are they lucky? Is it just a fluke? I don’t think so.

Searching for answers

In my search for answers, I asked American Nurse Today editorial advisory board member Joe Potts, BSN, RN, for his perspective because we’re both Navy veterans who try to understand why disciplined organizations achieve more predictable outcomes. I was fascinated as he talked about his interest in the science of magnets in nature and the correlations to Magnet -recognized organizations, especially those with multiple recognitions.

If you think about Magnet-recognized organizations, or those on the journey, and then consider some interesting facts about magnets in nature, you might understand why some hospitals are fundamentally different from others.

Natural vs. artificial magnets

All magnets that occur in nature are permanent and will never lose their magnetic power . The strongest natural magnetic material is lodestone; it was used in the first compasses. Today, if you visit a gem and mineral show, you’ll find lodestones on display. Play with them and you’ll experience their magnetic strength.

Artificial magnets, like those you use on your refrigerator door, can be temporary or permanent. Temporary magnets aren’t always magnetic; their magnetism can be turned on at will. Permanent magnets, like natural magnets, never lose their strength.

The force that drives Magnet-recognized organizations

The journey to earn Magnet recognition from the ANCC may stretch out over several years, and the required narrative for the application must tell a powerful story. Not surprisingly, research shows that nurses at Magnet-recognized hospitals are significantly more engaged in their work than nurses at other hospitals. That’s an important point for patients, too, since the level of nursing engagement is a reliable predictor of mortality and complication rates.

In my conversation with Joe Potts on this topic, he noted that sustainable nursing excellence is the result of a long-term organizational strategy that builds a healthy culture around staff engagement and empowerment. You might even think of it as a strong, permanent magnet toward which staff are drawn.

Conversely, striving for Magnet recognition as part of a short-term marketing tactic could make it a potentially temporary magnet. Worse yet, though, is the scenario where organizations don’t even begin the journey.

Follow your lodestone

Could it be that hospitals with multiple recognitions, the 2%, are natural magnets? Perhaps their lodestone is their identifiable, sustainable culture that’s clearly integrated across the organization’s fabric.

Lillee Gelinas , MSN, RN, CPPS, FAAN Editor-in-Chief [email protected]

Selected References

Aiken LH, Havens DS, Sloan DM. The Magnet Nursing Services Recognition Program: A comparison of two groups of Magnet hospitals. J Nurs Admin . 2009;39(suppl 7-8):S5-S14.

Blizzard R. Nurse engagement key to reducing medical errors . Gallup. December 27, 2005.

MaineHealth. MMC earns its third Magnet designation for nursing excellence . March 30, 2017.

Mayo Clinic. Mayo Clinic’s Minnesota campus awarded Magnet recognition® for fifth time . June 3, 2016.

Sentinel Watch, The. What are the forces of magnetism and why should you care about them? American Sentinel University. August 17, 2011.

1 Comment .

Would it be possible for me to have a pdf of the Characteristics of Nursing Excellence ?

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Nursing certification

“a mark of excellence”.

Lockhart, Lisa MHA, MSN, RN, NE-BC

Lisa Lockhart is the Director of Nursing Services at Saint Joseph East in Lexington, Ky., and a Nursing made Incredibly Easy! Editorial Board Member.

The author has disclosed no financial relationships related to this article.

Q: What are the benefits of specialty certification?

A: Certification is a formal, regulated process to validate a professional's skill level, knowledge base, and abilities within a designated role. This validation is based on standards set by other professionals in the same specialty. To become certified, you must meet the education requirements, have experience in your chosen area, and pass a qualifying exam. With 183 common nursing certifications and the myriad organizations that sponsor the exams and credentialing process, you may wonder where to begin. Start by choosing to become certified! Let's take a closer look.

According to the American Nurses Credentialing Center, which develops certification exams, the benefits of certification include meeting employers' increasing needs, protecting customers/consumers, ensuring excellence and standardization, and making a statement of professional engagement and pride. Professionally, you'll benefit from increased knowledge, ongoing development, and exposure to knowledge in your area of expertise. Personally, you'll have a sense of accomplishment. And in many organizations, there may be a financial reward as well. Certification also enhances your career development potential, improving marketability and leverage for professional growth.

According to the American Association of Critical-Care Nurses, “Everyone in the healthcare equation—patients, employers, nurses—benefits from certification as a mark of excellence.” These words were never truer than today as we function in a complex regulatory environment that focuses on value, quality, and outcomes. Value-Based Purchasing is a perfect example of this focus. Our patients, peers, and employers depend on our expertise, commitment, and continuous drive to improve. That's why specialty certification has become a must-have for career success and professional development.

The Magnet Recognition Program ® is a prime example of the professional benefits and importance of certification. Achieving Magnet recognition is viewed as the gold standard for nursing recognition and a sign of excellence. The journey to Magnet recognition demonstrates that an organization truly values its nursing professionals down to its structural operations, including specialty certification. Magnet organizations are known for setting the highest standards for safe patient care, promoting both professional and business growth, and fostering a just culture in which staff members feel valued and recognized for their contributions. Organizations may also consider Pathway to Excellence ® designation, which has professional development as one of its six standards.

When you become certified, it represents your expertise and commitment to excellence in the nursing profession. Choosing specialty certification isn't only an investment in your professional future, but also a dedication to providing the highest quality care.

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• Published: 07 February 2023

What is nursing professionalism? a concept analysis

• Huili Cao 1 , 2 ,
• Yejun Song 3 ,
• Yanming Wu 1 ,
• Yifei Du 1 ,
• Xingyue He 1 ,
• Yangjie Chen 4 ,
• Qiaohong Wang 1 , 4 &
• Hui Yang 1 , 4  

BMC Nursing volume  22 , Article number:  34 ( 2023 ) Cite this article

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Nursing professionalism plays an important role in clinical nursing. However, a clear conceptual understanding of nursing professionalism is lacking.

Walker and Avant’s strategy was used to analyse the concept of nursing professionalism. We searched electronic databases, including PubMed, Scopus, and CINAHL, for studies published from 1965 to 2021. Quantitative or qualitative studies published in English that focused on nursing professionalism were included in the study.

The three attributes of nursing professionalism are multidimensional, dynamic, and culture oriented. Based on the analysis, nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism.

Conclusions

This study offers a theoretical definition and conceptual model of nursing professionalism that may be applied to develop standardized assessment tools or nursing professionalism training programs.

Peer Review reports

Introduction

The COVID-19 outbreak has exposed deficiencies in the underinvestment of the global health system, including the shortage in nursing resources and nursing staff, and a similar situation is noted in China ( https://www.icn.ch/news/investing-nursing-and-respecting-nurses-rights-key-themes-international-nurses-day-2022 ). An unbalanced number of nurses and patients, high work pressure, lack of social occupational identity and other reasons have led to job burnout, low job satisfaction, and even the resignation of many nurses. Research has also shown that the lack of nursing professionalism adversely affects patient care and patient outcomes [ 1 ]. Ohman [ 2 ] pointed out that lower levels of professionalism may cause negative outcomes, such as turnover and attrition and lower productivity.

In recent years, researchers have tried to solve the above problems through professionalism.

However, nursing professionalism plays a more important role in clinical nursing. Some studies have shown that professionalism can improve the professional knowledge and skills of nurses and ameliorate reductions in institutional productivity and quality [ 3 ]. Higher levels of professionalism can improve nurses’ autonomy and empowerment, increase their recognition and facilitate organizational citizenship behaviours, establish nursing care standards and even improve quality services [ 4 , 5 ].

Nursing professionalism has been discussed for several decades. Hall (1968) developed the Professionalism Inventory Scale [ 6 ]. Miller et al [ 7 ] (1993) first specified the 9 standards criteria of nursing professionalism (educational background; adherence to the code of ethics; participation in the professional organization; continuing education and competency; communication and publication; autonomy and self-regulation; community service; theory use, development, and evaluation; and research involvement.). Yeun et al. (2005) summarized five themes regarding nurses’ perceptions of nursing professionalism: self-concept of the profession, social awareness, professionalism of nursing, the roles of nursing services, and originality of nursing [ 8 ]. Yoder defined nursing professionalism based on six components: acting in the patients’ interests; showing humanism; practising social responsibility; demonstrating sensitivity to people’s cultures and beliefs; having high standards of competence and knowledge; and demonstrating high ethical standards [ 9 ]. Although some researchers have explored the concept of professionalism. How can professionalism be evaluated in nursing clinical practice? Few studies have shown a clear conceptualization of nurses’ professionalism [ 10 , 11 ]. To nurture nursing professionalism, the concept of professionalism must be clarified.

Given that the meaning of professionalism varies across time, contexts, or cultures, it is difficult to define, quantify or measure professionalism [ 12 , 13 ]. The operational definition of nursing professionalism in studies has shortcomings. Sullivan et al. [ 14 ] found professionalism to be a multidimensional concept, but some papers have addressed only one dimension, such as values [ 15 ] or behaviours [ 16 ]. Moreover, professionalism is considered a complex concept. The links and dynamic processes between these different inner characteristics have not been included in the concept. Thus, a comprehensive definition of nursing professionalism, including its characteristics and the relations between them, is necessary.

Recognizing and understanding the concept of nursing professionalism may be an essential step towards providing quality care for people. It may also provide more information for further developing nursing professionalism for nurses.

Method of concept analysis

Walker and Avant’s method used linguistic philosophy techniques to contribute to the philosophical understanding of a concept [ 17 ]. The W & A method is considered a mark of the positivist paradigm, which views the concept as a stable factor that can be reduced or extracted from its context of application [ 18 ]. This study used Walker and Avant’s method, which assumes that nursing professionalism is a relatively mature and stable concept (numerous studies on nursing professionalism have been published to date). This approach to conceptual analysis, although not perfect, is helpful in clarifying the concept of nursing professionalism.

Using the structured method of Walker and Avant enables conceptual clarity to be obtained based on an inductive identification of the concept’s attributes, antecedents and consequences. The concept analysis helps to clarify meanings and develop operational definitions, considering evidence from a wide range of information resources for further research or clinical practice [ 17 , 19 ]. These features make this method particularly useful for the analysis of the concept of ‘nursing professionalism’. The conceptual attributes as well as antecedents and consequences are based on the research team's analysis of the literature using Walker and Avant’s strategy and are not the product of a priori theoretical categories.

Walker and Avant’s [ 17 ] eight-step method includes the following: 1) selecting a concept; 2) determining the aims or purposes of analysis; 3) identifying all uses of the concept; 4) determining the defining attributes of the concept; 5) constructing a model case; 6) constructing borderline, contrary, invented, and illegitimate cases; 7) identifying antecedents and consequences; and 8) defining empirical references.

Selection criteria

The inclusion criteria were as follows: related to the concept of nursing professionalism; included nurse professionalism, nursing spirit, or nurse spirit; written in the English language; qualitative, quantitative, mixed methods or systematic reviews; published between 1965 and 2021 (when professionalism was first introduced by nursing in 1965); and published in books or dictionaries. We excluded articles published in nonpeer reviewed journals, editorials and letters to the editor.

Data sources

We searched several online databases, including PubMed, Scopus, and CINAHL, for articles published from 1965 to 2021. We searched the words that appear in the title, abstract, and keyword section of the studies.

(((((((((Nursing professionalism[Title]) OR (Nursing professionalism[Title/Abstract])) OR (Nurse professionalism[Title])) OR (Nurse professionalism[Title/Abstract])) OR (Nursing spirit[Title])) OR (Nursing spirit[Title/Abstract])) OR (Nurse spirit[Title])) OR (Nurse spirit[Title/Abstract])).

TI Nursing professionalism OR AB Nursing professionalism OR TI Nurse professionalism OR AB Nurse professionalism OR TI Nursing spirit OR AB Nursing spirit OR TI Nurse spirit OR AB Nurse spirit.

TITLE-ABS-KEY (Nursing professionalism) OR TITLE-ABS-KEY (Nurse professionalism) OR TITLE-ABS-KEY (Nursing spirit) OR TITLE-ABS-KEY (Nurse spirit).

Any quantitative or qualitative studies published in English focusing on nursing professionalism were included in the study. Two researchers independently screened titles and abstracts to determine the selection criteria for electronic retrieval and application. The study was included only when both researchers agreed that the study met the inclusion and exclusion criteria. If the two researchers’ judgements were different, a third person was consulted to resolve the issue. Researchers identified the different usages of the concept and systematically recorded the characteristics of the concept that appeared repeatedly [ 17 ].

We used definitions and examples in the systematic record (Table 2 ) to define a cluster of antecedents, attributes and consequences (Figs. 1 and  2 ) frequently associated with the concept [ 20 ].

Flowchart of the study selection process of the concept analysis

We identified 6013 studies on nursing professionalism. After excluding duplicates, irrelevant studies, studies that were not original scientific studies or articles, and studies published in languages other than English, 138 studies were selected for analysis. Tables 1 and 2 show some typical literatures used in this study.

Uses of the concept

Dictionary definitions of the concept.

The Merriam-Webster Dictionary defines professionalism as ‘the conduct, aims, or qualities that characterize or mark a profession or a professional person’ [ 48 ], whereas the Cambridge Dictionary [ 49 ] defines professionalism as ‘the combination of all the qualities that are connected with trained and skilled people’. These definitions are generic and difficult to use to clarify the factors involved in nursing professionalism.

Definitions of the concept reported in the literature

Hwang et al. [ 50 ] defined professionalism as commitment to a profession and professional identity level. Health-care workers demonstrate professionalism through attitudes, knowledge, and behaviours, which reflect approaches to the regulations, principles, and standards underlying successful clinical practices [ 33 ]. Nursing professionalism reflects the value orientation, concepts of nursing, work attitude and standards of clinical nurses [ 51 ].

Subconcepts

The Nightingale Spirit, named in honour of the founder of professional nursing, refers to the spirit of altruism, caring, and honesty [ 52 ]. In the past, the Nightingale Spirit advocated that nurses are willing to dedicate themselves, but the term currently encompasses more innovation [ 53 ]. E-professionalism is defined as evidence provided by digital means, attitudes and behaviours reflects the traditional models of professionalism [ 54 ]. Nurses use the internet to communicate about work or daily life, blurring the boundaries between individuals and professions; thus, e-professionalism applies to nurses [ 55 ].

The defining attributes of nursing professionalism

The defining attributes of the concept aim to understand its meaning and differentiate it from other related concepts [ 17 ]. The key defining attributes are as follows.

Nursing professionalism is multidimensional

Nursing professionalism is a three-dimensional concept based on the knowledge, attitudes, and behaviours that underlie successful clinical practice [ 33 ].

Professionalism can be conceptualized as a ‘systematic body of knowledge’ with complex configurations of work expertise [ 21 ].

Professionalism refers to the attitude that represents levels of recognition and commitment to a particular profession [ 22 ]. Hall [ 6 ] noted that nurses’ attitudes have a high correspondence with the behaviours of the respondent. Measuring professionalism at the cognitive level can be thought of as measuring potential professionalism at the behavioural level. Researchers noted that given the reduced restrictions of environmental constraints, measuring professionalism at the cognitive level may be more precise than measuring it at the behavioural level [ 23 ].

Nursing professionalism is often described as a set of professional behaviours [ 11 ]. Some researchers judge whether nurses exhibit professionalism through their behaviours. Miller [ 24 ] (1988) developed the Wheel of Professionalism in Nursing Model. The model is considered a framework for understanding professional behaviours among nurses. Kramer [ 56 ] (1975) quantified professionalism by assessing the number of professional books purchased, subscriptions to journals, and the number of articles published.

In addition, the perspective of professional identity formation complements the behaviour-based and attitude-based perspectives on professionalism [ 57 ].

The formation and development of professionalism are dynamic processes

Nursing professionalism is an inevitable, complex, varied, and dynamic process [ 58 ].The professionalism concept is considered ever-changing, replacing static or definitive views [ 59 ].

Socialization process

Nursing professionalism is instilled through a process of socialization in formal nursing education [ 25 ]. Nurses’ socialization process begins with formal, entry-level education to acquire knowledge and skills.

Yeun et al. [ 8 ] (2005) discussed the developmental process of nursing professionalism in which the individual’s thoughts and beliefs are formed by socialization factors through perception. These thoughts and beliefs may in turn influence the individual’s professional image or self-concept, thereby influencing nurses’ actions and performance.

Process of interaction

The dynamic of professionalism is also reflected in the process of interaction. Dehghani et al. [ 26 ]noted that nursing professionalism means the appropriate interaction of the individual and the workplace and the maintenance of interpersonal communication.

Culture oriented

One study showed that altruism is an essential element of medical professionalism in Asia or North America but not Europe [ 27 ]. In China, medical professionalism was influenced by its longstanding Confucian traditions [ 28 ]. Therefore, any definitions of professionalism should match its rooted culture and be validated with respect to the culture and context in which it is applied [ 60 ].

The connotation of nursing professionalism

Professional, having a systematic nursing knowledge system.

The nursing process is considered a method for solving problems or dilemmas in a logical and scientific manner [ 11 ]. Freidson [ 29 ] (2001) noted that professionals perform their specialized work only with the required training and experience. Professionals have specific, tacit, almost esoteric knowledge to do their work [ 61 ]. Miller et al. [ 7 ] considered that a formal university education with a scientific background is critical for professionalism in nursing.

Professional certification

Nurses actively seek specialty certification given their personal commitment to the nursing profession [ 30 ]. Specialty certification promotes nursing professionalism. When attaining the highest levels of clinical knowledge, nursing professionalism also indicates personal responsibility and dedication to best practices [ 31 ].

Lifelong learning and participation in continuing education

Due to professional and ethical obligations, nurses should sustain continuous professional growth and development to maintain individual competence. Professional growth in nursing requires lifelong learning. Lifelong learning includes continuing education and self‐study, seeking advanced degrees, etc. [ 62 ].

Continuing education is one of the indicators of professionalism. Professionals keep up with the latest developments in the field and partake in continuing education. Additionally, continuing education is as important as other criteria for increasing professionalism in nursing [ 7 , 32 ]. Ongoing education brings fresh knowledge to health care, consequently leading to more efficient and quality service for people.

Evidence-based practice

Evidence-based practice (EBP) is a hallmark of professionalism [ 33 ]. Dollaghan [ 63 ] (2004) reported that we identify and use the highest quality scientific evidence as an integral part of our efforts to provide the best patient care; EBP is a knowledge base that responds to specific clinical issues in a clear, intelligent, and serious manner while considering clinical practice in the context of the highest-quality scientific evidence available.

Innovation in nursing helps to improve patient care quality and improve nurses’ job performance [ 64 ]. Shen et al. [ 34 ] noted that innovative education plays an important role in the professional quality of undergraduate nursing students.

Striving for excellence

Striving for excellence is a requirement and attribute of nursing professionalism. There is a growing need in nursing practice to possess knowledge and skills in quality improvement science, translational research, and implementation science [ 35 ]. Clinical nurses have the same responsibilities as nursing scientists.

Caring is considered the core attribute of nursing professionalism

The practice of caring is central to nursing [ 65 ]. Caring is defined as the moral ideal of nursing [ 36 ]. Therefore, caring is an important core attribute of nursing professionalism.

Creating a caring-healing environment

Nurses devoted to creating a caring-healing environment embody professionalism. Caring means nurses should create a healing environment at all levels by providing a supportive, protective environment as well as a corrective mental, physical, societal, and spiritual environment for patients. People’s basic needs include a clean environment, comfort measures, safety concerns, and feeling safe or protected [ 65 ].

Displaying kindness/concern/empathy for others

A nurse is defined as someone caring for the ill within the hospital setting [ 66 ]. Caring means showing or having compassion, concern and empathy for others [ 37 ]. Caring behaviours are an interactive and mental process between patients and nurses [ 38 ]. Displaying kindness and concern for others is shown by love, compassion, support and involvement [ 39 ].

Using all methods of knowing support and involvement

‘Human problems reside in ambiguity, paradox, and impermanence’. Therefore, suffering, healing, miraculous cures, and synchronicity are all part of knowing support and involvement.

Researchers suggest that nursing comprises Caritas Nursing, Energy Nursing, Transpersonal Nursing, Holistic Nursing, or Contemplative Nursing…… It goes beyond ordinary nursing. Nursing should have higher standards with excellence for caring, healing, and peace in the world. Therefore, caring means using all methods of knowing support and involvement [ 65 ].

Embracing the unknowns and miracles in life and practising loving

Nursing is a special profession. Nurses confront special circumstances daily and witness people’s struggles with life and death. Everyone has his or her own specific story about his or her experiences and predicaments. Each person seeks his or her own meanings to find inner peace and balance in the midst of fear, doubts, despair, and unknowns. Therefore, the care of nurses is not to blindly sacrifice their own needs but to be a real nurse, embracing the unknowns and miracles in life and caring for patients [ 65 ].

The central tenet of professionalism is to put the needs and best interest of others over self-interests. Altruism is an engagement in caring acts towards others without expecting something in return [ 67 ].

Patients first

To be altruistic means to put others’ needs before your own. Altruism is the selfless concern for others and doing things with the other person’s well-being in mind [ 40 ].

During pandemics, nurses were considered to have a high sense of duty and dedication to patient care [ 41 ]. Front-line nurses perceive high work engagement, especially in self-dedication [ 42 ]. Grøthe et al. [ 43 ] showed that cancer patients in a palliative unit appreciate nurses who have the most dedication and expertise characteristics.

Public service

Due to a strong sense of civic and social responsibility, nurses participate in public service. Nurses volunteer as participants in summer camps, schools, or health-care teams. Nurses are also committed to responding to large-scale crises, such as the terrorist attacks on the World Trade Center in New York, as well as national and international relief efforts, such as tsunamis and Hurricane Katrina [ 44 ].

Disaster and infectious disease rescue

Individuals involved in providing disaster relief face many challenges, experience fatigue and personal suffering, and encounter numerous personal stories of life and death [ 45 ]. Nurses have played a significant role in the fight against infectious diseases such as severe acute respiratory syndrome (SARS) and the coronavirus disease 2019 (COVID-19) pandemic [ 68 ]. Nurses are closest with patients. Nurses provide intensive care, regularly assessing and monitoring airways, tubes, medications, and physical therapy. Nurses are also devoted to reducing complications. Nurses assist with daily living activities when patients are unable to care for themselves [ 46 ].

Community service

In addition, emphasizing professionalism means respecting values and commitment to community service delivery [ 69 ].

According to Walker and Avant [ 17 ], cases help further clarify concepts.

Model cases (a real case example)

Model cases help demonstrate all the defining attributes of a concept and helps to better articulate its meaning [ 17 ].

MS A is a 63-year-old nursing director. She worked in clinical nursing and management for 42 years. As she progressed from a new nurse to a nursing expert, she gradually poured her enthusiasm (Multidimensional: Attitudes) into nursing work (Dynamic). She believes that the core of nursing professionalism in China is dedication and responsibility (Culture oriented). In 2020, COVID-19 broke out in Wuhan, China. She led a team to Wuhan to provide support (Multidimensional: Behaviours), reflecting the spirit of altruism (Altruism). She actively promoted exchanges and cooperation among disciplines and the development of academic conferences. She guided students to pay attention to practical innovation and develop evidence-based innovations (Professional). Although she is retired, she still imparts knowledge and experience to students everywhere (Multidimensional: Behaviours). She stated that the development of nursing professionalism is very difficult and requires nursing education and role models. (Multidimensional: Knowledge). The role of a nurse is like that of a mother, bringing care to the people (Caring).

Borderline cases (a real case example)

Borderline cases provide the examples that contain the most defining attributes of the concept [ 17 ].

B is a novice nurse. When working in the infection ward, she was so worried about being infected. She was reluctant to care for patients and wanted to escape from the ward environment. Fortunately, her nurse manager fully understood her situation and helped her adapt to work and reduce her anxiety. B observed that her nurse manager had been helping patients solve problems and giving them comfort and hope. This prompted her to think about what nursing truly means. In 2020, she volunteered to help COVID-19 patients (Altruism).

Related cases (a real case example)

Related cases are related to the concept but do not contain all its defining attributes [ 17 ].

C is a novice nurse. After graduating from nursing school, he became a nurse in the emergency department. He saw many patients who died or recovered, which made him realize the importance of caring (Caring). He said that emergency nurses need strong professionalism (Multidimensional: Attitudes). He participated in social service activities (Multidimensional: Behaviours), for example, promoting knowledge of cardiopulmonary resuscitation (Altruism) in the community. After working for five years, he returned to school for a master’s degree to help the head nurse conduct nursing research or evidence-based practice (Professional). In his Asian cultural milieu, his is embarrassed about his identity as a male nurse (Culture oriented), but he believes he can do well.

Contrary cases (a fictional case example)

A contrary case does not include any defined attributes of the concept [ 17 ].

D is a nurse in paediatrics. She disliked nursing when she was a nursing student and even did enjoy communicating with patients (poor dynamics). She was exhausted after work and felt her life was out of balance. One of the values of the hospital where she worked was dedication, which confused her (Poor culture orientation). She considers it unrealistic to require professionalism (Poor nursing professionalism knowledge) and thinks that taking care of new-borns is particularly troublesome (Poor nursing professionalism attitudes), so she is always careless in her work (Multidimensional: poor attitude). D’s child felt ill last week, so she secretly reduced a patient’s medicine (Poor nursing professionalism behaviours) and took the remaining medicine home for her child (lack of altruism). She stopped doing so after her colleagues sensed something strange. One day, a baby kept crying; D reported it to the doctor and did not make further observations (Poor professional). When the shift nurse took over, she observed abnormal limb activity on one side of the child. The child’s family asked the nurse to bear legal responsibility. D said it was no big deal; she no longer wanted to be a nurse (Poor dynamic, professionalism not established).

• Antecedents

Antecedents are events that occur before the intended concept [ 17 ].

Macro antecedents

Jin [ 28 ] suggested that the conceptualization of professionalism is influenced by culture. Employees defined organizational culture underlies an organization’s values and beliefs [ 70 ]. Nursing professionalism may be supported by a variety of cultures, so a firm understanding of and personal congruence with each particular culture is essential [ 71 ].

Religious beliefs

Religiosity is another contributing factor in the cultivation of altruism [ 72 ]. Taylor noted that nurses’ job motivation and views of the patient and nursing services are affected by their religious beliefs [ 73 ].

Micro antecedents

Snizek [ 74 ] (1972) reported that devotion to work is a professional value originating from a sense of calling to the field. Liaw et al. [ 75 ] (2016) found that nursing students who had caring and compassionate qualities as the most common personal characteristics strongly believed that they were called to nursing.

Individuals who pursue excellence in the workplace may be described as motivated and devoted to their work. Attree [ 76 ] (2005) noted that nurses’ perceived lack of autonomy over their practice could impact quality of care.

Personal characteristics

Nursing professionalism is influenced by various factors, such as educational background, personal interests, professional satisfaction, and professional values [ 77 , 78 , 79 ]. In each country, nurses with higher educational levels may have a higher level of professionalism [ 22 ]. Professionalism is thus a trait related to personal character and upbringing [ 80 ]. Researchers [ 81 ] have demonstrated that professionalism is positively associated with female gender, striving for professional goals, and acceptability. One study found that people’s values tend to shift to emphasize altruism over personal gain as they age [ 79 ]. Nursing professionalism is closely associated with personality traits (extraversion, conscientiousness, and agreeableness) [ 82 ].

Consequences of nursing professionalism

Consequences are events or incidents that are the result of the occurrence of a concept [ 17 ].

Consequences for patients 

Professionalism is one of the decisive factors that critically influences patient satisfaction [ 50 ]. Professionalism can also improve practising nurse career development and the quality of service [ 81 ].

Consequences for nurses

Studies have shown that professionalism and a sense of belonging with colleagues and managers affect the satisfaction [ 83 ] and retention rate of nursing students in academic institutions [ 84 ]. Izumi et al. [ 85 ] (2006) found that good nurses felt pride and happiness in caring for patients closely related to their professionalism.

Empirical references

As the last step to concept analysis, empirical references can further clarify the concept and facilitate its measurement [ 17 ].

Hall’s professionalism inventory scale

Hall’s Professionalism Inventory Scale [ 6 ] identified five attitudinal attributes of professionalism: (a) use of professional organizations as major referents, (b) belief in public service, (c) self-regulation, (d) a sense of calling to the field, and (e) autonomy. Nursing researchers used Hall’s Professionalism Inventory Scale to measure professionalism in nursing [ 22 , 47 ]. Snizek [ 74 ] (1972) modified the professionalism scale to more closely match the clinical context of nursing and better reflect the professionalism of nursing staff.

Kramer’s index of professionalism

Kramer (1974) [ 86 ] constructed an index of professionalism that includes indicators of behaviours, such as the number of professional books published, subscriptions to professional journals, hours spent on professional reading, continuing education, participation in professional organizations, number of professional publications, speeches given, committee activity, and participation in research.

The behavioural inventory for professionalism in nursing (BIPN)

The Behavioural Inventory for Professionalism in Nursing [ 7 ] (BIPN) identifies professional behaviours and values among nurses. The nine categories in the BIPN are (1) educational background; (2) adherence to the code of ethics; (3) participation in the professional organization; (4) continuing education and competency; (5) communication and publication; (6) autonomy and self-regulation; (7) community service; (8) theory use, development, and evaluation; and (9) research involvement.

Definition of the concept

Based on the present analysis, we define nursing professionalism as follows: ‘Nursing professionalism is a multidimensional concept manifested by the knowledge, attitudes, and behaviours that underlie successful clinical practice. Nursing professionalism is dynamicized through a process of socialization in formal nursing education. This feature is also reflected in the process of interaction. Therefore, nursing professionalism should match its rooted culture.

The connotations of nursing professionalism include professional, caring, and altruism. These connotations are detailed as follows:

Possesses a systematic nursing knowledge system; professional certification

Exhibits lifelong learning and participation

Participates in evidence-based practice

Demonstrates innovation

Strives for excellence

Creates a caring-healing environment

Displays kindness/concern/empathy for others

Uses various methods of knowing support and involvement

Embraces the unknowns and miracles in life and practices loving

Patient-first

A conceptual model of nursing professionalism is shown in Fig.  2 .

Antecedents, attributes, and consequences of nursing professionalism

Defining the connotation of nursing professionalism

Nursing professionalism has been defined as professional, caring, and altruistic.

Professional values are characteristic of nursing professionalism. Nursing work requires rich knowledge and scientific evidence-based work to improve the quality of nursing services for patients. Nurses need lifelong learning, qualification certification, and participation in academic and practical activities.

Caring is regarded as the core of professionalism. This study suggests creating a caring-healing environment, displaying kindness/concern/empathy for others, employing all methods of knowing support and involvement, embracing the unknowns and miracles in life and practising loving to care for people to obtain high professionalism. This study notes that nursing professionalism emphasizes care for the individual patient and that the nurse does everything possible to create a caring and healing environment for patients. In different health systems worldwide, nurses have incorporated caring about nursing professionalism into everything they do. This characteristic is consistent with Nightingale's view that “Nurses need to be sensitive. A nurse must use her brain, heart and hands to create healing environments to care for the patient’s body, mind and spirit” [ 87 , 88 ].

Nursing has an altruistic nature, and people interested in helping patients are attracted to this profession [ 89 ]. However, some studies have shown that altruistic care is equated with self-sacrifice, self-denial, and unidirectional and unconditional care [ 90 ]. Care for a nurse’s own needs is equally important, but nurses should be able to put aside their own needs when required to focus on the needs of others [ 91 ]. Nurses should view self-care and altruism as dialectical. Self-realization and providing care for others are not conflicting concepts [ 92 ].

Defining the attributes of nursing professionalism

In this study, we defined nursing professionalism as multidimensional, dynamic, and culture oriented.

Nursing professionalism is a multidimensional concept that includes knowledge, attitudes, and behaviour. Previous studies have defined professionalism as the degree of commitment by individuals to the values and behavioural characteristics of a specific career identity [ 6 , 7 ]. However, current research on nursing professionalism is mostly single dimensional. The Behavioural Inventory for Professionalism in Nursing (BIPN) is based on Miller’s model and is used to measure professional behaviours among nurses [ 7 ]. Hall’s Professionalism Inventory Scale [ 6 ] identified five attitudinal attributes of professionalism. This study highlights that it is also necessary to focus on the knowledge dimension of professionalism. Nursing students and nurses should first understand the nursing professionalism that is necessary to become a nurse, which may be the first step in developing professionalism. Nursing students and nurses need to know the values that are necessary to practice the nursing and not have vague impressions. Some studies have shown that nursing students or nurses learn values and norms in informal trainings [ 93 ]. Therefore, this study suggests that the development of assessment tools for the knowledge dimension of professionalism is also necessary. Multidimensional evaluation tools are not available for nursing professionalism. Thus, clarifying the multidimensional nature of nursing professionalism will contribute to the development of multidimensional evaluation tools.

Moreover, understanding the dynamics of professionalism is helpful for cultivating nursing professionalism in stages and steps. Inquiries into medical professionalism should be integrated into the culture of social media interaction [ 94 ]. Nursing educators and managers should dynamically cultivate nursing professionalism in their interactions.

Differences in the connotation of nursing professionalism are noted in different cultures. This study suggests that the cultivation and evaluation of nursing professionalism need to consider the cultural attributes of different regions and countries.

Future research directions

Exploring the antecedents of nursing professionalism can help schools or hospitals cultivate nursing professionalism and develop courses and specific measures.

The macro antecedents of nursing professionalism include culture and religion, and the micro antecedents include calling, autonomy, and personal characteristics. Some researchers have explored methods to cultivate nursing professionalism; for example, role modelling, feedback, group discussions, case-based discussions, reflection, holding ethical rounds, and reports potentially represent more effective methods [ 95 ]. Some researchers have tried to enhance professionalism through social media [ 96 ]. One of the findings this study is that nursing professionalism is complex and its cultivation difficult. Studies have shown that didactic lectures are ineffective for teaching professionalism [ 97 ]. The development of true nursing professionalism requires national advocacy and the immersion of a good professional environment that incorporates professionalism into daily nursing practice. Role modelling is considered an effective method for developing professionalism in nursing [ 98 ]. Therefore, this study suggest that studies should be actively conducted to deeply discuss the causes and processes affecting professionalism and to cultivate and intervene at macro and micro levels as well as the key time periods and populations that form professionalism to truly shape the formation of professionalism. Moreover, an environment for building professionalism [ 99 ] is very important. Williams [ 100 ] (2015) considered that the development of professionalism should begin as early as the first semester of an undergraduate nursing course. One of the themes of nursing students’ professional identity development is ‘doing-learning-knowing-speaking’. Students should develop professionalism in all these areas of nursing practice.

The relationship between nursing professionalism and health outcomes or nurses’ human resources needs to be further studied.

Our research suggests that the ultimate goal of nursing professionalism is to serve patients with professional knowledge and special professional quality. The public has become increasingly aware of certain possibilities, limitations, and consequences of professionalism. COVID-19 significantly increased the discussion of professionalism and patient outcomes.

Improving professionalism has a positive impact on job satisfaction, professional quality of life, and the willingness to continue in the profession [ 101 , 102 , 103 ]. Therefore, it is important to improve support for nurses, create a good environment for professionalism, and establish a training system for professionalism, thus paving the way to enhance training in professionalism and create opportunities for nurses.

Implications for nursing management

In April 2020, the World Health Organization (2020) issued the First State of the World’s Nursing 2020 [ 104 ]. The report highlighted that nursing professionals are the largest occupational group in the health sector, numbering 27.9 million worldwide. Nurses spend more time with patients than any other health care professionals [ 105 ].

Worldwide, nursing professionalism is considered important and associated with expectations. This study clarifies the concept of nursing professionalism and contributes to a framework for developing a theoretical model as well as instruments to measure the concept. A conceptual model of nursing professionalism may increase nurse managers’ insight into nurses’ behaviours and values, creating a good working environment.

Nurse managers should integrate nursing professionalism into their philosophy, mission, and objectives and provide necessary resources, tools, and projects to develop professionalism among nurses. Nurses should cultivate professionalism to provide good nursing services to patients. Further research should explore the relationship between nursing professionalism and patient health outcomes and formulate effective training programs for professionalism.

Limitations

This conceptual analysis has some limitations. First, research on nursing professionalism published in English may be conducted in different countries and cultures. However, it is also necessary to obtain a more comprehensive and mature concept of the study of different national languages. Second, the lack of research on the combination of all elements of professionalism may lead to overestimation of the impact of these subelements on professionalism. Third, the concept analysis focused on the research process and the researchers’ perspectives, possibly reflecting a lack of other professional understandings of nursing professionalism in medical groups. In addition, the concept analysis included a risk of selection bias, extraction bias, and analysis bias because the study selection process, data extraction, and analysis were all conducted by two researchers. Despite these risk, the studies were all described accurately and systematically.

Nursing professionalism is one of the important foundations of clinical nursing. It is multidimensional, dynamic, and culture oriented. Based on the analysis, nursing professionalism has been defined as providing people care based on principles of professionalism, caring, and altruism. The definition, attributes, antecedents, consequences, and reference analysis of the experience of nursing professionalism determined in this study provide a theoretical basis for future research. This information can be used to evaluate nursing professionalism, develop assessment tools, or generate theory-based training courses and interventions.

Availability of data and materials

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

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Acknowledgements

The authors would like to thank Hui Yang for the great efforts made in designing the research. We would like to thank linbo Li for providing valuable suggestions for this study.

Postgraduate Education Innovation Program of Shanxi Province in China (No. 2020BY067).

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Hl C and HY made substantial contributions to conception and design. HL C, YJ S, YM W, YF D Collectioned and analysis the data. Hl C was a major contributor in writing the manuscript. XY H, YJ C, QH W revised it critically for important intellectual content. All authors read and approved the final manuscript.

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Cao, H., Song, Y., Wu, Y. et al. What is nursing professionalism? a concept analysis. BMC Nurs 22 , 34 (2023). https://doi.org/10.1186/s12912-022-01161-0

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Hallmarks of the Professional Nursing Practice Environment

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The work environment for the practice of nursing has long been cited as one of the most demanding across all types of work settings. Nurses provide the vast majority of patient care in hospitals, nursing homes, ambulatory care sites, and other health care settings (AONE, 2000). The first objective of the professional practice environment for nurses is to put the patient first. Nurses and health care organizations must focus on patient safety and care quality and always ask the question, "What is best for our patients?" In recent years a variety of factors have converged to challenge the work environments of contemporary nurses. Rapid advances in biomedical science, improved disease prevention and management, integration of new clinical care technologies, and shifts in care delivery to a broad array of clinical sites have contributed to the rapidly increasing need for well-educated, experienced nurses. Additionally, population demographics are changing as the public ages in growing numbers and becomes increasingly diverse in culture and language.

The charge of this AACN task force was to identify those environmental characteristics or "hallmarks" of the practice setting that best support professional nursing practice and allow baccalaureate- and higher degree-prepared nurses to practice to their full potential. These "hallmarks" may inform students and new graduates, nurse educators, executives, and practicing nurses about key characteristics of health care settings that promote professional nursing practice.

Current Environment for the Practice of Nursing

Health care delivery has changed dramatically and rapidly. The Board of the American Hospital Association's Society for Healthcare Human Resources believes that the attractiveness of careers in health care, especially hospital care, is markedly different than twenty years ago. "In a single generation, health care has moved from a favored to a less favored employment sector" (AHA, 2001). Significant drivers of this change have been economic constraints resulting from changes in reimbursement for care, rapid advances in clinical technologies and care modalities, and corporatism of health care systems. Hospitals and health systems have been forced to focus on cost control and restructuring of operations to achieve maximum efficiencies. Many cost savings in health care have been realized at the expense of direct caregivers, including downsizing of the professional nursing workforce, restructuring of nursing services, changes in staffing mix, rapid movement of patients to alternative care settings, and decreased support services for patient care. Furthermore, poor collaboration among health care providers hampers efforts to provide quality care in today's health systems. Many nurses describe the current work environment as highly stressful and professionally unfulfilling (Josiah Macy Foundation, 2000). 

Exacerbating the challenges to the work environment for nursing practice is the nationwide shortage of nurses and other allied health professionals. Key government agencies and professional nursing organizations have reported on issues related to the national nursing workforce. Evidence suggests that, if left unchecked, current shortages of nurses will escalate into a national health care crisis by the year 2010. Multiple factors of demand, supply, and the aging workforce have contributed to the problem of insufficient numbers of nurses available to care for the rising needs of the American public. Although the actual supply of nurses has continued to grow; it has not kept up with the significant increase in demand for nurses. 

Increasing Demand 

• Demand for nurses has exceeded supply in certain types of patient care specialties, such as critical care, cardiac, neonatal, and perioperative nursing (ANA, 2000). 
• Demand is particularly great in some geographical regions due in part to a maldistribution of nurses throughout the United States, e.g., Massachusetts has twice the number of nurses per capita as California. 
• Demand has intensified for more baccalaureate-prepared nurses with skills in critical thinking, case management, and health promotion skills across a variety of inpatient and outpatient settings (Goode, et al., 2001). 
• Demand has increased for more culturally competent nurses with knowledge of gerontology and long-term care because of rapidly changing population demographics (President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). 

Slow Growth in Supply 

• Supply of new nurses has decreased with declining numbers of new students and declining applications to schools of nursing (NACNEP, 1996; AACN, 1999b; AACN, 2001). 
• Supply of nurses is adversely impacted by faculty shortages in schools of nursing making it difficult to increase the number of students across the country (AACN, 1999a). 
• Supply of nurses is affected by a highly competitive labor market that attracts the best candidates away from health professions careers (AHA, 2001). 
• Supply of nurses is negatively influenced by the inaccurate media images of nursing, decreasing the selection of nursing career options by young people (William Mercer, Inc., 1999). 

Aging of the Nursing Workforce 

• The current nursing workforce is estimated to be nearly 2.7 million, with the average age of nurses at 45.2 years. Of these, only 82% or 2.2 million are employed either full- or part-time in nursing with an average age of 43.3 years. (U.S. Department of Health & Human Services, Bureau of Health Professions, Division of Nursing, 2001). 
• The largest cohort of currently practicing nurses will be in their 50s or 60s in the next decade, with many of these nurses retiring or decreasing their work time (Buerhaus, Staiger & Auerbach, 2000). 
• The average age of nurses is increasing at more than twice the rate of all other occupations in the U.S. workforce, with the number of nurses under age 30 decreasing by 41 percent from 1983 to 1998 (Needleman, et al., 2001). 

The impact of increasing demand and decreasing supply of registered nurses and rapid aging of the nursing workforce means that by the year 2020 there will be a 20 percent shortage in the number of nurses needed in the U.S. health care system. This translates into an unprecedented shortage of more than 400,000 registered nurses (Buerhaus, Staiger & Auerbach, 2000).

Magnet Hospital Recognition  

In 1983, with the publication of the original Magnet Hospital study, nursing leaders began to have a greater understanding of factors that helped to attract and retain professional nurses in the nation's health care system (McClure, et al., 1983). The American Academy of Nursing of the American Nurses Association initiated a nationwide investigation of hospitals known for successful nurse recruitment and retention. In this original study, 41 hospitals were identified that met selection criteria for "best practices" supporting nursing practice. Follow-up studies of these hospitals through the 1980s and 1990s contributed important evidence to support those factors that earned these hospitals a reputation for excellence in nursing practice (Kramer & Schmalenberg, 1988; Kramer & Hafner, 1989; Aiken, Smith & Lake, 1994; Aiken, Sochalski & Lake, 1997; Havens & Aiken, 1999). By 1993, the American Nurses Association through the American Nurses Credentialing Center established the Magnet Hospital Recognition Program to identify excellence in the provision of nursing services. This program recognized those health care institutions that acted as a "magnet" for professional nurses by creating a work environment that rewarded quality nursing services. The name of the program was changed in 1996 to the Magnet Nursing Services Recognition Program for Excellence in Nursing Services. The program was expanded in 1998 to include long-term care facilities. Today, the Magnet Nursing Services designation is a four-year recognition and the highest level of reward that can be accorded to organized nursing services in health care organizations (ANCC, 2001). The foundation for the Magnet Nursing Services program is the Scope and Standards for Nurse Administrators (ANA, 1995). The program provides a framework to recognize excellence in: 

• Nursing services management, philosophy, and practices;
• Adherence to standards for improving the quality of patient care;
• Leadership of the chief nurse executive and competence of nursing staff;
• Attention to the cultural and ethnic diversity of patients, their significant others, and the care providers in the health care system. 

Nurse scientists have continued to evaluate magnet hospitals. Recent studies have substantiated improved patient outcomes within organizational environments that support professional nursing practice. The Magnet Nursing Services designation remains a valid marker of excellence in nursing care (Aiken, Havens & Sloane, 2000). 

Preceptorships and Residencies  

With the increased complexity of health care environments, there has been an identified need to provide clinical experiences that assist students and graduates to make the transition to the work setting with more realistic expectations and maximal preparation (Mills, Jenkins & Waltz, 2000). One approach has been for education and service to partner to create summer internships, externships, and senior capstone preceptored experiences. Students working closely with staff nurses have the opportunity for role socialization as well as increasing clinical skills, knowledge, competence, and confidence (Letizia & Jennrich, 1998; Mills, Jenkins & Waltz, 2000; Nordgren, Richardson & Laurella, 1998). In addition, extended preceptorships have proven to be excellent recruitment devices, often decreasing the cost of lengthy orientation programs and reducing turnover rates (Mills, Jenkins & Waltz, 2000; Woodtli, Hazzard & Rusch, 1988). 

Post-graduate residencies or internships are another mechanism being developed to more effectively transition the new graduate into the practice arena. Residencies are usually described as formal contracts between the employer and the new graduate defining clinical activities to be performed by the new nurse in exchange for additional educational offerings and experiences to further the new graduate's professional development (NLN, 1983). In a University HealthSystem Consortium survey of chief nursing officers (2000), 85 percent of responding CNOs reported having an extended program of orientation for new graduates. Mentoring of the new graduate by experienced professional nurses can be a key component in producing beneficial outcomes for both the mentor and mentee (Talarczyk & Milbrandt, 1988). Overall, residencies have been shown to facilitate recruitment, increase retention, and increase commitment (Currie, Vierke & Greer, 2000; Hunter, Pollman & Moore, 1990; Kasprisin & Young, 1985). 

Differentiated Nursing Practice 

Differentiated practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making (AACN, AONE & N-OADN, 1995: Bellack & Loquist, 1999; Moritz, 1991; Pitts-Wilhelm, Nicolai & Koerner, 1991). Differentiated practice models have been implemented in acute care inpatient settings, rural community nursing centers, and acute care operating rooms (Anderko, Robertson & Lewis, 1999; Hutchens, 1994; Anderko, Uscian & Robertson, 1999; Graff, Roberts & Thornton, 1999; Malloch, Milton & Jobes, 1990; Milton, et al., 1992). 

Evidence indicates that differentiated practice models foster positive outcomes for job satisfaction, staffing costs, nurse turnover rates, adverse events (i.e., patient falls and medication errors), nursing roles, and patient interventions and outcomes (Anderko, Robertson & Lewis, 1999; Anderko, Uscian & Robertson, 1999; Hutchens, 1994; Malloch, Milton & Jobes, 1990). Differentiated practice outcomes include the opportunity for healthcare delivery organizations to capitalize on the education and experience provided by varied educational programs leading to RN licensure. The registered nurse has the opportunity to practice to his or her potential, taking full advantage of educational preparation. Often, differentiated models of practice are supported by a clinical "ladder" or defined steps for advancement within the organization based on experience in nursing, additional education, specialty certification, or other indicators of professional excellence. 

Interdisciplinary Collaboration 

In 1999, the Institute of Medicine (IOM) issued a comprehensive report, To Err is Human: Building a Safer Health System, summarizing problems of patient safety in the U.S. health system (IOM, 1999). One important recommendation was to create improved safety systems inside health care through implementation of safe practices at the delivery level, including interdisciplinary clinical practice among health professionals. Interdisciplinary practice or collaboration is defined as a joint decision-making and communication process among health care providers with the goal of satisfying the needs of the patient while respecting the unique abilities of each professional involved in the care (Colluccio & McGuire, 1983). Attributes of interdisciplinary collaboration include trust, knowledge, mutual respect, good communication, cooperation, coordination, shared responsibility, and optimism (Arcangelo, et al., 1996). 

Many professional education programs for medical, nursing, and allied health students now require curricula that support interdisciplinary practice in a variety of clinical settings. These programs should emphasize teamwork, conflict resolution, and the use of informatics to promote collaboration in patient care planning and implementation (Wakefield & O'Grady, 2000). Today's best integrated health delivery systems are evolving toward a model of care in which interdisciplinary teams of providers manage the care of complex patients. Studies of environments that support collaboration among physicians, nurses and allied health professionals have shown evidence of improved outcomes for both acutely and chronically ill patients (Pew Health Professions Commission, 1998). 

Recommendations 

In this era of increasing health care workforce shortages, there is an ever expanding need for high-quality professional nursing care due largely to changes in the socio-demographics of the population and in the health care system itself. There is a critical need to fully utilize the knowledge and skills of professional nurses and to ensure their retention in the profession as well as attract an increased number of individuals into the discipline. The hallmarks of the practice setting that support and optimize professional nursing practice and allow the baccalaureate- and higher degree-prepared nurse to practice to their full potential are identified. Clinical practice refers to all direct and indirect patient care activities undertaken to provide nursing care to individuals, families, or groups. Practice sites encompass a wide array of settings, including acute care facilities, extended care institutions, clinics, homes, and other community venues (AACN, 1999a). These hallmarks are intended to apply to all professional practice settings and all types of nursing practice. The hallmarks may be useful to new graduates, practicing nurses, students, faculty, nurse executives and managers, and employers across all nursing practice settings. AACN has developed this list of hallmarks, with accompanying specific questions in Appendix A, to assist nursing students educated at the baccalaureate level and above in making the best decision on where to practice following graduation.

Hallmarks are characteristics of the practice setting that best support professional nursing practice and allow baccalaureate and higher degree nurses to practice to their full potential. These Hallmarks are present in health care systems, hospitals, organizations, or practice environments that: 

1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, for example: 

• The organization has a philosophy and mission statement that reflects these criteria; 
• Nursing staff have meaningful input into policy development and operational management of issues related to clinical quality, safety, and clinical outcomes evaluation; 
• Nurse staffing patterns have an adequate number of qualified nurses to meet patients' needs, including consideration of the complexity of patient care; 
• Nursing is represented on the organization's staff committees that govern policy and operations; 
• The organization has a formal program of performance improvement that includes a focus on nursing practice, safety, continuity of care, and outcomes; and 
• Nursing staff assume responsibility and accountability for their own nursing practice. 

2. Recognize contributions of nurses' knowledge and expertise to clinical care quality and patient outcomes, for example: 

• The organization differentiates the practice roles of nurses based on educational preparation, certification, and advanced preparation; 
• The organization has a compensation and reward system that recognizes role distinctions among staff nurses and other expert nurses, e.g. based on clinical expertise, reflective of nursing practice, education, or advanced credentialing; 
• The organization's performance improvement program has criteria to evaluate whether nursing care practices are based on the most current research evidence; 
• Professional and educational credentials of all disciplines, including nurses, are recognized by title on nametags and reports; 
• Nurses and other disciplines participate in media events, public relations announcements, marketing of clinical services, and strategic planning; 
• Nurses are encouraged to be mentors to less experienced colleagues and to share their enthusiasm about professional nursing within the organization and the community; and 
• Advanced nursing roles, including clinical nurse specialists, nurse practitioners, scientists, educators, and other advanced practice roles, are utilized in the organization to support and enhance nursing care. 

3. Promote executive level nursing leadership, for example: 

• Nurse executive participates on the governing body; 
•  Nurse executive reports to highest level operations or corporate officer; 
•  Nurse executive has the authority and accountability for all nursing or patient care delivery, financial resources, and personnel; and 
•  Nurse executive is supported by adequate managerial and support staff. 

4. Empower nurses' participation in clinical decision-making and organization of clinical care systems, for example: 

• Decentralized, unit-based program or team organizational structure for decision making; 
•  Organization or system-wide committee and communication structures include nurses; 
•  Demonstrated leadership role for nurses in performance improvement of clinical care and the organization of clinical care systems; 
• Utilization review system for nursing analysis and correction of clinical care errors and patient safety concerns; and 
• Staff nurses have the authority to develop and execute nursing care orders and actions and to control their practice. 

 5. Maintain clinical advancement programs based on education, certification, and advanced preparation, for example: 

• Financial rewards available for clinical advancement and education; 
•  Opportunities for promotion and longevity related to education, clinical expertise and professional contributions; 
•  Peer review, patient, collegial, and managerial input available for performance evaluation on annual or routine basis; and 
• Individuals in nursing leadership/management positions have appropriate education and credentials aligned with their role and responsibilities. 

 6. Demonstrate professional development support for nurses, for example: 

• Professional continuing education opportunities available and supported; 
•  Resource support for advanced education in nursing, including RN-to-BSN completion programs and graduate degree programs; 
•  Preceptorships, organized orientation programs, re-tooling or refresher programs, residency programs, internships, or other educational programs available and encouraged;
• Incentive programs for registered nursing education for interested licensed practical nurses and non-nurse health care personnel; 
• Long-term career support program targeted to specific populations of nurses, such as older individuals, home care or operating room nurses, or nurses from diverse ethnic backgrounds; 
• Specialty certification and advanced credentials are encouraged, promoted, and recognized; 
• APNs, nurse researchers, and nurse educators are employed and utilized in leadership roles to support clinical nursing practice; and 
• Linkages are developed between health care institutions and baccalaureate/graduate schools of nursing to provide support for continuing education, collaborative research, and clinical educational affiliations. 

7. Create collaborative relationships among members of the health care provider team, for example:  

• Professional nurses, physicians, and other health care professionals practice collaboratively and participate in standing organizational committees, bioethics committees, the governing structure, and the institutional review processes; 
• Professional nurses have appropriate oversight and supervisory authority of unlicensed members of the nursing care team; and 
• Interdisciplinary team peer review process is used, especially in the review of patient care errors. 

 8. Utilize technological advances in clinical care and information systems, for example: 

• Documentation is supported through appropriate application of technology to the patient care process; 
• Appropriate equipment, supplies, and technology is available to optimize the efficient delivery of quality nursing care; and 
• Resource requirements are quantified and monitored to ensure appropriate resource allocation. 

AACN Task Force on Hallmarks of the Professional Practice Setting 

References Cited In Text

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Suggested Questions for Interview for a Professional Nursing Practice Position  

1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability. 

• Does the organization have a written philosophy and mission statement that reflect an emphasis on quality, safety, interdisciplinary collaboration, continuity of care, and professional nursing accountability?
• Does the organization have committees with nursing representation that provide input into policy development and operational management of issues related to quality of care, safety, continuity of care, patient-staff ratios, and clinical outcomes?
• Does the organization have a formal mechanism for quality assurance that includes criteria to assess whether nursing practice is based on the most current research evidence?
• What is the nurse-to-patient ratio? What support staff are available on the unit to assist nurses?

2. Recognize the contributions of nurses' knowledge and expertise to clinical care quality and patient outcomes. 

• Request a copy of the job description(s) of the registered nurse.
• How does the organization hold professional nurses accountable for high quality practice?
• Does the annual performance evaluation have explicit criteria related to level of practice expertise?
• Are there differentiated practice levels or roles for nursing congruent with differences in educational preparation, certification, and other advanced preparation in nursing (i.e. continuing education)?
• Does the organization have differentiated pay scales that recognize role distinctions and educational preparation among staff nurses?
• Does the organization recognize professional role distinctions among all disciplines by title on nametags, etc?
• Does the organization utilize clinical nurse specialists, nurse practitioners, nurse scientists and/or educators to support and enhance the work of staff nurses in clinical care?

3. Promote executive level nursing leadership.

• What are the key responsibilities/accountabilities of the top nurse executive? (Request a copy of the job description.)
• Where is the top nursing voice in the organizational chart?
• Where are nurses represented in key committees and activities of governance?
• What is the chain of command?
• What resources and functions fall under the domain of the nurse executive?
• What professional development, educational, and research functions are included in nursing services?

4. Empower nurses' participation in clinical decision-making and organization of clinical care systems.

• Do nurses control decisions directly related to nursing practice and delivery of nursing care, such as staffing, nursing quality improvement, and peer review?
• Do nurses have input into the systems, equipment, and environment of care?
• How is nurse staffing addressed in the hospital plan of care? (Request a copy of the hospital plan of care.)
• What is the specific patient population and nature of nursing care on this unit?
• What issues are evident in the performance improvement plans for this department?
• What role is defined for nursing staff in the unit plan?
• How are nurses involved in establishing and monitoring the workload measurement system?
• How does this system influence daily staffing?
• Is the role of nursing evident?
• What are the key issues reflected in this overall hospital plan? 

5. Maintain clinical advancement programs based on education, certification, and advanced preparation. 

• Employment responsibilities?
• Opportunities for advancement and promotion?
• Initial pay schedule or salary? If yes, what are the differences? 
• What rewards based on educational preparation are available? 
• How are clinical competencies and professional contributions evaluated?
• How does this evaluation relate to the promotion process?
• Patient satisfaction?
• Self-initiated education?
• Dissemination of clinical information, e.g. nursing rounds, case presentations, articles?
• Improvement of clinical outcomes and efficiency?
• Evidence-based practice?
• Ability to delegate to and guide non-bachelor's prepared nursing staff?
• Serving as mentor, consultant, or preceptor to students and recent graduates?
• Demonstrated ability to work in an interdisciplinary context?
• Leadership role in institutional self-governance and practice committees? 
• How are nurses recognized for meeting the professional practice criteria listed above, e.g. public acknowledgement, salary increases, time release, additional education, support to attend conferences, etc.?
• How do peers, patients, and supervisors provide input into the review process?
• Is peer review included in this process?
• What are salary increases based on? 

6. Demonstrate professional development support for nurses.

• What resources are committed to the ongoing professional development of nurses, i.e. tuition, continuing education, and certification?
• How much is budgeted annually per staff nurse for attendance at professional development activities?
• Do you provide tuition reimbursement for nursing course work completed towards obtaining the next higher degree?
• Is there an internship or its equivalent in your institution for bachelor's degree nursing students?
• Is there an internship or mentorship program to prepare nurses for clinical leadership positions?
• Do the graduates who have completed an internship program in your institution as students start at a higher pay scale/salary than those who have not?
• What are the opportunities for promotion within the clinical practice model?
• What types of incentive programs exist for licensed practical nurses and other non-nurse health care personnel who wish to pursue registered nurse education?
• Do you use case managers or their equivalent in your institution and what is the minimal nursing education required for that role?
• What are the opportunities for my own professional growth? What can I learn here and how would employment here facilitate my career goals?

7. Create collaborative relationships among members of the health care provider team. 

• How is the quality of patient care and safety reviewed?
• Who is involved in this process? Is it a peer review process?
• Do nursing units or departments of the practice setting have interdisciplinary or shared leadership models?
• Does the practice setting have interdisciplinary standing committees for peer review, patient safety, quality care, or disease state management?
• Does an interdisciplinary team participate in the process for quality improvement and review of patient care errors?
• Does the practice setting offer clinical practice privileges to advanced practice nurses and other health care providers as part of the medical staff bylaws and credentialing system?
• Are nursing units or departments of the practice setting organized from a discipline-centered perspective or from a patient-centered perspective?
• Do nurses from the practice setting refer to other members of the patient care team when discussing their role or work?
• Do nursing units or departments of the practice setting hold routine interdisciplinary care planning sessions?
• What collaborative, interdisciplinary articles, books or research reports have been published by clinicians from the practice setting?

8. Utilize technological advances in clinical care and information systems.

• Does this institution utilize an electronic patient care documentation system? If yes, who has access to this system and who inputs information? If a patient goes to a unit/department outside of this building, do the staff in that unit/department have access to the system?
• Do nurses have electronic access to clinical nursing and health care knowledge and research results, including Web access? Is this access available on nursing units or departments of the practice setting?
• Does the practice setting allocate budgeted resources for new equipment and patient care technology? Do clinical care providers have routine opportunities to provide input to the budget planning process?
• What clinical information system, including patient care documentation, does the practice setting use? Is the system integrated throughout all or most clinical departments?
• Do nurses feel that their practice is supported by up-to-date clinical care technology?
• What continuing nursing education programs are in place to help nurses and other providers assimilate new technologies and information systems?

Other key statistics and information that should be requested: 

• RN vacancy rate and RN turnover rate
• Patient satisfaction scores (preferably percentile ranking)
• Employee satisfaction scores
• Average tenure of nursing staff
• Education mix of nursing staff
• Percentage of registry/travelers used

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What Are the Qualities of a Good Nurse?

4 min read • June, 08 2023

If you're considering a career in nursing and have wondered what the qualities of a good nurse are, you're probably already displaying some of these essential nursing characteristics. Whether you're entering the nursing field or are a seasoned nurse, taking the time to understand nursing strengths demonstrates insight and a desire for ongoing self-improvement.

You might assume those entering the nursing field must have the qualities of a good nurse, but that's not always the case. Some nurses pursue a career in this profession because it's lucrative and offers many growth opportunities. They then end up dissatisfied with their career choice or  suffer from burnout  when they realize they don't possess the characteristics needed to succeed in nursing.

What Makes a Good Nurse?

There are many ways to define a good nurse. In general, it means bringing your best qualities to work to promote positive patient outcomes and striving to strengthen the nursing profession. While working as an essential member of a health care team, you seek solutions to improve patient care and advocacy. And certain personality traits and characteristics of a nurse go a long way in helping you succeed in the nursing profession.

Essential Qualities of a Nurse

• Communication skills: Excellent verbal and written communication skills are crucial areas of strength for nurses. Practicing active listening and being aware of nonverbal cues help you understand how communication approaches may differ. Clear communication and cultural awareness reduce miscommunication and medical errors and enable patients to make informed decisions about their care.
• Empathy and compassion: Although these characteristics often go hand and hand and are both qualities of a good nurse, they aren't the same. Empathy allows you to have a patient-centered approach to caregiving by relating to what they're experiencing. Compassion fuels your desire to help ease the pain and suffering of others. These two skills contribute to inspiring trust in your patient relationships.
• Critical thinking and problem-solving skills: Nurses often work autonomously under pressure and must make decisions using critical thinking to put their knowledge into practice. A solid analytical skill set lets you collect information, evaluate the facts, and develop a rational conclusion to improve patient outcomes.
• Attention to detail: Mistakes in nursing can have severe consequences, and caring for multiple patients increases the risk of human error. That could cause you to miss changes in a patient's condition if you don't understand the importance of minor details. Excellent  time management skills  and the ability to balance competing priorities can help you hone this skill.
• Integrity and advocacy: Core nursing strengths include a strong moral compass while providing care with integrity, and a strong focus on  patient advocacy . Patients are often vulnerable and trust nurses to be honest and make decisions with their best interests in mind.
• Willingness to learn: Health care is constantly changing, so you must be willing to continue to improve and expand upon your nursing qualifications and skills. Take advantage of education and in-services offered by your employer, review and implement  evidence-based nursing practice , participate in  nurse mentorship programs ,  join nursing associations , and pursue  continuing education . These are all effective ways to stay current in nursing practice and continue to thrive.

Other sought-after personality traits of a nurse include:

• Being even-tempered, hardworking, and flexible
• Displaying a sense of humor
• Practicing self-care
• Demonstrating leadership skills

How to Develop the Qualities of a Good Nurse

Reviewing the qualities of a good nurse and nurturing those virtues within your nursing practice can help you provide effective care that contributes to your professional growth.

If you want more clarification about the primary goals and values of the nursing profession, the American Nurses Association (ANA)  Code of Ethics for Nurses with Interpretive Statements  is an excellent resource regarding ethical principles.

Additional ways to nurture strong qualities include:

• Working with a nurse mentor
• Surrounding yourself with nurses who hold the qualities you wish to develop
• Accept and learn from constructive criticism regarding your professional practice
• Pursue  continuing education
• Work as a team with your peers to help strengthen the nursing profession
• Practice how to identify and address issues affecting patient and staff safety

Would I Be a Good Nurse?

If you’re a  student nurse  or considering a  career in nursing , understanding the desired characteristics of a nurse can help you determine how to be a good nurse. It also allows the seasoned nurse to assess their own nursing strengths and weaknesses. Health care organizations look for these traits when seeking quality nurses. Regardless of your level of experience, cultivate the positive qualities of a good nurse to get recognized by prospective employers.

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Evidence and practice    

Engaging nurses to achieve a culture of excellence: a children’s hospital journey towards pathway to excellence accreditation, andrea cronshaw clinical nurse specialist (burns and plastics) and pathway to excellence project lead, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, ellen boddye staff nurse, nottingham integrated sexual health services, nottingham university hospitals nhs trust, nottingham, england, lesley reilly divisional lead nurse, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, rachel boardman deputy divisional lead nurse, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, lee portas charge nurse, nottingham integrated sexual health services, nottingham university hospitals nhs trust, nottingham, england, janet hagan ward sister, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, susan griffiths matron, nottingham integrated sexual health services, nottingham university hospitals nhs trust, nottingham, england, helen donovan ward manager, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, david clark lead for practice education and development, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, lorraine collins sister, neonatal intensive care unit, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, barbra linley matron, neonatal services, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, sophie salt staff nurse, nottingham children’s hospital; sophia wright, staff nurse, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, mags sheahan-parry clinical nurse specialist, trent regional cleft network, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, joanne cooper assistant director of nursing, institute of nursing and midwifery care excellence, nottingham university hospitals nhs trust, nottingham, england, kerry jones magnet and pathway to excellence programme director, institute of nursing and midwifery care excellence, nottingham university hospitals nhs trust, nottingham, england, mandie sunderland chief nurse, nottingham university hospitals nhs trust, nottingham, england (retired), joseph charles manning clinical associate professor, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england, takawira chrispen marufu clinical academic nursing research lead, nottingham children’s hospital, nottingham university hospitals nhs trust, nottingham, england.

• To learn how accreditation can support organisations to develop excellence in nursing care

• To understand how Nottingham Children’s Hospital obtained accreditation for its nursing care

• To find ideas you can use to work towards accreditation for your organisation

High-quality nursing care is linked to improved patient experience and patient outcomes, so having work environments that nurture a culture of nursing excellence is fundamental to delivering high-quality patient care. The American Nurses Credentialing Center (ANCC) runs the Pathway to Excellence programme, an international accreditation recognising healthcare organisations that provide nurses with a positive and safe practice environment in which they can excel. In 2020, Nottingham Children’s Hospital became the first children’s hospital in Europe to gain Pathway to Excellence accreditation, demonstrating that it has developed a culture of nursing excellence and a positive environment for nurses to work in. This article describes the hospital’s journey towards accreditation. Crucial to its success were strategic planning, transformational leadership and using a change management approach, as well as effective staff engagement guided by the ADKAR model for change, an acronym representing five individual outcomes in terms of awareness, desire, knowledge, ability and reinforcement.

Nursing Management . doi: 10.7748/nm.2021.e1980

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@nottmchildrens

[email protected]

Joseph Charles Manning is a current recipient of an NIHR HEE funded ICA Clinical Lectureship. The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. All authors conceptualised and designed the Pathway to Excellence project and were involved in its implementation, and contributed to the drafting, critical review and revision of the manuscript.

Cronshaw A, Boddye E, Reilly L et al (2021) Engaging nurses to achieve a culture of excellence: a children’s hospital journey towards Pathway to Excellence accreditation. Nursing Management. doi: 10.7748/nm.2021.e1980

The authors acknowledge the nursing staff at Nottingham Children’s Hospital for their engagement, support and resilience to achieve and maintain Pathway to Excellence accreditation. The accreditation process was funded by the Nottingham Hospitals Charity.

Published online: 17 August 2021

change management - decision-making - leadership - management - organisational culture - professional - recruitment and retention - shared decision-making - staff welfare - workforce

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Nursing Named a 2024 Center of Excellence in Nursing Education

Widener's School of Nursing was one of 13 institutions named a Center of Excellence in Nursing Education by the National League for Nursing. The prestigious honor recognizes nursing's evidence-based and innovative efforts to enhance student learning and professional development. This is nursing's second Center of Excellence honor in the student learning and professional development category from the premier organization for nurse faculty and leaders in nursing education.

In addition to being named a Center of Excellence for student learning and professional development in 2020 and 2024, Widener’s nursing program earned a designation for its work to advance the science of nursing education in 2013, 2018, and 2023. Widener nursing is just one of seven schools nationwide to hold that designation, which runs through 2027. To date, only 95 institutions hold the Center of Excellence in Nursing Education designation.

Share link: https://www.widener.edu/news/noteworthy/nursing-named-2024-center-excellence-nursing-education

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BSN—Bachelor of Science in Nursing

Start your journey where excellence meets impact

Our prelicensure Bachelor of Science in Nursing (BSN) program offers students a rigorous education taught by leading-edge researchers, clinical experts, and health equity leaders. The BSN program at the UW Seattle Campus is a two-year professional program that prepares you for a career as a registered nurse. We prepare students for the full spectrum of nursing practice, from community care to hospital bedside. #7 in the nation among schools offering a BSN, our program’s emphasis on leadership and innovation equips students with the skills needed to impact the future of healthcare positively.

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Interested in learning more? Join an upcoming online information session or contact us at [email protected] to find out if this program would be a great fit and how to create a quality application.

BSN students begin as college-level juniors, having already completed 90 quarter/60 semester college-level credits or a previous bachelor’s degree in a non-nursing field. A solid foundation of science and humanities prerequisite coursework sets you up for success in our program.

The BSN is a full-time program, including:

• academic coursework focused on critical thinking, care and therapeutics, and healthcare resources
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Many of our BSN graduates continue on to graduate nursing study and careers in research, administration, and education.

UW Tri-Campus A/BSN Program Goals

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• Integrate concepts from the arts and sciences in promoting health and managing complex nursing care situations.
• Apply leadership concepts, skills, and decision-making in the provision and oversight of nursing practice in a variety of settings.
• Translate principles of patient safety and quality improvement into the delivery of high-quality care.
• Appraise, critically summarize, and translate current evidence into nursing practice.
• Integrate knowledge, processes, and skills from nursing science, information and patient care technologies, and communication tools to facilitate clinical decision-making and the delivery of safe and effective nursing care.
• Describe the effects of health policy, economic, legal, political, and socio-cultural factors on the delivery of and advocacy for equitable health care.
• Demonstrate effective professional communication and collaboration to optimize health outcomes.
• Deliver and advocate for health promotion and disease prevention strategies at the individual, family, community, and population levels.
• Demonstrate value-based professional behaviors that integrate altruism, autonomy, integrity, social justice, and respect for diversity and human dignity.
• Demonstrate critical thinking, clinical decision-making, and psychomotor skills necessary for the delivery of competent, evidence-based, holistic, and compassionate care to patients across the lifespan.
• Demonstrate critical interrogation of positionality, recognition of implicit biases, as well as knowledge and application of anti-racism principles to promote health equity.

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Specialist hospital joins nursing excellence scheme in UK first

02 September, 2024 By Edd Church

Source:  Stevekeiretsu / Wikimedia Commons

A specialist hospital in London has become the first non-NHS site in the UK to receive a prestigious international designation of nursing excellence.

The Royal Hospital for Neuro-disability (RHN), Putney, announced last week that it had been given Pathway to Excellence accreditation.

"As a national centre of excellence for neuro-disability, the RHN is an environment where staff feel supported and empowered" Paul Allen

Set up by the American Nurses Credentialing Centre (ANCC), Pathway to Excellence is given to a hospital which meets six “essential” standards deemed key to good working environments for nurses.

These standards relate to shared decision-making, leadership, quality, safety, wellbeing and professional development.

Hospitals seeking the designation must pass an assessment period in which the criteria are checked, and a final confidential survey of its nursing staff.

RHN, which is charity funded and specialises in care for adults with brain injuries, has become the first independent hospital in the UK to achieve Pathway to Excellence accreditation.

Hospital chief executive Paul Allen said the award was a “testament to the dedication and hard work” of his workforce.

He thanked director of nursing and quality Della Warren, and director of pathway Justin Finbow, for their work on achieving the designation.

Mr Allen said: “I am also grateful to all our staff, especially our nursing team, whose dedication to caring for our patients and residents is at the heart of everything we do."

He added: “As a national centre of excellence for neuro-disability, the RHN is an environment where staff feel supported and empowered and to have this recognised internationally is very rewarding for everyone.”

RHN joins several other hospitals across the country on Pathway to Excellence, including Charing Cross Hospital , which received the designation in July.

Northampton General Hospital became the first in the country to join the scheme in 2016 , and a push by former chief nursing officer for England Dame Ruth May in 2019 saw others begin working towards it in earnest.

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First London HCAs join campaign to demand up-banding

Healthcare support workers at Lewisham and Greenwich NHS Foundation Trust have begun a 48-hour strike in what their union has described as a “historic” walk out.

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Theatre nurses at a hospital trust in London have escalated a dispute over working hours by taking their strike directly to the government.

Nurse vacancies in Scotland drop by almost half

Nursing and midwifery vacancies in NHS Scotland have dropped by almost half in a year, according to latest figures.

Revised nursing profiles set to be published in 2025

The revised national NHS job profiles for nursing and midwifery will not be published until early 2025, to allow time for more bands to be reviewed, it has been announced.

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

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9 Nurses Leading Change

Minister to the world in a way that can change it. Minister radically in a real, active, practical, and get your hands dirty way. —Chimamanda Ngozi Adichie, author

As demonstrated by the COVID-19 pandemic, nurses at every level and across all settings are positioned to lead. Nurses can lead teams, promote community health, advocate for systems change and health policy, foster the redesign of nursing education, and advance efforts to achieve health equity. Even so, educational institutions and health systems can better prepare and empower new and practicing nurses, including licensed practical nurses, registered nurses, advanced practice registered nurses, and those with doctoral degrees to develop and grow in leadership roles. To this end, it will be necessary to place more intentional focus on providing models and opportunities for the emergence of more diverse nurse leaders who can reflect the people and families they care for and can mentor and serve as role models for underrepresented students.

Creating a future in which opportunities to optimize health are more equitable will require disrupting the deeply entrenched prevailing paradigms of health care, which in turn will require enlightened, diverse, courageous, and competent leadership. The seminal Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century ( IOM, 2001 ) calls for broad and sweeping transformation of the health care system in order to improve the quality of care. It identifies six aims for improvement that define quality health care: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable ( IOM, 2001 ). The Institute for Healthcare Improvement (IHI) has found that progress on health equity has lagged behind that on the other five aims, calling it “the forgotten aim” of health care ( Feely, 2016 ). The Crossing the Quality Chasm report emphasizes the importance of leadership in achieving the six aims, noting that leaders have a wide variety of roles and responsibilities that include

creating and articulating the organization’s vision and goals, listening to the needs and aspirations of those working on the front lines, providing direction, creating incentives for change, aligning and integrating improvement efforts, and creating a supportive environment and a culture of continuous improvement that encourages and enables success. ( IOM, 2001 , p. 137)

It must be emphasized that having this type of leadership only at the top of an organization or initiative is not enough. Rather, leadership is needed at multiple levels to “provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions” ( IOM, 2001 , p. 137) and to ensure that health equity is a strategic priority at every level ( Feely, 2016 ).

This chapter focuses on how nurse leaders can, and do, address social determinants of health (SDOH) and health equity in all settings and all nursing roles. It begins by articulating how nurses are well suited to lead in such efforts, and then outlines the committee’s vision for nursing leadership specific to these challenges in the future. Next is a discussion of the competencies that will enhance nurses’ ability to lead effective change. Finally, the chapter explores ways to help achieve the committee’s vision for nursing leadership through training and leadership development specific to advancing an agenda of greater health equity.

• NURSES LEADING IN HEALTH EQUITY

Nurses have a rich history of both advocacy and the provision of holistic care that includes meeting social needs of individuals and focusing on SDOH. As presented in this report, there are numerous examples illustrating how nurses are already working effectively as leaders on equity issues across a variety of settings. If nurses are to build on this rich tradition, it will not be enough for them to see themselves as leaders; the organizations that employ them will have to provide them with ample opportunities, resources, and mentorship to fully realize their leadership potential. This is the case even for nurses who are self-employed, who can benefit from opportunities provided by the external systems around them.

Nursing’s Focus on Social Determinants

Nurses have always been key to the health and well-being of individuals and communities, but a new generation of nurse leaders is now needed—one that recognizes the importance of SDOH and diversity and is able to use and build on the increasing evidence base supporting the link between SDOH and health status. Today’s nurses are called on to lead in the development of effective strategies for improving the nation’s health ( Lathrop, 2013 ; Ogbolu et al., 2018 ) with due attention to the needs of the most underserved individuals, neighborhoods, and communities and the crucial importance of advancing health equity.

Leadership can be defined as a process of social influence that maximizes the efforts of others toward achievement of a goal ( Kruse, 2013 ). Leaders set direction, build an inspiring vision, press for change, and create new ways of thinking and doing. Nurses as a professional group manifest many of the characteristics of strong leadership—including courage, humility, caring, compassion, intelligence, empathy, awareness, and accountability—that are essential to leading the way on health equity ( Shapiro et al., 2006 ). In addition to their deep understanding of how health intersects with SDOH ( Olshansky, 2017 ), they have a holistic view of people across systems and settings, they are active listeners, they establish therapeutic relationships, and they practice person-centered care. Increasingly, nurses are serving as innovators and codesigners of health care in their roles in the public health and health care systems ( Jouppila and Tianen, 2020 ), and by continuing to learn and apply improvement and innovation skills, will be able to help create new care models for the decade ahead. Given the wide range of settings and roles in which nurses at all levels serve (see Chapter 1 ), their leadership in this regard can have broad and far-reaching impacts on equity in health and health care.

THE COMMITTEE’S VISION FOR NURSING LEADERSHIP

Implementing change to address SDOH and advance health equity will require the contributions of nurses in all roles and all settings, and recognition that no one nurse can successfully implement change without the collaboration of others. Clinical nurses manage the nursing care of patients and coordinate care, making decisions and communicating with families and other health care professionals. These nurses can influence clinical practice environments and local organizational culture, as well as organizational processes and policies, often working with members of other health care disciplines. Public health and school nurses and other community-based nurses engage with the community to identify and address individual- and community-level needs, often working with professionals from other disciplines and sectors. Some nurses serve on boards, manage organizations, direct programs, and have direct responsibility for developing policies and practices. Nurses leading community organizations often lead team members and partner with community members and organizations in other sectors. Nurses serving on health care boards can exert leadership influence on the organization’s policies and structures while not leading day-to-day organizational operations. Still other nurses work with but outside the health care system, advocating for and working toward public- and private-sector policies and structures that can have positive impacts on health and well-being. These nurses (e.g., a public health nurse advocating for more equitable transportation policy) may lead individuals and organizations as part of a multidisciplinary, multisector coalition. And nurses with formal leadership roles, such as nurse managers, chief executive officers (CEOs), and deans, can use their positions to establish organizational cultures and implement practices that advance health equity. In addition to collaboration among members of the nursing profession and across other disciplines and sectors, the creation of enduring change requires the involvement of individuals and community members. Rather than a more hierarchal system of leadership, collaborative leadership assumes that everyone involved has unique contributions to make and that constructive dialogue and joint resources are needed to achieve ongoing goals ( Eckert et al., 2014 ).

Each of the various leadership roles described above involves different skills and responsibilities, as shown in the framework for nurse leadership in Table 9-1 . It is important to note that an individual nurse may lead in multiple areas of this framework and can lead in both formal and informal capacities. While some nursing positions (e.g., CEO, dean, nurse manager) entail more explicit leadership responsibilities, all nurses can lead according to their own interests, capacities, and opportunities. For example, a staff nurse who has no official leadership position in the workplace can lead others by modeling behaviors that promote a culture of diversity, equity, and inclusion, and can also lead beyond health care through involvement in political advocacy. As noted earlier, fulfillment of this potential will require support, encouragement, mentorship, and advancement opportunities, with nurses operating to the full scope of their education, training, and expertise.

A Framework for Nurse Leadership.

The subsections below detail the leadership roles nurses can play at the four levels shown in Table 9-1 : leading self, leading others, leading health care, and leading beyond health care. Nurses engaging in each of these leadership levels are important to advancing health equity. Together, the various roles at these four levels constitute the committee’s vision for nursing leadership.

Leading Self

Before nurses can lead others, they need to be able to lead themselves. To address SDOH, nurses need to understand and acknowledge how social determinants affect them personally, and to be aware of implicit biases that may influence the decisions they make and the outcomes of the people and communities they serve. They must understand and manage their own emotional responses, invest in their own physical and mental health, serve as role models for others, and continue their personal and professional development. Nurses can lead at this level by advocating for themselves and others in the workplace, functioning as effective team players, and developing coping and self-care skills ( NASEM, 2020 ).

Part of leading oneself is seeing oneself as a leader and viewing leadership as an integral part of one’s role. One barrier to effective leadership is that not all nurses see themselves in this way or have the bandwidth to take on or understand what leadership entails ( Dyess et al., 2016 ; Sherman, 2019 ). Given the right environment and support, however, nurses can overcome these barriers. (See Chapter 7 for further discussion of implicit bias and Chapter 10 for further discussion of self-care.)

Leading Others

In the pursuit of health equity, nurses have the opportunity to lead others, including other nurses, students, health care professionals, staff, community members, and partners. Leading others may occur in a wide range of contexts, including working with clinical nurse managers, community organization leaders, nurses engaging in policy development, and educators and research teams. Leading and managing effective teams requires building and maintaining trusting relationships among team members, communicating effectively, and supporting each team member. In this role, nurses can leverage and actively promote diversity within their teams and create an atmosphere of equity, inclusion, innovation, support, and growth. As team leaders, they can use their position to motivate and empower others to work to identify and address social in addition to health care needs, take action on health equity, and provide the tools and resources needed to do so.

One example of nurses leading others in pursuit of health equity is Cultivando Juntos, a community wellness program aimed at helping farmworkers live longer, healthier lives ( Berger, 2019 ). Two nursing students designed the program, which has expanded to include a biostatistician, a postdoctoral fellow, and undergraduate nursing students. The team meets with local Hispanic farmworkers to discuss their health and well-being and to conduct demonstrations on cooking healthy food. Baseline and longitudinal data are collected across the program to track progress on outcomes that include HgbA1c and lipid levels and body mass index ( Berger, 2019 ). This program is an example of nurses leading others by bringing multiple sectors together to engage with a community in order to address the community’s needs.

Nurses Leading Health Care

Nurses lead in numerous ways within health care, both in health care organizations and beyond their organizational boundaries. Within an organization, nurses can assess the organization’s readiness to address issues of equity and recommend related improvement. For example, a staff nurse on an inpatient unit can advocate for incorporating an assessment tool that can systematically collect data on SDOH within the electronic health record. Or a nursing director within a health care organization can engage other leaders, as well as members of the community, in initiating a healthy foods program within the hospital and connecting with related community-based agencies. Nurses can also identify and disseminate best and evidence-based practices to ensure equitable health care services within departments and across patient populations, improving and sustaining a supportive culture of care for both staff and those they serve, and advocate for policy changes that address population health and SDOH at the organizational and public policy levels. Nurses leading at higher levels within health care, such as nurse CEOs, chief nursing officers (CNOs), and chief operating officers, can work collaboratively with their organization to set direction and develop a vision and strategies for advancing organization-wide goals that include the drive for greater health equity through engagement with SDOH to meaningfully impact communities served by the health system. Successful organizational leaders can span boundaries between disciplines and sectors in an inclusive way to create meaningful, respectful, and sustainable partnerships to address issues of health equity. For example, public health nurse leaders can bring together representatives of the community served along with leaders from other sectors, including health care, transportation, housing, and food security, to address community needs (see the section below on leading multisector partnerships).

Nurses also have the capacity to lead in health care more broadly. For example, a nurse can seek to influence SDOH by working with a specialty organization such as the National Black Nurses Association, which focuses on the professional development of Black nurses and the delivery of culturally competent care, or serve as a leader for the Council of Public Health Nursing Organizations (CPHNO) or the National Rural Health Association. Many nurses also serve on boards of health care organizations, where they can provide their unique perspective on health-related issues facing individuals, families, and communities ( Harper and Benson, 2019 ). And nurses can serve as leaders in a variety of interprofessional contexts within health care; an example is a nurse researcher leading a multiorganizational research team. In each of these contexts and roles, nurses can share nursing’s perspective and expertise while collaborating with others to address health disparities, SDOH, and health equity.

Leading Beyond Health Care

Nurses have myriad opportunities to lead entirely outside the traditional boundaries of health care, in both the public and private sectors. In the public sector, they can lead through positions in local, state, and national government organizations, such as departments of human services, public health, and education. Nurses can be appointed to senior government positions or stand for election to political office, positions in which they can use their expertise and voice to advocate for policy change in the areas of SDOH and health equity. Applying her expertise, U.S. House of Representatives member Lauren Underwood, a registered nurse, discussed the disproportionate health and economic impacts of COVID-19 on communities of color, particularly Black Americans, in a Committee on Education and Labor virtual hearing in June 2020, calling these disparities “the pandemic inside this pandemic.” 1 She also sponsored a number of bills to eliminate disparities, such as H.R. 6142, 2 focused on maternal health outcomes among minority populations.

A number of other nurses serve in state legislatures, the U.S. Congress, state and federal executive branch positions, and national and state commissions and committees. Nurse leaders also can bring nursing perspective and expertise to private organizations. For example, Microsoft employs a CNO, and AARP has been served by several nurse CEOs. Nurses can facilitate and convene multisector partnerships, leading efforts to disseminate and implement interventions aimed at improving population health, and can engage communities and partners through local, regional, and national networks. Just as nurses serve as board members within health care, they can also serve on boards for programs or organizations that are outside of health care but have impact on health. The Nurses on Boards Coalition works to create opportunities for nurses to participate in a wide range of boards outside of health care, from boards of local schools or places of worship to those of Fortune 500 companies and large international corporations ( Harper and Benson, 2019 ). In the next 10 years, nurse leaders in these types of positions can become drivers for change within their communities by advocating for social change and health equity, and bringing nursing’s perspective to organizational and public policy-making discussions.

• LEADERSHIP COMPETENCIES FOR ADVANCING HEALTH EQUITY

While nurses’ specific leadership roles vary depending on the focus of their work, the setting in which they work, and the people whom they lead, there are certain skills and competencies on which all nurse leaders need to draw as they work to advance health equity by creating a vision and culture of equity, putting the necessary structures and supports in place, and working both within and across boundaries to achieve the vision of health for all. The committee identified eight skills and competencies that are essential for nurse leadership in nearly every setting, which are described in turn below:

• visioning for health equity,
• leading multisector partnerships,
• leading change,
• innovating and improving,
• teaming across boundaries,
• creating a culture of equity,
• creating systems and structures for equity, and
• mentoring and sponsoring.

Visioning for Health Equity

In all types of work, a leader is responsible for articulating a vision, setting direction and goals, and developing clear expectations for individuals and teams. Nurse leaders are no exception, whether the vision they create is for providing quality patient care in a clinic, meeting the needs of a community, setting the direction and goals for an organization or company, or redesigning the nation’s health care system. In the context of this report, nurse leaders at all levels and in all settings can work collectively with others to develop and communicate a clear and compelling vision for a future state of greater health equity. The creation of a vision for greater health equity can be squarely rooted in existing data demonstrating profound differences in care quality and health outcomes among people of color compared with their White counterparts ( Betancourt et al., 2017 ).

The most effective visions are a shared product ( Boyatzis et al., 2015 ). Nurse leaders can articulate ideas for a vision, and develop a shared vision by working collaboratively with others. Fully understanding the needs, hopes, and aspirations of a community or population is critical to achieving an effective shared vision ( Kouzes and Posner, 2009 ). To this end, nurse leaders can engage in dialogue with community members, whether that community consists of patients in a clinical setting; a subpopulation such as juveniles in the justice system; or residents of a neighborhood, city, or state. Regardless of the specific target community, this engagement requires a nurse leader to apply such skills as listening, acknowledging, and collaborating in order to create trusted relationships that are needed to build community-centric, community-informed solutions to complex health and social needs. Additionally, data collection and analysis to identify, assess, and prioritize opportunities for advancing health equity is essential ( Wesson et al., 2019 ).

Nurses can work with communities to identify and address their needs in a number of ways, including collecting and analyzing data, leading community meetings, presenting at city council meetings, and working to implement and evaluate strategies for eliminating health disparities. One established mechanism in which nurse leaders can engage is community health needs assessments, which are a statutory requirement for nonprofit hospitals (see Chapter 4 for a fuller description). Ensuring that these needs assessments explicitly target health disparities and prioritize SDOH and that they are conducted with input from members of the community on which they focus are examples of the considerations nurses can advance while helping to align community needs with culturally sensitive and relevant resources. Nurse leaders in both health care systems and public health (the entities involved in developing these needs assessments) can use these data to develop nurse-led and other innovative solutions for meeting the identified needs ( Swider et al., 2017 ).

Leading Multisector Partnerships

Strategic partnerships involving a broad range of stakeholders are essential to address factors that perpetuate structural inequities in health and health care ( NASEM, 2017 ). In the Framework for Achieving Health Equity of IHI, developing partnerships with community organizations is identified as one of the framework’s fundamental elements ( Laderman and Whittington, 2016 ). Nurses are skilled in working on and leading clinical teams. However, the role of the interprofessional health team is evolving beyond individual clinical encounters and extending beyond the walls of health care systems into the communities where people live ( NASEM, 2019a ; Pittman, 2019 ). Multisector models involving innovative interprofessional collaboration among, for example, police, emergency services, the legal system, housing, and public works and the health care system are showing promise and demonstrating positive health outcomes for underserved populations ( Hardin and Mason, 2020 ).

The ability to develop and lead multisector partnerships is critical to achieving health equity for a number of reasons ( NASEM, 2017 ). First, community needs are complex and wide-ranging, and necessarily involve actors from multiple sectors (e.g., employment services, education transportation, health). Collaboration across sectors is essential to break down existing silos that are counterproductive to improving health and health care ( NAM, 2017 ). Second, collaboration among partners introduces “more expertise and knowledge than what resides in any one stakeholder group” ( Wakefield, 2018 ), and multisector partnerships can leverage unique skills and resources from multiple stakeholders (e.g., faith leaders, philanthropists, researchers). Third, working with community partners can help nurses reach underserved populations, including the homeless, recent immigrants, and non-English-speaking families. Fourth, multisector partnerships increase a community’s capacity to make sustainable changes by bringing energy, expertise, and perspectives from multiple arenas. Fifth, multisector partnerships can simultaneously address upstream, midstream, and downstream SDOH and ensure alignment of efforts across these levels. Finally, bringing people together from multiple sectors can facilitate and encourage creative approaches; the intersections across boundaries are “where the promise of innovation lies” ( Pittman, 2019 , p. 27). As Johansson (2004 , p. 2) puts it, “When you step into an intersection of fields, disciplines, or cultures, you can combine existing concepts into a large number of extraordinary new ideas.”

It is important for multisector partnerships to be formal, structured, and collaborative relationships ( Siegel et al., 2018 ) in which partners have mutual respect for one another, and time and attention are devoted to maintaining those relationships ( Chandra et al., 2016 ). Trust among partners is also essential for a collaborative relationship, and once established, can serve as a foundation for future collaborations ( Wakefield, 2018 ). Nurses leading and engaged in multisector partnerships can help ensure that collaborative efforts are based on an understanding that health is a value shared among all partners ( Erickson et al., 2017 ; Mason et al., 2019 ; Realized Worth, 2018 ).

Nurses need to be able to build partnerships that include a focus on integrating clinical and nonclinical services and ensuring access to health and human services. Collaborative multisector efforts are common in the work of public health nurse leaders, and their experience and expertise can inform new approaches. Nurses currently have limited opportunities to learn from such efforts working in traditional health care systems. There is a need to start providing nurses with substantial exposure to experiences that involve developing and maintaining effective cross-sector partnerships, rather than what is often quite limited observational experience in public health and other social services settings.

While nurses have long worked at the intersection of individuals, families, other health professionals, social workers, educators, and others to improve health, more nurses will increasingly need to apply and expand this skill set to participating in or leading community-engaged multisector partnerships. The Crossing the Quality Chasm report ( IOM, 2001 ) calls for health care leaders to invest in their nursing workforce to enable nurses to achieve their full potential as individuals, team members, and leaders. Going forward, then, there is an expanding need to build and engage teams that reach beyond health care to include other sectors. Just as working in health care teams represented a “fundamental shift” in perspective in 2001 ( IOM, 2001 , p. 139), so, too, working across health and social sectors for the benefit of individuals and communities will require a fundamental shift in perspective, resources, and academic preparation.

Leading Change

Reducing disparities and achieving health equity will require nurse leaders to be skilled in leading change. To be effective, these efforts will need to be anchored in the theoretical constructs of change management and occur at multiple levels, within clinical practice, organizations, communities, populations, health authorities, and nations ( Browne et al., 2018 ). Evidence suggests that health care leaders are knowledgeable about disparities and what can be done to eliminate them, but that a number of barriers to successful change exist ( Betancourt et al., 2017 ). These barriers, including a lack of leadership buy-in, competing organizational priorities, existing culture, and ineffective execution, can be addressed through effective change management ( Betancourt et al., 2017 ). Effective change management requires that individuals learn and apply new behaviors and skills, as well as lead and collaborate with others in driving change within and outside of the organizations where they work. Empirically based interventions to drive change that can reduce health disparities include developing a vision for change (as discussed above), aligning executive support, engaging a coalition of committed stakeholders, setting expectations, establishing clear goals and a plan for change, anchoring change in the existing culture, measuring progress, iterating as needed, and communicating status reports and results ( Betancourt et al., 2017 ). Nurses at all levels can exert substantial influence on SDOH by using their experience and knowledge to engage in such change management efforts.

Innovating and Improving

Changing the prevailing health care paradigm to address SDOH and advance health equity will require innovation. The U.S. Department of Commerce’s Advisory Committee on Measuring Innovation in the 21st Century Economy defines innovation as the “design, invention, development, and/or implementation of new or altered products, services, processes, systems, organizational structures, or business models for the purpose of creating new value” ( ESA, 2007 ). For the complex work of eliminating disparities and impacting SDOH, knowledge and skill in innovation will be an important competency for nurses. Nurse leaders can facilitate the creation of innovative approaches by challenging the status quo, breaking down traditional barriers to change, teaching and encouraging team members to solve problems using design thinking, identifying best practices, and facilitating the translation and adoption of new ideas.

Virtually all nurses have opportunities to innovate by developing new ideas for improving health and translating these ideas into practice and policy. Over the past several years, nurse-designed and nurse-led innovations addressing SDOH among underserved populations have increasingly appeared in the literature. As described in Chapter 4 , for example, nurses in the Netherlands developed and implemented Buurtzorg, an innovative nurse-led, nurse-run organization of self-managed teams that provide home care to individuals in their neighborhoods (Monsen and de Blok, 2013 ). Similarly, the SOAR (Supporting Older Adults at Risk) program reimagined how to prepare and support frail older adults in the transition back to their homes following a hospital admission. The program addresses issues of transportation, nutrition, and medication access ( IHI, 2018 ).

Yet, while some nurses are already leading efforts focused on health equity in their work settings and communities, this focus is not consistent across the profession. It is a leader’s responsibility to create an environment that allows for innovation ( IOM, 2000 ). Leaders can provide a forum for continual innovation in and testing of strategies for improving population health and health equity, and ensure that their organization is flexible and able to adapt to those changes ( IOM, 2001 ). For example, leaders of front-line health teams can encourage team members to share their own observations and ideas for improving patient health and facilitate the transfer of new ideas across professional boundaries ( IOM, 2001 ). Likewise, nurse leaders working in the community or in multisector partnerships can encourage communication and collaboration without regard for traditional boundaries and recognize that innovative ideas can surface from an array of individuals across sectors, such as those working in aging-related services or Medicaid managed care organizations.

Nurses have a rich tradition of working creatively to solve problems and improve the quality of care in clinical settings ( Thomas et al., 2016 ), and these experiences and skills can apply to efforts designed to address SDOH. These types of initiatives require systematic, continuous, data-driven, and rigorous processes of assessment, innovation, implementation, evaluation, and diffusion or translation of the evidence or best practices into tangible strategies or policies for improving population health. For example, IHI’s Model for Improvement for quality improvement initiatives uses a Plan-Do-Study-Act (PDSA) cycle that involves planning exactly how the intervention will be implemented; implementing it; studying whether and how it is being conducted; and then acting to either adapt it, adopt it as a standard practice, collect more data, or abandon it ( IHI, 2020 ). This model has been used with great success in the clinical setting. Transforming Care at the Bedside (TCAB), was one such model using the PDSA cycle. A partnership between the Robert Wood Johnson Foundation and IHI, TCAB created learning collaboratives at the front lines of care on medical-surgical units that engaged nurses and other front-line staff in generating and testing ideas that led to processes and practices that improved the efficiency, safety, and satisfaction of care. 3 This process has the potential to be equally successful in addressing SDOH and health equity ( IHI, 2020 ).

Teaming Across Boundaries

As nurses work within and across organizations to address SDOH and advance health equity, they will need the skills to develop, engage, and lead cross-boundary teams. Cross-boundary teaming is a strategy for driving innovation that engages diverse stakeholders and subject-matter experts to expand the range of views and ideas on which teams can draw ( Edmondson and Harvey, 2018 ). In cross-boundary teams, individuals work across knowledge boundaries. Teams are diverse in expertise, knowledge, and educational background, characterized by deep-level differences or what Edmondson and Harvey call “knowledge diversity” (p. 3480).

Addressing SDOH and advancing health equity will require a cross-boundary team approach that includes not only people from different disciplines and sectors but also individuals and organizations from within the community. Regardless of the composition of the team, the cross-boundary team leader will need to support each team member, balance the use of resources, facilitate communication, and ensure the team’s effectiveness. A leader’s job is to “optimize the performance of teams that provide various services in pursuit of a shared set of aims” ( IOM, 2001 ). Evidence suggests that high-performing team members listen to one another and show sensitivity to feelings and needs ( Duhigg, 2016 ). To support the team and optimize its performance, a nurse leader will need to work to help its members achieve their full potential, both individually and collectively. This investment may include providing support and time for self-care, providing access to and time for ongoing professional development, and supporting individuals as they seek higher levels of education and responsibility. Facilitating nurses’ well-being and self-care is one particularly important way in which nurse leaders can support and optimize cross-boundary teams (see Chapter 10 on the importance of facilitating nurse well-being).

Creating a Culture of Equity

Nurse leaders in many positions of authority, including academic leaders ( DeWitty and Murray, 2020 ), journal editors ( Villarruel and Broome, 2020 ), educators ( Graham et al., 2016 ), and managers ( ANA, 2018 ), can act to call out and dismantle racism. To advance equity in society, nursing needs first to work to create a culture of equity within the profession itself. Nursing has a history of racism that continues to impact the experiences of nursing faculty, nurses in practice, communities, and patients ( DeWitty and Murray, 2020 ; Iheduru-Anderson, 2020a ; Villarruel and Broome, 2020 ; Waite and Nardi, 2019 ; Whitfield-Harris et al., 2017 ). The nursing profession’s substantive and sustained attention is required to address and eliminate racism in nursing and in broader organizations where nurses work. Waite and Nardi (2019 , p. 20) call on nurse leaders to “urge their colleagues and students to characterize, name, contest, and transform the norms, traditions, structures, and establishments that preserve White supremacy through continued effects of American colonialism.” Over the past few years, the nursing literature, including statements issued by national nursing organizations, has reflected increased attention to these issues.

Nurse leaders must acknowledge existing disparities and facilitate open, honest, and respectful discussions about factors that drive disparities (Oruche, and Zapolski, 2020 ; Purtzer and Thomas, 2019 ) and the challenges staff face as they engage in this work within organizations and with communities. It will be essential for these discussions to include opportunities for and support of the expression of patient and community perspectives ( NASEM, 2017 ). Specific strategies for promoting equity and inclusion include (1) creating safe spaces to engender trust and open communication; (2) reassessing recruitment and advancement processes; (3) examining and redesigning equity policies, procedures, and practices; (4) requiring a diverse pool of applicants for applicant selection; (5) moving from mentorship to sponsorship, which focuses on protégé advancement; (6) creating an infrastructure to monitor and track progress with development programs; and (7) dismantling racism, including applying an equity lens to all practices ( Fitzsimmons and Peters-Lewis, 2021 ). Nurse leaders need to set an example of inclusion and confront negative and toxic cultural norms in nursing, such as bullying and in-fighting ( Kaiser, 2017 ). Nurse leaders need to be knowledgeable about and able to lead others in cultural humility and culturally competent practices, which are critical for reducing health disparities and improving access to high-quality health care ( Powell, 2016 ).

In a recent analysis of six models of cultural competence, Botelho and Lima (2020) argue that existing approaches to the delivery of culturally appropriate care may assist with cultural respect, but tend to oversimplify patients’ cultural experiences and overlook the complexities associated with power dynamics ( Botelho and Lima, 2020 ). They propose the practices of not only cultural humility but also relational ethics 4 to facilitate cross-cultural work. To practice cultural humility, clinicians relinquish their role as experts in a culturally diverse world where power imbalances exist and embrace an attitude characterized by constant questioning, openness, self-awareness, absence of ego, and self-reflection and -critique, willingly interacting with diverse individuals. Practicing with cultural humility can foster mutual empowerment, respect, partnerships, optimal care, and lifelong learning ( Foronda et al., 2016 , p. 213). (See Chapter 7 for further discussion of cultural humility.)

Creating Systems and Structures for Equity

Nurse leaders at all levels and in all settings can help create systems and structures that promote equity and do not unintentionally exacerbate inequalities through unintended incentives. For example, working midstream (see Chapter 2 ), a nurse leader who oversees a home visiting program can educate around the concept of equitable care and establish expectations of nurses that encourage the provision of equitable care, including meeting social needs, rather than orienting nursing’s interventions to the volume of visits they make ( IOM, 2001 ). A nurse leader who manages an organization can develop organization-wide policies that put equity at the forefront of the staff’s work, and ensure that the provision of services does not exacerbate existing inequalities. Upstream, a nurse leader can influence government policy by advocating for policies that improve equity, such as a city transportation policy that prioritizes traditionally underserved rather than higher-income neighborhoods, or by highlighting exposure to noise pollution and associated health impacts related to building low-income housing near railroad tracks.

The goal of health equity is more likely to be achieved when it becomes deeply ingrained in official systems and structures and becomes inherent in a cultural shift that includes inner reflections on bias and structural racism ( Chin, 2020 ), rather than being pursued through one-off initiatives or well-intentioned efforts that are not formalized. Systems and structures are never neutral—they either entrench or dismantle existing health inequities. Nurse leaders have a responsibility to advocate for and build systems that promote equitable health for all.

Mentoring and Sponsoring

The transformation toward a health system that is more equitable and just will require explicit preparation of and support for future nurse leaders in multiple settings ( AACN, 2016 ). A key strategy for achieving this goal is mentorship and sponsorship of the next generation of nurses and nurse leaders. Mentoring is critical across the trajectory of nurses’ professional lives, particularly as they take on new and increasingly complex leadership roles ( Vitale, 2018 ). Given the overarching need for nurse leaders with expertise and commitment to achieving equity in health and health care, and given the need for more nurses with expertise in such priority areas as care for the aging, maternal mortality, mental and behavioral health, rural health, and public health (see Chapter 3 ), mentoring is critical to building and supporting the next generation of nurses.

Mentoring is associated with positive benefits, including professional development, greater skills, a better fit with one’s choice of specialty, and greater life–work balance ( Disch, 2018 ). In mentoring new nurses in the application of concepts related to health equity or in needed specialty areas as identified above, nurses with experience can encourage collaboration among nurses of different ages and at different professional development stages. In general, a lack of support and mentoring by senior nurses has negative impacts on well-being and workforce turnover ( IOM, 2011 ), and mentoring is therefore a critical part of building capacity in the profession and of mitigating the loss of knowledge and experience that results when retiring nurses leave the profession.

A particularly critical role for nurse leaders is mentoring nurses from traditionally underrepresented communities to build a more diverse nursing workforce and increase the number of nurses from underrepresented groups in leadership positions ( Phillips and Malone, 2014 ). Mentoring is a critical component of recruiting, supporting, and advancing nurses of color through the ranks of leadership ( DeWitty and Murray, 2020 ; Iheduru-Anderson, 2020b ; Whitfield-Harris et al., 2017 ). As discussed in Chapter 3 , diversity in the nursing workforce—and in nursing leadership in particular—is essential to achieving health equity. There are relatively few nurses of color in leadership positions, particularly in more senior executive positions ( Phillips and Malone, 2014 ; Schmieding, 2000 ). A 2019 National Academies report on increasing the number of professionals of color in science, technology, engineering, and mathematics found that structured mentorship programs in minority-serving institutions 5 can improve leadership diversity in nursing and the health care field generally ( NASEM, 2019b ). One such effort is being led by the Center to Champion Nursing in America (CCNA) in its convenings of mentor training programs with historically Black colleges and universities (HBCUs). CCNA will continue to convene mentoring programs in Hispanic- and American Indian–serving nursing schools as well ( CCNA, 2020 ).

Serving as a sponsor becomes even more critical than mentoring when a more active role is required to help nurses rise in leadership ranks ( Williams and Dawson, 2021 ). The expectations of a sponsor include being a staunch advocate for career advancement for the protégé, including making assignments and connecting the protégé to key decision makers while keeping her or him protected from negative influences. Sponsors take advantage of the organizations and people in their sphere to present their protégés in the most positive light, with the goal of career advancement. This more active approach has been shown to be especially helpful in helping nurses of color rise in the leadership ranks ( Beckwith et al., 2016 ).

ACHIEVING THE COMMITTEE’S VISION OF NURSE LEADERSHIP

As previously noted, many nurse leaders are currently focused on incorporating equity into their work. To achieve the committee’s vision, however, a significant investment in broader and deeper development of nurse leadership will be needed. New and established nurse leaders—at all levels and in all settings—are needed to lead change that results in meeting social needs, eliminating health disparities, addressing SDOH, and ultimately achieving equity in health and health care, with the aim of improved health for all individuals and communities. Nurse leaders need to both develop and expand the leadership competencies described in this chapter, and implement strategies targeted to achieving diversity among nurse leaders. Nurse leadership competencies and knowledge can be developed through approaches that encompass education, fellowships, and nursing organizations, as discussed below.

Increasing Diversity in Nurse Leadership

Diverse leaders can serve as particularly important role models, provide guidance and mentoring for other nurses, influence the allocation of resources, and shape policies aimed at eliminating inequities ( Phillips and Malone, 2014 ). The prior The Future of Nursing report identifies the need for a renewed focus on diversity in nursing, calling for the development of novel education models that promote respect for diversity along a number of dimensions, such as race, ethnicity, geography, background, and personal experiences ( IOM, 2011 ). Even when nurse leaders hold similar positions, salary disparities are seen among racial and ethnic groups. Among nurse leaders with the highest salaries (ranging from clinical staff to C-suite executives), only 11 percent are Black, compared with 27 percent who are Asian American, 25 percent who are Hispanic, and 21 percent who are White. Not only are few Black nurses in positions of leadership at all, but even fewer advance to careers as nurse executives ( Iheduru-Anderson, 2020a ; Jefferies et al., 2018 ).

Understanding and addressing the reasons for the diversity gap in nursing leadership is essential. The existing literature identifies racism as a significant factor ( Iheduru-Anderson, 2020a ). Nursing’s roots in the United States have been shaped within the context of colonialism, a history that has influenced the makeup of the profession’s leaders ( Waite and Nardi, 2019 ). As discussed earlier, acknowledging and addressing how racism has been internalized and how it has manifested within the field, including in the advancement of nurses of color, is key ( Brathwaite, 2018 ; Waite and Nardi, 2019 ). Other barriers include stereotyping; a lack of career development opportunities ( Carroll, 2020 ); a lack of mentorship ( Ihederu-Anderson, 2020b ); inadequate support systems; isolation; the perception of being overlooked for positions in contrast to White counterparts ( Kolade, 2016 ); and the cultural taxation or diversity tax ( Gewin, 2020 ), characterized by the role assigned to the ethnic representative of a group involving the expectation that this individual will provide unofficial diversity consultation. 6

Numerous innovative programs aimed at cultivating diversity in nursing leadership have been developed and implemented. A number of these programs target nurses early in the trajectory of development (in prebaccalaureate or baccalaureate programs), while others are aimed at later stages of professional growth. Examples of programs focused on early leadership training include EMBRACE (Engaging Multiple communities of BSN [bachelor of science in nursing] students in Research and Academic Curricular Experiences), which was developed to provide comprehensive experiences in research and leadership for undergraduate students of color who are underrepresented in nursing, and the Duke University School of Nursing’s Making a Difference program ( Carter et al., 2015 ; Stacciarini and McDaniel, 2019 ). Likewise, the University of North Dakota has a program called Recruitment & Retention of American Indians into Nursing (RAIN), which provides academic support and assistance to American Indian nursing students, from prenursing programs through doctoral education ( UND, 2020 ). (See Chapter 7 for further discussion of recruiting and supporting underrepresented students.) To fully support the goal of diversity in nurse leadership, such programs will need to be evaluated and scaled.

Nursing Education, Fellowships, and Certificates

While nursing school curricula often include some information about public health, SDOH, and health equity, they do not always prepare students to engage fully with and serve as leaders on these issues. Nursing education traditionally has emphasized the development of clinical skills over leadership and management skills ( Joseph and Huber, 2015 ). As discussed in Chapter 7 , the American Association of Colleges of Nursing’s (AACN’s) Essentials 7 provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP) programs. Introducing the concept of health equity in school is a necessary first step in professional role development and leadership, but nurses also need to take every opportunity to supplement their preparation through continuing education.

A number of fellowships support education in leadership skills with a focus on health equity and community health. 8 Nearly all of these fellowships are interdisciplinary, bringing together professionals from multiple sectors, including health care, business, community organizing, education, and the law. These types of fellowships present opportunities for nurses to grow their leadership skills, to collaborate and innovate with professionals from multiple disciplines and sectors, and to develop and implement projects within their areas of interest that relate directly to achieving health equity. In addition to equity-specific fellowships, a wide variety of fellowships available for nurses are focused on general leadership skills that can be transferred to any area and any setting, including addressing SDOH and pursuing health equity.

One fellowship specifically for nurses and focused on equity is the Environmental Health Nurse Fellowship, which trains nurses to work with communities to address environmental health threats. In 2019, the Alliance of Nurses for Healthy Environments (ANHE) launched this fellowship to focus on environmental health equity and justice and on the disproportionate impact of environmental conditions on underserved groups. The 30 fellows, all of whom are nurses, work with mentors to help communities identify environmental needs and build support for community-driven solutions ( ANHE, 2019 ).

The Global Nursing Leadership Institute 9 (GNLI) fellowship, sponsored by the International Council of Nurses and supported by the Burdett Trust for Nursing, is available to nurses worldwide. This fellowship is focused on policy leadership, with a special emphasis on strengthening political and policy understanding and influence. Its framework includes in-depth work on the United Nations’ Sustainable Development Goals, which reflect multiple SDOH. The focus of 2020 was on health disparities in the context of the COVID-19 pandemic.

Many certificate programs in the United States can help nurses develop leadership skills that can be leveraged to lead work in equity in health and health care. Examples include the Health Equity Certificate at the University of Pittsburgh School of Public Health 10 and the Graduate Certificate in Health Equity at the Vanderbilt University Medical Center. 11

The Role of Nursing Organizations

Most professional nursing organizations recognize and specifically call out leadership as an essential competency for nurses in all settings ( NAHN, 2020 ; NCEMNA, 2020 ; NLN, 2005 ; Quad Council, 2018 ). These organizations offer leadership courses, resources, and support, most pertaining to leadership in general rather than leadership on health equity, for current and aspiring nurse leaders. Nursing organizations also have undertaken specific initiatives to develop and support nurse leaders that include content related to equity in health and health care. Examples include the following: (1) the American Public Health Association Public Health Nursing Section, with the vision of advancing social justice and equity to achieve population health for all 12 ; (2) the Future of Nursing: Campaign for Action, with the vision of working toward an America in which everyone can live a healthier life, supported by nurses as essential partners in providing care and promoting health equity and well-being 13 ; (3) the Black Coalition Against COVID-19, 14 an interprofessional multisector coalition, co-led by the National Black Nurses Association, focused on urgently mobilizing and coordinating all available community assets in a collaborative effort with the government of Washington, DC; and (4) the National Coalition of Ethnic Minority Nurse Associations (NCEMNA), which stands as a unified force advocating for equity and justice in nursing and health care for ethnic minority populations. 15 In addition, professional associations offer nurses an opportunity to build leadership competencies by leading within the association. While some nursing associations are small and others large, each can offer nurses an opportunity to meet other nurses, join boards and workgroups, and help guide the association’s direction, especially toward the goals germane to this report.

Nursing associations that are organized around a racial or ethnic identity may offer a particularly good opportunity for underrepresented nurses to hone their leadership skills. The NCEMNA is an umbrella organization of five national ethnic nurse associations: the Asian American/Pacific Islander Nurses Association, the National Alaska Native American Indian Nurses Association, the National Association of Hispanic Nurses (NAHN), the National Black Nurses Association, and the Philippine Nurses Association of America. One of the five strategic goals of the NCEMNA is to “promote ethnic minority nurse leadership in areas of health policy, practice, education and research” through the implementation of leadership development and mentorship programs ( NCEMNA, 2020 ).

• CONCLUSIONS

All nurses have the capability to lead and engage in meaningful roles in addressing SDOH and health equity, with their specific roles and functions depending on individual interests, capacities, and opportunities.

Conclusion 9-1: Nurse leaders at every level and across all settings can strengthen the profession’s long-standing focus on social determinants of health and health equity to meet the needs of underserved individuals, neighborhoods, and communities and to prioritize the elimination of health inequities.

Given that social determinants that affect health exist largely outside of the health care system (e.g., poverty, literacy, housing, transportation, and food security), addressing SDOH and eliminating health disparities will require collaboration and partnership among a broad group of stakeholders. Public health nurses have a long history of working collaboratively to meet social needs and address SDOH, and their experiences can be used as models for other nurses seeking to work collaboratively across sectors.

Conclusion 9-2: Achieving health equity will require multisector collaboration, and nurse leaders can participate in and lead these efforts. Conclusion 9-3: Many community and public health nurse leaders have expertise and experience in leading cross-sector partnerships to meet social needs and address social determinants of health, and their expertise can be leveraged to inform the broader nursing profession in both practice and education.

Racism and discrimination are deeply entrenched in U.S. society and its institutions, and the nursing profession is no exception. Nurse leaders have an important role to play in acknowledging the history of racism within the profession and in moving forward to dismantle structural racism and mitigate the effects of discrimination and implicit bias on health. Role modeling listening, engagement, and inclusivity within and outside of nursing will be necessary to foster trust and achieve needed change. A critical part of these efforts will be building a more diverse nursing workforce and supporting these nurses in their pursuit of and success in leadership roles.

Conclusion 9-4: Nurse leaders have a responsibility to address structural racism, cultural racism, and discrimination based on identity (e.g., sexual orientation, gender), place (e.g., rural, urban), and circumstances (e.g., disability, mental health condition) within the nursing profession and to help build structures and systems at the societal level that address these issues to promote health equity. Conclusion 9-5: A critical role for nurse leaders is mentoring and sponsoring nurses from traditionally underrepresented communities in order to build a more diverse nursing workforce and increase the number of underrepresented nurses in leadership positions.

• AACN (American Association of Colleges of Nursing). Advancing healthcare transformation: A new era for academic nursing. 2016. [April 8, 2021]. https://www ​.aacnnursing ​.org/Portals/42/Publications ​/AACNNew-Era-Report.pdf .
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The full committee hearing is available at https://edlabor ​.house ​.gov/hearings/inequities-exposed-how-covid-19-widened-racial-inequities-in-education-health-and-the-workforce- (accessed April 8, 2021).

See https://www ​.congress ​.gov/bill/116th-congress ​/house-bill/6142?q= ​%7B%22search%22%3A ​%5B%22Black+Maternal+Health+Momnibus+Act ​%22%5D%7D&s=1&r=1 (accessed April 8, 2021).

See http://www ​.ihi.org/Engage ​/Initiatives/Completed ​/TCAB/Pages/default.aspx for more information about TCAB (accessed April 8, 2021).

Relational ethics is defined in health care as actions that take place within relationships and consider the existence of the other (i.e., patient, nurse) ( Bergum and Dossetor, 2005 ). Core tenets include mutual respect, engagement, embodied knowledge, environment, and uncertainty; the most important tenet is mutual respect ( Pollard, 2015 ).

Institutions serving people of color are commonly defined in two distinct categories: historically Black colleges and universities and tribal colleges and universities (NASEM, 2019).

Cultural taxation refers to the phenomenon whereby faculty who are individuals of color are asked routinely to take on extra, uncompensated work to address a lack of diversity in their institutions.

The February 2021 final draft ( AACN, 2021 ) is available at https://www ​.aacnnursing ​.org/Portals/42/AcademicNursing ​/pdf/Essentials-Final-Draft-2-18-21 ​.pdf?ver=hNeCl7OjgamIA9sHgDi ​_Yw ​%3d%3d&timestamp=1613742420447 (accessed April 8, 2021).

See, for example, the Atlantic Fellows for Health Equity at The George Washington University Health Workforce Institute, the Diversity and Health Equity Fellowship of the American Hospital Association, and the Robert Wood Johnson Foundation’s Health Policy Fellows and Culture of Health Leaders programs.

See https://www ​.icn.ch/what-we-do ​/projects/global-nursing-leadership-institutetm-gnli (accessed April 8, 2021).

See https://catalog ​.upp.pitt ​.edu/preview_program ​.php?catoid=73&poid ​=23709&returnto=6375 (accessed April 8, 2021).

See https://www ​.vumc.org ​/healthequity/graduate-certificate-health-equity (accessed April 8, 2021).

See https://www ​.apha.org ​/apha-communities/member-sections ​/public-health-nursing (accessed June 7, 2021).

See https: ​//campaignforaction.org/about (accessed June 7, 2021).

See https: ​//blackcoalitionagainstcovid.org (accessed June 7, 2021).

See https://ncemna ​.org/about (accessed June 7, 2021).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 9, Nurses Leading Change.
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