Nurses' Work Identities

The nursing profession relies on a standardized system of education and training that is consistent across all European Union member states, following common guidelines set forth in 1977. This framework encompasses both certified general nurses and specialized nursing roles, including head nurses, intensive care specialists, surgical specialists, clinical trainers, and others [1]. Professional identities are intricately connected to the ways in which individuals relate to their work, workplace, or employer. This identity is expressed through various aspects of the work environment that resonate with individuals. The terms "professional," "work," or "occupational" identity refer to the process of identity formation that arises from the interaction between individuals and their work contexts, which encompass education and training. This identification primarily revolves around the work environment, the organization and its objectives, as well as the specific activities and tasks that contribute to both individual and collective productivity. Even in the most challenging and restrictive working conditions, a degree of identification with one’s profession and work is acknowledged, despite the complexities of the experience [2].

The exploration of work identities broadens the understanding of work identification and commitment beyond the confines of the employment organization. It acknowledges that an individual's work-related identity and commitment can encompass not only the organization itself but also their profession, professional community, work team, specific work environment, and individual work actions, all of which may hold varying significance for individuals as time progresses. Furthermore, the notion of work identity includes possible sources of identification with non-work responsibilities that a working individual may possess, such as obligations to family and friends [2,3]. Nursing is rooted in a rich history of professional traditions, with a distinct identity and standards that date back to the era when nuns, charitable organizations, and entities like the Red Cross initiated healthcare services by establishing and managing hospitals and other care facilities. These historical underpinnings have shaped job responsibilities and fostered a largely consistent perspective on the attitudes, qualities, and skills that define an effective nurse [4]. Since the 1980s, the nursing field has experienced considerable transformations. Financial constraints, the need for efficiency, and the introduction of new quality standards have led to a shift from traditional hierarchical structures and rigid professional roles to a more flexible work organization that incorporates service outsourcing. Evolving job requirements, the emergence of new skill sets, and the movement towards enhanced professionalism in delivering quality healthcare challenge and contradict the conventional perception of nursing [5].

The healthcare sector is experiencing significant growth, driven by demographic shifts and the aging population in Europe. This evolution brings forth new demands and expectations, prompting nurses to adopt greater flexibility and mobility. It is essential to approach healthcare needs and delivery from a comprehensive viewpoint, considering staffing and skill requirements across different countries. Additionally, there is a need to transition from merely providing care to emphasizing prevention, guidance, and support that fosters a patient-centered self-help model. As the organization of work, standards, and expectations within nursing evolve, traditional professional roles and identities are also being reexamined. Nursing has become a recognized profession, leading to the decline of outdated perceptions of nurses as mere 'angels' or 'servants.' Today, nurses seek acknowledgment as experts in their field. In this context, opportunities for ongoing professional development are crucial, and many nurses are pursuing academic careers. Nursing is increasingly aiming for equal collaboration with the medical profession, particularly as nurses take on more responsibility for the financial management of healthcare organizations [4,6].

The degree of autonomy and accountability is a fundamental aspect of nurses' connection to their work, especially concerning direct patient interactions. Once nurses assume full responsibility for their actions following their training, they adopt a markedly different perspective on their professional roles. This change signifies their full integration into the professional community, which is another crucial factor in the development of nurses' professional ownership and identity. The professional identity of nurses evolves over time, making work experience a critical element, alongside ongoing education and training, as they gradually transition into the role of a "specialist nurse." In the nursing field, the primary mode of learning is experiential, encompassing on-the-job training, practical application, and self-directed learning, with the expectation that tacit knowledge and skills will grow with experience. Additionally, pursuing further qualifications is vital for both nurses and their employers. For nurses, continuing formal education serves as a source of motivation, enabling them to enhance their expertise, support the nursing process, build self-confidence, engage in professional dialogue with peers, and integrate new learning opportunities into their daily routines [6].

For healthcare professionals, there is a widespread consensus that, ideally, their roles should encompass more than mere technical skills. Delivering healthcare services involves not only practical care but also a significant emotional aspect that demonstrates respect for each individual patient. This concept serves as a fundamental motivation for individuals pursuing a nursing career and is integral to the professional identity of nurses. Key motivational factors include the desire to assist others, along with structural elements such as job security, the universal demand for the profession-highlighted by the notion that "nurses are always needed”-and the high degree of responsibility and autonomy associated with the role. Additionally, flexible working hours and part-time options enhance the compatibility of nursing with family life, making the profession particularly appealing to women. After an extended maternity leave, returning to work is relatively straightforward, allowing nurses to reintegrate without facing significant disadvantages compared to their continuously employed counterparts. This ease of transition is partly attributed to ongoing staff shortages and the fact that the essential qualities and responsibilities of nursing remain largely unchanged over time. Furthermore, collaboration and teamwork are vital motivational aspects that foster mutual support and recognition among colleagues and within the broader professional community. These factors are crucial in strengthening nurses' commitment to their work and shaping their professional identity [4,6].

A significant aspect of professional identity in nursing arises from direct patient interactions and the ethical principles inherent to the profession. The commitment to prioritizing patients is an attitude that evolves gradually through practical experience. Trainee and newly qualified nurses often cite a general interest in medicine as their primary motivation for entering the nursing field. In contrast, nurses with more extensive experience tend to focus on direct patient care as the core of their professional activities. This emphasis on caregiving is typically linked to a distinct set of values and a strong work ethic. Nurses who are patient-centered often prefer roles that allow them to engage directly with patients rather than pursuing administrative or managerial positions. The combination of high responsibility and relative autonomy in direct patient care fosters a deep commitment to their work and the ethical standards of their profession. While these elements form the foundation of nurses' professional identity, they appear to be largely unaffected by structural changes. Nonetheless, alterations in work organization, task division, demands for increased flexibility and mobility, structural reforms, and medical advancements significantly influence nurses' daily responsibilities, skill enhancement, and time management for various tasks, including direct patient care. As nurses encounter heightened pressure and time limitations, a conflict arises between providing patient-centered care and the push for efficiency. This tension impacts nurses' professional identity, as the movement towards professionalism can challenge some fundamental values of an idealized nursing model that encompasses total personal commitment [6].

Conversely, nursing has several negative aspects, including the profession's low status within the healthcare sector and society at large, time constraints, substantial daily workloads, and the physically and psychologically demanding nature of the work, particularly when pursued as a lifelong career. Furthermore, nurses often grapple with the personal sacrifices associated with caregiving, the need for unconditional service, and the authenticity of their emotional expressions. Newly qualified nurses encounter specific challenges in managing these expectations, and the pressure to maintain high standards can adversely affect their well-being when they feel they fall short of the ideal. Morrison (1992) highlights that individuals in caregiving roles must navigate emotional engagement, stress, work limitations, and uncertainty regarding their roles. This underscores the necessity of establishing mechanisms that facilitate discussions about these challenges with colleagues and supervisors. Support from peers and groups is vital and frequently serves as the primary source of motivation and encouragement, especially in the face of extreme psychological stress, such as the loss of a young patient. Additionally, nurses often experience pressure to adapt to changes in job roles, departments, and responsibilities. In many private and public healthcare settings, nurses are expected to be reassigned based on staffing needs and shortages.

Typically, nurses do not form a strong bond or attachment to their employers; instead, their professional identity is more closely tied to their area of expertise and the immediate team, as well as the broader professional community represented by nursing associations [6,7]. Addressing psychological stress is a significant concern for nurses, who frequently feel insufficiently supported in their work environment. Consequently, their professional identity can become precarious, often due to burnout or compassion fatigue, which are prevalent issues in caregiving professions. Despite the mounting pressures, the nursing profession continues to suffer from low status both within the medical community and society at large. The ongoing conflict faced by nurses—between their substantial responsibilities and the inadequate recognition of their contributions remains a critical factor that adversely impacts their self-esteem and professional identity [5].

Nurses’ Professional Values

The Code of Ethics for Nurses comprises the principles, values, and regulations that dictate the interactions between nurses, patients, and fellow healthcare professionals within the nursing field. All certified and registered nurses in the United States are anticipated to conduct their nursing practice in accordance with this shared ethical framework [8]. In 2004, the European Federation of Nursing Regulators was established with the aim of promoting shared ethical and moral standards throughout Europe, thereby enhancing the protection of citizens and fostering professional growth. The federation's primary goal is to safeguard European citizens by ensuring that nursing practice competencies meet high standards, facilitating the safe mobility of nurses across the continent. It seeks to establish common professional standards that lead to excellent healthcare outcomes, as well as to develop and uphold professional competencies and codes of conduct grounded in shared principles to better protect the public. European citizens are entitled to expect high-quality care from nurses, in alignment with the established Code.

Patients have the right to anticipate that nurses will deliver care of superior quality, consistent with their respective national codes of ethics and conduct, as well as all applicable legislation [9]. The Code of Ethics and Conduct for European Nursing was created by the European Federation of Nursing Regulators and includes the common values for liberal professionals in Europe. This code includes the eight common values confidentiality, continuing professional development, independence and impartiality, honesty and integrity, supervision of support staff, compliance with codes of ethics and practice, professional indemnity insurance, conflict with ethical or religious beliefs [10]. Furthermore, the code for Europe includes, in addition to the common values of the liberal professions that have been developed, the directives of the European Commission and the European Parliament [11,12], human rights legislation [13], legislation on citizens' rights across Europe [14] and elements from codes of other important global nursing organizations [15]. The basic principles of the nursing code of ethics and conduct are [10]:

1. Quality and excellence: Patients can expect that nurse regulators have systems in place to define and monitor the content, standards and quality of the education and practice required to become and continue to work as a nurse.

2. Continuing professional development: Patients have the right to expect that nurses will maintain their competence throughout their working lives. This statement implies professional accreditation of excellence through lifelong learning that will accompany nurses in a dynamic and changing society. The right to safe nursing services must be ensured by a professional who applies the principles of evidence-based nursing practice.

3. Human rights: Patients have the right to human dignity, which is the basis of human rights. Human rights are of the highest importance in this Code and all relevant human rights legislation applies, regardless of nationality or country’s law. Patients have the right to be protected by healthcare providers and never be subjected to torture, cruelty or other inhuman or degrading treatment.

4. Fair and equitable access to quality healthcare: Patients have the right to fair and equitable access to quality healthcare and treatment by nurses, according to their needs. The responsibility for moving towards fairer and equitable access in order to benefit from the right to health must include all social actors in the health sector and their institutions.

5. Compliance with the Code of Ethics and Professional Conduct for European Nursing: European citizens have the right to expect high-quality care from nurses, in accordance with the Code. Patients have the right to expect that nurses will provide high-quality care that is consistent with their national codes of ethics and conduct and all relevant legislation

6. Honesty and integrity: Patients have the right to expect that nurses will be honest, truthful and trustworthy and that they will assist them with integrity. Honesty and integrity imply consistent decisions that are related to the values that professionals declare and practice. The tendency for congruence in behaviors and choices should characterize professional quality. An honest professional is someone whom patients can trust and be sure that this trust will not be betrayed.

7. Relationships with others: Patients have the right to demand that nurses fulfill their duty and uphold ethical and professional values. Nurses should build their relationship with patients, colleagues and other workers on the basis of trust, solidarity, cooperation, integration and mutual respect.

8. Information: Patients have the right to demand that nurses communicate with them and provide information and suggestions in an appropriate, clear, easy and understandable way. The level of communication should be simple and easily understood by patients, so that nurses can demonstrate the support and advocacy needed.

9. Informed consent: Patients have the right to self-determination and to freely communicate their wishes as an expression of their personal autonomy. They have the right to decide whether or not to accept nursing care (informed consent) or to refuse to receive information, suggestions or assistance. Nurses must respect these decisions.

10. Confidentiality: Patients have the right to expect that any information they disclose is confidential between themselves and their nurses. The protection and non-disclosure to others of information acquired in the course of professional activity is of paramount importance and is noted in all national codes of ethics and conduct consulted. This right applies to all patients, even very young people and adults who are not able to make their own decisions. It persists even after a person’s death.

11. Conflict with ethical and moral beliefs: In the event of a conflict caused by deeply held ethical or moral beliefs, during their work, nurses are called upon to find solutions through dialogue with the relevant parties: the patient, the employer, the regulatory board and their professional organization. If nurses are unable to find a solution for stated reasons or intend to activate conscientious objection, they must consult and respect the legislation in force in the country where they work. In an emergency situation or if there is an immediate risk to the patient's life, nurses must provide the necessary assistance and set aside any conflict with their own ethical or moral beliefs.

12. Assignment and supervision of personnel: Patients have the right to demand that anyone providing health services is adequately trained and has the ability to provide such assistance. To ensure patient safety, nurses must manage support staff and ensure that they are adequately trained.

13. Professional indemnity insurance: Patients have the right to demand that the nurse caring for them is adequately insured.

Nurses cultivate their professional values through diverse psychological and educational experiences. Rest's (1984) moral development theory serves as a foundation for exploring how nurses acquire these values. He proposed a framework of internal processes that are integral to an individual's moral growth. According to Rest, these interactive internal mechanisms are essential for ethical behavior and play a crucial role in shaping professional values as outlined in ethical guidelines. This theory is particularly relevant to nursing practice, which necessitates translating internalized professional values into actionable behavior within clinical environments [16,17]. Given the critical significance of ethical conduct in nursing, it is essential to evaluate how well nurses adhere to the standards set forth in their professional code of ethics. Discrepancies concerning professional values can lead to adverse outcomes, including moral distress, threats to patient safety, diminished quality of care, challenges in career longevity, and potential legal issues. As the healthcare landscape grows more intricate and technologically advanced, nurses require enhanced support to uphold the profession's ethical standards, maintain a commitment to exceptional patient care, and participate effectively in interdisciplinary ethical discussions [17,18].

References

1. Leon MW (1995) Krankenpflegeausbildung in Europa, Kohlhammer, Stuttgart/Berlin/Ko¨ln.
2. Walsh K, Gordon JR (2008) Creating an individual work identity. Human resource management review 18(1): 46-61.
3. Ibarra H (2003) Working Identity: Unconventional Strategies for Reinventing Your Career, Harvard Business School Press, Boston, MA.
4. Chiarella M (2002) Legal and Professional Status of Nursing, Churchill Livingstone, Edinburgh.
5. Brown A, Kirpal S (2003) Old nurses with new qualifications are best: managers’ attitudes towards the recruitment of health-care professionals in Estonia, France, Germany, Spain and the United Kingdom, in Warhurst, C., Keep, E. and Grugulis, I. (Eds), The Skills that Matter, Palgrave, New York, NY.
6. Kirpal S (2004) Work identities of nurses: Between caring and efficiency demands. Career Development International (3): 274-304.
7. Morrison P (1992) Professional Caring in Practice: A Psychological Analysis, Avebury, Aldershot.
8. American Nurses Association (2015) Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.org.
9. Sasso L, Stievano A, González Jurado M, Rocco G (2008) Code of ethics and conduct for European nursing. Nursing ethics 15(6): 821-836.
10. European Council of the Liberal Professions (CEPLIS) (2007) Common values for liberal professions in Europe.
11. Εuropean Parliament (2005) Directive 2005/36/EC of the European Parliament and of the Council of Europe. On the recognition of professional qualifications. Official Journal of the European Union. L 255/22.
12. Εuropean Parliament (2006) Directive 2006/123/EC of the European Parliament and of the Council of Europe. On serv-ices in the internal market. Official Journal of the European Union. L 376/36.
13. United Nations (1948) Universal declaration of human rights. General Assembly of the United Nations.
14. Council of Europe (1997) Oviedo Declaration: convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine: Convention on Human Rights and Biomedicine.
15. International Council of Nurses (ICN) (2005) Code of ethics for nurses. Geneva.
16. Rest JR (1984) The major components of morality. In W. M. Kurtines & J. L. Gewirtz (Eds.), Morality, moral behavior, and moral development. New York, NY: John Wiley & Sons: 24-38.
17. Monroe HA (2019) Nurses' professional values: Influences of experience and ethics education. Journal of clinical nursing 28(9-10): 2009-2019.
18. Ulrich CM, Taylor C, Soeken K, O’Donnell P, Farrar A, et al. (2010) Everyday ethics: Ethical issues and stress in nursing practice. Journal of Advanced Nursing 66(11): 2510-2519.