nursing professional issues essays

Top Nursing Argumentative Essay Topics: Engage in Thought-Provoking Debates

This article was written in collaboration with Christine T. and ChatGPT, our little helper developed by OpenAI.

Nursing is a diverse and evolving field, constantly presenting new challenges and debates. As a nursing student or professional, engaging in these discussions allows you to develop critical thinking and writing skills while expanding your field knowledge. This blog post will explore various nursing argumentative essay topics to help you find inspiration for your next paper.

Patient Care and Ethics

• The ethics of administering experimental treatments to terminally ill patients
• Balancing patient autonomy and nurse responsibility in care decisions
• Addressing cultural and religious beliefs in end-of-life care
• The role of informed consent in patient care and treatment decisions
• Ethical considerations in the allocation of scarce medical resources
• The ethics of withholding information from patients for their benefit
• Patient privacy and confidentiality in the age of electronic health records
• Comparing faith practices in healthcare: Sikhism, Judaism, Bahaism, and Christianity
• The ethics of using restraints in patient care
• The ethical implications of non-compliance with prescribed treatments
• The role of nursing in advocating for patients’ rights
• Ethical considerations in caring for patients with mental health disorders
• The ethics of mandatory vaccinations for healthcare workers
• Addressing moral distress among nurses in patient care situations
• The ethics of caring for patients who refuse life-saving treatments
• The role of advance directives in ethical decision-making for patient care
• Ethical considerations in the care of patients with substance use disorders
• The ethics of healthcare rationing in times of crisis
• The ethical implications of assisted reproductive technologies
• Addressing ethical dilemmas in neonatal and pediatric nursing
• The ethics of pain management in nursing practice
• Pediatric oncology: working towards better treatment through evidence-based research
• Ethical considerations in the care of patients with dementia and cognitive decline
• The ethics of genetic testing and personalized medicine in patient care
• The ethical implications of clinical trials and research involving human subjects
• The role of nursing in addressing ethical issues related to organ transplantation
• Ethical considerations in the care of prisoners and detainees
• The ethics of involuntary treatment and psychiatric care
• Euthanasia: an analysis of utilitarian approach
• Addressing ethical challenges in the care of patients with disabilities
• The ethical implications of medical tourism and cross-border healthcare
• The role of nursing in addressing ethical issues related to global health
• Ethical considerations in the care of military veterans and their families
• The ethics of surrogate decision-making in patient care
• Addressing ethical challenges in the care of patients with chronic and terminal illnesses
• The role of nursing in promoting patient advocacy and self-determination
• Ethical considerations in the care of patients with rare diseases and conditions
• The ethics of care rationing in the context of an aging population
• The role of nursing in addressing ethical issues related to access to healthcare
• Ethical considerations in the care of patients during public health emergencies
• The ethics of triage and prioritization of care in emergencies
• The role of nursing in promoting environmental sustainability and addressing ethical issues related to climate change
• Ethical challenges in the care of patients at the end of life

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Technological Advancements in Nursing

• The impact of electronic health records on nursing practice and patient care
• The role of telemedicine in expanding access to healthcare services
• How wearables and remote monitoring devices are changing nursing care
• The integration of artificial intelligence in nursing practice and decision-making
• The use of virtual reality in nursing education and training
• Ethical considerations in the use of advanced technologies in nursing practice
• The role of robotics in patient care and nursing support
• The impact of mobile health apps on nursing practice and patient engagement
• The use of big data and analytics in improving patient outcomes and nursing practice
• The role of 3D printing in medical device innovation and patient care
• The integration of telehealth in the management of chronic conditions
• The use of social media and online platforms for professional development and networking in nursing
• Usability, integration, and interoperability of healthcare technology
• The impact of advanced diagnostics and imaging technologies on nursing practice
• The role of blockchain technology in improving healthcare data security and management
• The use of gamification in nursing education and patient engagement
• The impact of technology on nursing workflow and time management
• The role of virtual assistants and chatbots in patient care and nursing support
• Clinical laboratory IT security: challenges, implications, and solutions
• The use of augmented reality in nursing education and practice
• The integration of telepsychiatry and mental health services in nursing care
• The impact of technology on nurse-patient communication and relationship-building
• The role of electronic prescribing and medication management systems in reducing medication errors
• The use of telemonitoring and remote care in the management of high-risk pregnancies
• The impact of technology on infection control and prevention in healthcare settings
• The role of smart home technologies in supporting aging-in-place and home-based care
• The use of technology in promoting self-care and patient empowerment
• Safeguarding patient information: nursing informatics best practices for privacy and security in healthcare
• The integration of genomics and personalized medicine in nursing practice
• The role of technology in addressing healthcare disparities and promoting health equity
• The impact of technology on nursing workforce planning and resource allocation
• The use of predictive analytics in identifying high-risk patients and improving care coordination
• The role of technology in promoting interprofessional collaboration and communication in healthcare
• The impact of technology on nursing education and the development of future nursing competencies
• The role of technology in supporting disaster response and emergency preparedness in nursing
• The use of technology in promoting patient safety and reducing medical errors
• The impact of technology on nursing leadership and management
• The role of technology in addressing the social determinants of health and promoting community health
• The integration of technology in palliative and end-of-life care
• The use of technology in enhancing patient engagement and satisfaction in nursing care
• The role of technology in promoting evidence-based practice and research in nursing
• The impact of technology on nursing ethics and professional boundaries
• The role of technology in addressing the global nursing shortage and promoting workforce sustainability

Nursing Education and Professional Development

• The role of simulation-based learning in nursing education
• The impact of online learning on nursing education outcomes
• Integrating cultural competence in nursing curricula
• Strategies for promoting lifelong learning in nursing practice
• The role of mentorship in nursing professional development
• Addressing the transition from student nurse to professional nurse
• The impact of interprofessional education on nursing practice and patient outcomes
• The role of nursing preceptorship in clinical education
• Strategies for reducing nursing student attrition and promoting retention
• The integration of evidence-based practice in nursing education
• The role of reflective practice in nursing professional development
• Addressing the nursing faculty shortage: Challenges and solutions
• The impact of standardized testing on nursing education and practice
• The role of nursing leadership development in healthcare transformation
• Strategies for enhancing critical thinking skills in nursing education
• Global health learning in nursing and health care disparities
• The impact of clinical experience on nursing students’ confidence and competence
• The role of continuing education in maintaining nursing competency and licensure
• Addressing the needs of diverse learners in nursing education
• The impact of technology on nursing education and the development of digital literacy skills
• Digital healthcare and organizational learning: enhancing patient care through technology and knowledge management
• The role of nursing education in promoting health literacy and patient education
• Strategies for promoting resilience and self-care in nursing education
• The impact of global health experiences on nursing students’ cultural competence and professional development
• The role of nurse educators in shaping the future of nursing practice
• Addressing the challenges of teaching nursing ethics and professional values
• The impact of accreditation standards on nursing education and program quality
• The role of professional nursing organizations in supporting continuing education and development
• Strategies for fostering a culture of learning and professional growth in nursing practice
• The impact of nursing education on patient outcomes and quality of care
• The role of nursing education in addressing healthcare disparities and promoting health equity
• The integral role of nurses in healthcare systems: the importance of education and experience
• Addressing the challenges of teaching and assessing clinical judgment in nursing education
• The impact of nursing education on workforce development and nursing shortages
• The role of nursing education in promoting environmental sustainability and planetary health
• Strategies for promoting effective communication and teamwork in nursing education
• The impact of nursing education on patient safety and error prevention
• The role of nursing education in promoting innovation and entrepreneurship in healthcare
• Addressing the needs of adult learners and nontraditional students in nursing education
• The impact of nursing education on interprofessional collaboration and healthcare team dynamics
• The role of nursing education in promoting ethical decision-making and moral courage in practice
• Strategies for enhancing nursing students’ clinical reasoning and decision-making skills
• The impact of nursing education on the development of professional identity and role socialization

Healthcare Policies and Nursing Practice

• The role of nurses in shaping healthcare policy and advocating for reform
• The impact of the Affordable Care Act on nursing practice and patient care
• Addressing the nursing shortage: policy initiatives and workforce strategies
• Understanding the impact of the American Healthcare System Regulatory Acts
• The role of nursing scope of practice regulations on healthcare delivery and outcomes
• The impact of healthcare reimbursement policies on nursing practice and patient care
• The role of nursing in addressing the opioid crisis: policy and practice implications
• The impact of public health policies on nursing practice and community health
• The role of nursing in promoting healthcare access and reducing disparities
• The impact of healthcare quality and safety regulations on nursing practice
• The role of nursing in implementing evidence-based practice guidelines and policies
• The impact of health information technology policies on nursing practice and patient care
• The role of nursing in addressing social determinants of health through policy and practice interventions
• The impact of nurse staffing regulations on patient outcomes and workforce planning
• The role of nursing in promoting health literacy and patient-centered care through policy and practice initiatives
• Healthcare management: career paths and requirements
• The impact of healthcare privacy and confidentiality policies on nursing practice and patient trust
• The role of nursing in promoting environmental sustainability and climate change policies in healthcare
• The impact of healthcare workforce diversity policies on nursing practice and cultural competence
• The role of nursing in promoting global health and addressing international healthcare challenges
• The impact of mental health policies on nursing practice and the care of patients with mental health disorders
• The role of nursing in promoting value-based care and payment models in healthcare
• The impact of healthcare cost containment policies on nursing practice and resource allocation
• The role of nursing in promoting patient safety and quality improvement through policy and practice initiatives
• The impact of healthcare reform on nursing education and workforce development
• Understanding the US health care reform: necessity, challenges, and implementation
• The role of nursing in promoting health equity and addressing healthcare disparities through policy and practice interventions
• The impact of healthcare policies on nursing leadership and management roles
• The role of nursing in promoting interprofessional collaboration and teamwork through policy and practice initiatives
• The impact of healthcare policies on the integration of technology in nursing practice and patient care
• The role of nursing in promoting ethical decision-making and moral courage through policy and practice initiatives
• The impact of healthcare policies on nursing practice in rural and underserved communities
• The role of nursing in promoting innovation and entrepreneurship in healthcare through policy and practice initiatives
• Combating health care-associated infections: a community-based approach
• The impact of healthcare policies on advanced practice nursing roles and scope of practice
• The role of nursing in promoting palliative and end-of-life care through policy and practice initiatives
• The impact of healthcare policies on infection control and prevention in nursing practice and patient care
• The role of nursing in addressing the challenges of an aging population through policy and practice initiatives
• The impact of healthcare policies on nursing practice in the care of patients with chronic and complex conditions
• The role of nursing in promoting patient advocacy and self-determination through policy and practice initiatives
• The impact of healthcare policies on nursing practice in disaster response and emergency preparedness
• The role of nursing in promoting evidence-based practice and research through policy and practice initiatives
• The impact of healthcare policies on nursing practice in the care of vulnerable and high-risk populations
• The role of nursing in addressing the global nursing shortage and promoting workforce sustainability through policy and practice initiatives

Cultural Competence and Health Equity

• The role of cultural competence in reducing healthcare disparities
• Integrating cultural competence into nursing education and practice
• Addressing implicit bias in nursing practice and patient care
• The impact of cultural competence on patient satisfaction and outcomes
• The role of nursing in promoting health literacy among diverse populations
• Strategies for effective communication with patients from diverse backgrounds
• Mental health and gender inequality
• The impact of cultural competence on nurse-patient relationship-building and trust
• The role of nursing in addressing social determinants of health and promoting health equity
• Addressing the challenges of providing culturally competent care in rural and remote settings
• The impact of cultural competence on interprofessional collaboration and teamwork
• Bridging the gap: tackling maternal and child health disparities between developed and underdeveloped countries
• The role of nursing in promoting cultural competence in healthcare organizations
• Addressing health disparities among LGBTQ+ populations through culturally competent nursing care
• The impact of cultural competence on the prevention and management of chronic diseases
• The role of nursing in promoting culturally competent mental health care
• Addressing health disparities among immigrant and refugee populations through culturally competent nursing care
• The impact of cultural competence on patient safety and error prevention
• The role of nursing in promoting cultural competence in palliative and end-of-life care
• Addressing health disparities among indigenous populations through culturally competent nursing care
• The impact of cultural competence on the care of patients with disabilities
• The role of nursing in promoting culturally competent care for patients with substance use disorders
• Addressing health disparities among racial and ethnic minority populations through culturally competent nursing care
• The impact of cultural competence on the care of patients with rare diseases and conditions
• The role of nursing in promoting culturally competent care in global health settings
• Addressing the challenges of providing culturally competent care in disaster response and emergency preparedness
• The impact of cultural competence on nursing leadership and management
• The role of nursing in promoting culturally competent care in the context of an aging population
• Addressing health disparities among low-income populations through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with complex and chronic conditions
• The role of nursing in promoting culturally competent care for military veterans and their families
• Addressing health disparities among women and girls through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with infectious diseases
• The role of nursing in promoting culturally competent care for incarcerated individuals and detainees
• Addressing health disparities among individuals with limited English proficiency through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients at the end of life
• The role of nursing in promoting culturally competent care in the context of climate change and environmental health
• Addressing health disparities among individuals experiencing homelessness through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of patients with traumatic experiences
• The role of nursing in promoting culturally competent care in the context of medical tourism and cross-border healthcare
• Addressing health disparities among individuals with low health literacy through culturally competent nursing care
• The impact of cultural competence on nursing practice in the care of vulnerable and high-risk populations

Mental Health and Burnout in Nursing

• The prevalence of burnout among nursing professionals
• Strategies for preventing and addressing nurse burnout
• The impact of nurse burnout on patient care and outcomes
• The role of nursing leadership in addressing mental health and burnout
• Promoting self-care and resilience among nursing professionals
• The impact of nurse burnout on job satisfaction and retention
• The role of nursing education in addressing mental health and burnout
• Strategies for fostering a healthy work-life balance in nursing
• The impact of nurse burnout on interprofessional collaboration and teamwork
• The role of peer support and mentorship in addressing mental health and burnout
• The impact of nurse burnout on nursing errors and patient safety
• The role of workplace wellness programs in addressing mental health and burnout
• Strategies for managing stress and anxiety in nursing practice
• The impact of nurse burnout on professional development and career progression
• The role of professional nursing organizations in addressing mental health and burnout
• The impact of nurse burnout on healthcare costs and resource allocation
• The role of nursing research in understanding and addressing mental health and burnout
• Strategies for promoting emotional intelligence and self-awareness in nursing practice
• The impact of nurse burnout on the nursing workforce and workforce planning
• The role of nursing in promoting mental health and well-being among patients and families
• The impact of nurse burnout on ethical decision-making and moral distress
• The role of nursing in addressing mental health disparities and stigma
• Strategies for promoting a culture of empathy and compassion in nursing practice
• The impact of nurse burnout on nurse-patient communication and relationship-building
• The role of nursing in addressing mental health needs in rural and underserved communities
• The impact of nurse burnout on nursing advocacy and policy engagement
• The role of nursing in promoting mental health and well-being in global health settings
• Strategies for addressing mental health and burnout among nursing students and new graduates
• The impact of nurse burnout on nursing education and faculty well-being
• The role of nursing in addressing mental health needs in disaster response and emergency preparedness
• The impact of nurse burnout on nursing practice in the care of patients with mental health disorders
• The role of nursing in promoting mental health and well-being in the context of an aging population
• Strategies for addressing mental health and burnout among advanced practice nurses
• The impact of nurse burnout on nursing practice in the care of patients with chronic and complex conditions
• The role of nursing in promoting mental health and well-being among military veterans and their families
• The impact of nurse burnout on nursing practice in the care of patients with substance use disorders
• The role of nursing in addressing mental health needs in the context of climate change and environmental health
• Strategies for addressing mental health and burnout among nurses working with vulnerable and high-risk populations
• The impact of nurse burnout on nursing practice in the care of patients at the end of life
• The role of nursing in promoting mental health and well-being in the context of healthcare innovation and change

Now that you have a list of thought-provoking nursing argumentative essay topics, you can engage in meaningful debates and expand your knowledge in the field. Consider various perspectives, use credible sources to support your arguments, and practice clear, concise writing. Happy writing!

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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.

What’s Really Behind the Nursing Shortage? 1,500 Nurses Share Their Stories

• Survey Results
• What Is the Nursing Shortage?
• Reasons Nurses Quit
• Hope For the Future
• What Nurses Need Now
• How to Take Action

Winner of the Gold Award for the Digital Health Awards, Best Media/Publications Article, Spring 2022

Update 10/10/2022

The findings of  Nurse.org's 2021 State of Nursing Survey revealed some harsh truths about the profession but also spoke to the strength, perseverance, and passion that nurses have for their work. Nurse.org has relaunched the State of Nursing survey in 2022 with the aim to capture a complete picture of the true state of the profession - from how nurses feel about work, how nurses are being treated, how nurses feel about the future of nursing, nurse's mental wellbeing and what nurses think needs to change within the profession. Take the survey now (it takes less than 10 minutes.)

>> Take Nurse.org's NEW 2022 "State of Nursing Survey" and let your voice be heard about issues in nursing that matter most. 

January 26, 2022

If the past two years have taught the world anything, it's that nurses are NOT okay. The truth is that despite the 7 pm cheers, the commercials thanking nurses for their dedication and selflessness, and the free food from major retailers – the overwhelming majority of nurses are burnt out, underpaid, overworked, and underappreciated.  

With millions of nurses worldwide, Nurse.org wanted to truly understand the current state of nursing and give nurses a voice to share their thoughts, feelings, and apprehensions about the nursing profession. We surveyed nearly 1,500 nurses to find out how they felt about the past year and get to the real reasons behind the nursing shortage . The responses were heartbreaking, but not without hope.  

What We Found: Nurses Are Struggling

Nurses are struggling. Regardless of practice specialty, age, or state of practice – the answers were all the same. Nurses, NPs, and APRNs are all struggling and need help.  

Only 12% of the nurses surveyed are happy where they are and interestingly, 36% would like to stay in their current positions but changes would need to be made for that to happen. Nurses report wanting safe staffing, safer patient ratio assignments, and increased pay in order to stay in their current roles.  

Nurses didn’t hold back when discussing their feelings regarding the current state of nursing:  

• 87% feel burnt out 
• 84% are frustrated with administrators 
• 84% feel they are underpaid 
• 83% feel their mental health has suffered 
• 77% feel unsupported at work 
• 61% feel unappreciated 
• 60% have felt uncomfortable having to work outside of their comfort zone in the past year 
• 58% of nurses have felt frustrated with their patients 
• 58% of nurses have felt unsafe at work in the past year 

The numbers don’t lie. It’s astounding that a profession continually recognized for its compassion, strength, and resilience is suffering . And the suffering is universal.  

One nurse responded with the following, “I have been an RN for 34 years and in my specialty of nursing for 31 years and I am burned out.” 

What Is the Nursing Shortage and Why is it Happening?

You’ve likely heard about the nursing shortage, but what does that mean and why is it happening? 

According to the U.S. Bureau of Labor Statistics (BLS) , the employment of registered nurses is projected to grow 9% from 2020 to 2030.  Approximately 194,500 openings for registered nurses are projected each year, on average, over the decade. However, this number was projected prior to the pandemic, and before the mass exodus of bedside clinical nurses. As a result, it’s likely substantially lower than what the real demand for nurses will look like.

The American Nurses Association (ANA) reports that the increased need for nurses spans beyond the current pandemic. In fact, they sent a letter to the U.S. Department of Health and Human Services (HHS) on September 1, 2021, urging the country to declare the current and unsustainable nurse staffing shortage to be a national crisis. 

The ANA attributes the needs for thousands of nurses to the following:  

• The Affordable Care Act made access to health care services possible for more people
• Increased focus “primary care, prevention, wellness, and chronic disease management” 
• Aging baby-boomer population
• Growing interest in community-based care

Why Are Nurses Really Leaving The Bedside? 

However, those stats don’t address some of the systemic issues nurses face every day, particularly in the midst of a pandemic. That’s why we asked nurses why they are really leaving the bedside.

What we heard is that, overwhelmingly, the number one reason nurses want to leave the bedside is because of unsafe staffing ratios. This leads to a never-ending cycle of shortages: nurses face unsafe staffing ratios so they decide to leave the bedside, this results in even fewer nurses available to care for patients, so the downward cycle continues.

Essentially, nurses are dealing with an increased workload with fewer resources. Typically, pre-covid ICU nurses would experience a 1:1 or 2:1 patient-to-nurse ratio. Now ICU nurses throughout the country are experiencing a 3:1 or 4:1 patient-to-nurse ratio which exacerbates staff burnout and unsafe nursing practices.  

One nurse reported, “With increased patient census, staffing ratios are very unsafe especially with high acuity patients. Having 4+ critically ill patients not only puts licenses at risk but the patients do not benefit at all. We’re just running around doing tasks, not providing adequate care.”

Unsafe Staffing Ratios Are Just Part of the Problem

While a big piece of the puzzle, unsafe staffing issues are, unfortunately, one part of a long list of issues plaguing nurses today. 

 Nurses are leaving the bedside because of issues like: 

• Inadequate staffing ratios 
• Not getting equal pay for equal experience 
• Not receiving hazard pay during a pandemic 
• Not having adequate back up 
• An inability to take breaks, sick days, or even turn down extra shifts 

To learn more about the nursing shortage and learn ways you can get involved, check out the full report here . 

Despite All This, Nurses Still Have Hope

70% of nurses still think that nursing is a great career and 64% still think that new nurses should join the profession. 

“If you’re a student considering becoming a nurse, please know that you are not walking into a doomed profession. You will never meet anyone who is more determined, more resourceful, or more ready to jump in and lend a helping hand than a nurse." 

--– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org

If you’re a nurse, you know that nursing isn’t just a profession, it’s a calling. It’s devastating to see that so many nurses are suffering in their quest to heal and give care, but it’s heartening to know they are not without hope. 

What Nurses Need Now 

If you’re a nurse, know that your job is simply to put yourself first. If we want to solve the nursing shortage (and we do!), it can't happen without nurses recognizing that they are NOT the problem. 

"The problem is not with nurses or nursing; the problem is that nurses have been so busy taking care of others that no one has taken care of them. And we’re here to change that--and by entering the nursing profession, you will be part of the solution too”

 – Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

The truth is nurses need a lot more to be incentivized to stay practicing clinically at the bedside. Nurses reported needing:  

• Higher pay 
• Safe nurse-to-patient ratios 
• Hazard pay 
• REAL mental health resources 
• Adequate staff support 
• Support programs for new nurses

4 Ways to Support Nurses and Take Action

While we may not be able to make this change at an individual level, collectively, we can amplify the voice of nurses and shed some light on the issues that they are facing every day. Together, we have the power to create meaningful, lasting change for current and future nurses.  Here's how to get involved: 

1. Sign the Pledge

Sign the pledge seen below and encourage your friends & colleagues to do the same. While you’re at it, print it out and post it in your break room. 

2. Spread the Word 

Change can’t happen unless we get the word out about what’s really going on. Share what you’ve heard and what you’ve experienced, and encourage others to do the same. 

3. Contact Your Elected Officials 

It’s time for elected officials to stand up for nurses. Write them a letter. Call their office. Demand change for nurses. Click here to get the contact information for your local and state Officials. 

4. Download and Share the Report

Get even more in-depth insights into what’s going on with the state of nursing and the issues that nurses face today, click here to download the full State of Nursing report or read about the best and worst specialties for nurses during COVID . 

“If you are a current nurse considering leaving the profession, be assured that you are not alone in your struggles. If all you’ve had the energy for is keeping your head down and getting through your shifts, sleeping, and getting up to do it all over again, know that you are doing enough. It’s not your responsibility to solve the nursing shortage.” 

– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

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Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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What is nursing professionalism? a concept analysis

1 Nursing College of Shanxi Medical University, Taiyuan, 030001 Shanxi People’s Republic of China

2 Linfen Hospital Affiliated to Shanxi Medical University (Linfen People’s Hospital), Linfen, 041000 Shanxi People’s Republic of China

3 The Third Peoples Hospital of Taiyuan, Taiyuan, 030001 Shanxi People’s Republic of China

Yangjie Chen

4 The First Hospital of Shanxi Medical University, Taiyuan, 030001 Shanxi People’s Republic of China

Qiaohong Wang

Associated data.

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

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.

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 ​ (Table2) 2 ) to define a cluster of antecedents, attributes and consequences (Figs. ​ (Figs.1 1 and  2 ) frequently associated with the concept [ 20 ].

Flowchart of the study selection process of the concept analysis

The connotations of nursing professionalism

Antecedents, attributes, and consequences of nursing professionalism

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 ​ and2 2 show some typical literatures used in this study.

The attributes of the nursing professionalism

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 .

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.

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.

Author’s contributions

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.

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

Availability of data and materials

Declarations.

Our study was approved by the ethical committee of The First Hospital of Shanxi Medical University,Shanxi, China,(approval no. 2020K061).

Not applicable.

There is no conflict of interest in this study.

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Issues and Trends in Professional Nursing Research Paper

Course objectives, the influence of the material on practice, the role of nursing trends and problems awareness.

The course program was extensive, and students were challenged to focus on several areas simultaneously while thoroughly following the course instructions. To achieve my goals, I first studied the necessary and additional materials, reinforcing my knowledge by observing the necessary video materials. This step enabled the critical information analysis, followed by the synthesis phase of the data obtained and the assignments’ completion. Consistent work organization facilitated the fulfillment of tasks on time from different perspectives. Nevertheless, comprehending the significance of the subject, it was obvious that a thorough study of the topic is necessary for the course and further practice. Completing all assignments eventually led to the development of the ability to explain the reasons for certain trends, awareness of healthcare issues, and the nurse’s role in dealing with legal issues (American Nurses Association, 2021). Merely as notably, the end of the course provided an awareness of the specifics of making changes in nursing practice based on the knowledge gained and identifying strategies to socialize in the profession.

Undoubtedly, the course material had a tremendous impact on professional practice. After reading the information presented in the course, it became clear what transformations had taken place in the medical field and where to focus on. Moreover, the detailed analysis of the problems of modern nursing made it possible to identify the roots of these problems and, consequently, solve them more quickly in practice. It has become apparent that technology now has an important role in patient care, leading to awareness of how modern strategies can help patients more quickly and effectively. Humanization of education aims to create conditions for the student’s self-determination in modern culture, which reveals the creative potential of personality, shows value orientations, and forms moral qualities with their subsequent actualization in professional activity (American Nurses Association, 2021). It was the essence of the material which donated to the desire for continuous improvement. Moreover, I am now aware of the social and historical experience of nursing, and the knowledge gained has become a motivator for greater initiative in both practice and social life.

While nursing trends and issues concern everyone, they most affect professional practice. For example, examining tendencies assembles wisdom about contemporary modes of precluding, diagnosing, and managing conditions and unique medicines and procedures. At the same time, medical invention is about developing the proficiency base and converting currently utilized technology and business models in practice to satisfy more practical changing conditions and anticipations (National Academy of Sciences, 2011). Moreover, the course included history, which, as part of the general theoretical block of fundamental disciplines, acts as a propaedeutic discipline, uniting the curriculum disciplines within the specialty and at different levels of medical education. Analysis of historical features can affect the specificity of understanding individual disciplines in their mastering and, accordingly, more appropriate application of them in practice. The history of medicine has concretized the idea of the peculiarities of nursing care while influencing the level of humanization and professional culture.

Notably, nursing trends are changing the entire philosophy of the profession. For example, digitalization and its features will help provide care more efficiently and satisfy patients’ wishes. The issue of quality improvement is now directly dependent on the resources invested in nurse education and retraining. However, learning and understanding the issues and trends allows one to focus on the proper material already at the training stage and be much more successful in applying new technologies in practice (National Academy of Sciences, 2011). Moreover, the study of problems contributes to understanding areas that need to be focused on in further training and practice. This course is thus an integral part of learning, as it is vital to developing an understanding of the specifics, challenges, and opportunities of nursing. In turn, awareness of these factors allows me to actively implement innovations in practice and maximize patient health while minimizing risks.

American Nurses Association. (2021). Nursing: Scope and standards of practice . IOM Future of Nursing Report ANA CMA Activities 3/3/11 (nursingworld.org)

National Academy of Sciences. (2011). The future of nursing: Leading change, advancing health . Key Messages of the Report – The Future of Nursing – NCBI Bookshelf (nih.gov)

• Chicago (A-D)
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IvyPanda. (2024, March 3). Issues and Trends in Professional Nursing. https://ivypanda.com/essays/issues-and-trends-in-professional-nursing/

"Issues and Trends in Professional Nursing." IvyPanda , 3 Mar. 2024, ivypanda.com/essays/issues-and-trends-in-professional-nursing/.

IvyPanda . (2024) 'Issues and Trends in Professional Nursing'. 3 March.

IvyPanda . 2024. "Issues and Trends in Professional Nursing." March 3, 2024. https://ivypanda.com/essays/issues-and-trends-in-professional-nursing/.

1. IvyPanda . "Issues and Trends in Professional Nursing." March 3, 2024. https://ivypanda.com/essays/issues-and-trends-in-professional-nursing/.

Bibliography

IvyPanda . "Issues and Trends in Professional Nursing." March 3, 2024. https://ivypanda.com/essays/issues-and-trends-in-professional-nursing/.

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• Published: 28 March 2024

Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study

• Rachel Gilbert 1 &
• Daniela Lillekroken   ORCID: orcid.org/0000-0002-7463-8977 1  

BMC Nursing volume  23 , Article number:  216 ( 2024 ) Cite this article

Metrics details

Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto’s theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

The content analysis generated five categories that were labelled similar to Tronto’s five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses’ autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto’s theory contributes to greater reflectiveness around what may constitute ‘good’ end-of-life care.

Conclusions

Tronto’s care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto’s care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what ‘good’ end-of-life care should be.

Peer Review reports

In recent decades, improving end-of-life care has become a global priority [ 1 ]. The proportion of older residents dying in nursing homes is rising across the world [ 2 ], resulting in a significant need to improve the quality of end-of-life care provided to residents. Therefore, throughout the world, nursing homes are becoming increasingly important as end-of-life care facilities [ 3 ]. As the largest professional group in healthcare [ 4 ], nurses primarily engage in direct care activities [ 5 ] and patient communication [ 6 ] positioning them in close proximity to patients. This proximity affords them the opportunity to serve as information brokers and mediators in end-of-life decision-making [ 7 ]. They also develop trusting relationships with residents and their next-of-kin, relationships that may be beneficial for the assessment of residents and their next-of-kin’s needs [ 8 ]. Moreover, nurses have the opportunity to gain a unique perspective that allows them to become aware of if and when a resident is not responding to a treatment [ 9 ].

When caring for residents in their critical end-of-life stage, nurses form a direct and intense bond with the resident’s next-of-kin, hence nurses become central to end-of-life care provision and decision-making in nursing homes [ 10 ]. The degree of residents and their next-of-kin involvement in the decision-making process in practice remains a question [ 11 ]. Results from a study conducted in six European countries [ 12 ], demonstrate that, in long-term care facilities, too many care providers are often involved, resulting in difficulties in reaching a consensus in care. Although nurses believe that their involvement is beneficial to residents and families, there is a need for more empirical evidence of these benefits at the end-of-life stage. However, the question of who should be responsible for making decisions is still difficult to answer [ 13 ]. One study exploring nurse’s involvement in end-of-life decisions revealed that nurses experience ethical problems and uncertainty about the end-of-life care needs of residents [ 14 ]. Another study [ 10 ] reported patients being hesitant to discuss end-of‐life issues with their next-of-kin, resulting in nurses taking over; thus, discussing end-of-life issues became their responsibility. A study conducted in several nursing homes from the UK demonstrated that ethical issues associated with palliative care occurred most frequently during decision-making, causing greater distress among care providers [ 15 ].

Previous research has revealed that there are some conflicts over end-of-life care that consume nurses’ time and attention at the resident’s end-of-life period [ 16 ]. The findings from a meta-synthesis presenting nurses’ perspectives dealing with ethical dilemmas and ethical problems in end-of-life care revealed that nurses are deeply involved with patients as human beings and display an inner responsibility to fight for their best interests and wishes in end-of-life care [ 17 ].

Within the Norwegian context, several studies have explored nurses’ experiences with ethical dilemmas when providing end-of-life care in nursing homes. One study describing nurses’ ethical dilemmas concerning limitation of life-prolonging treatment suggested that there are several disagreements between the next-of-kin’s wishes and what the resident may want or between the wishes of the next-of-kin and what the staff consider to be right [ 18 ]. Another study revealed that nurses provide ‘more of everything’ and ‘are left to dealing with everything on their own’ during the end-of-life care process [ 19 ] (p.13) . Several studies aiming to explore end-of-life decision-making in nursing homes revealed that nurses experience challenges in protecting the patient’s autonomy regarding issues of life-prolonging treatment, hydration, nutrition and hospitalisation [ 20 , 21 , 22 ]. Other studies conducted in the same context have described that nurses perceive ethical problems as a burden and as barriers to decision-making in end-of-life care [ 8 , 23 ].

Nursing, as a practice, is fundamentally grounded in moral values. The nurse-patient relationship, central to nursing care provision, holds ethical importance and significance. It is crucial to recognise that the context within which nurses practice can both shape and be shaped by nursing’s moral values. These values collectively constitute what can be termed the ethical dimension of nursing [ 24 ]. Nursing ethos and practices are rooted in ethical values and principles; therefore, one of the position statements of the International Council of Nurses [ 25 ] refers to nurses’ role in providing care to dying patients and their families as an inherent part of the International Classification for Nursing Practice [ 26 ] (e.g., dignity, autonomy, privacy and dignified dying). Furthermore, ethical competence is recognised as an essential element of nursing practice [ 27 ], and it should be considered from the following viewpoints: ethical decision-making, ethical sensitivity, ethical knowledge and ethical reflection.

The term ‘end-of-life care’ is often used interchangeably with various terms such as terminal care, hospice care, or palliative care. End-of life care is defined as care ‘to assist persons who are facing imminent or distant death to have the best quality of life possible till the end of their life regardless of their medical diagnosis, health conditions, or ages’ [ 28 ] (p.613) . From this perspective, professional autonomy is an important feature of nurses’ professionalism [ 29 ]. Professional autonomy can be defined based on two elements: independence in decision-making and the ability to use competence, which is underpinned by three themes: shared leadership, professional skills, inter- and intraprofessional collaboration and a healthy work environment [ 30 ].

As presented earlier, research studies have reported that nurses experience a range of difficulties or shortcomings during the decision-making process; therefore, autonomous practice is essential for safe and quality care [ 31 ]. Moreover, autonomous practice is particularly important for the moral dimension in end-of-life care, where nurses may need to assume more responsibility in the sense of defining and giving support to matters that are at risk of not respecting ethical principles or fulfilling their ethical, legal and professional duties towards the residents they care for.

To the best of the researchers’ knowledge, little is known about nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents; therefore, the aim of this study is to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Theoretical framework

Joan Tronto is an American political philosopher and one of the most influential care ethicists. Her theory of the ethics of care [ 32 , 33 , 34 ] has been chosen as the present study’s theoretical framework. The ethics of care is a feminist-based ethical theory, focusing on caring as a moral attitude and a sensitive and supportive response of the nurse to the situation and circumstances of a vulnerable human being who is in need of help [ 33 , 34 , 35 ]. In this sense, nurses’ caring behaviour has the character of a means—helping to reach the goal of nursing practice—which here entails providing competent end-of-life care.

Thinking about the process of care, in her early works [ 32 , 33 , 34 ], Tronto proposes four different phases of caring and four elements of care. Although the phases may be interchangeable and often overlap with each other, the elements of care are fundamental to demonstrate caring. The phases of caring involve cognitive, emotional and action strategies.

The first phase of caring is caring about , which involves the nurse’s recognition of being in need of care and includes concern, worry about someone or something. In this phase, the element of care is attentiveness, which entails the detection of the patient and/or family need.

The second phase is caring for , which implies nurses taking responsibility for the caring process. In this phase, responsibility is the element of care and requires nurses to take responsibility to meet a need that has been identified.

The third phase is care giving , which encompasses the actual physical work of providing care and requires direct engagement with care. The element of care in this phase is competence, which involves nurses having the knowledge, skills and values necessary to meet the goals of care.

The fourth phase is care receiving , which involves an evaluation of how well the care giving meets the caring needs. In this phase, responsiveness is the element of care and requires the nurse to assess whether the care provided has met the patient/next-of-kin care needs. This phase helps preserve the patient–nurse relationship, which is a distinctive aspect of the ethics of care [ 36 ].

In 2013, Tronto [ 35 ] updated the ethics of care by adding a fifth phase of caring— caring with —which is the common thread weaving among the four phases. When care is responded to through care receiving and new needs are identified, nurses return to the first phase and begin again. The care elements in this phase are trust and solidarity. Within a healthcare context, trust builds as patients and nurses realise that they can rely on each other to participate in their care and care activities. Solidarity occurs when patients, next-of-kin, nurses and others (i.e., ward leaders, institutional management) engage in these processes of care together rather than alone.

To the best of our knowledge, these five phases of caring and their elements of caring have never been interpreted within the context of end-of-life care. The ethics of care framework offers a context-specific way of understanding how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with Tronto’s five phases, which has motivated choosing her theory.

Aim of the study

The present study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The current study has a qualitative descriptive design using five individual interviews and one focus group to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Setting and participants

The setting for the study was four nursing homes located in different municipalities from the South-Eastern region of Norway. Nursing homes in Norway are usually public assisted living facilities and offer all-inclusive accommodation to dependent individuals on a temporary or permanent basis [ 37 ]. The provision of care in the Norwegian nursing homes is regulated by the ‘Regulation of Quality of Care’ [ 38 ], aiming to improve nursing home residents’ quality of life by offering quality care that meets residents’ fundamental physiological and psychosocial needs and to support their individual autonomy through the provision of daily nursing care and activities tailored to their specific needs, and, when the time comes, a dignified end-of-life care in safe milieu.

End-of-life care is usually planned and provided by nurses having a post graduate diploma in either palliative nursing or oncology nursing– often holding an expert role, hence ensuring that the provision of end-of-life care meets the quality criteria and the resident’s needs and preferences [ 39 ].

To obtain rich information to answer the research question, it was important to involve participants familiar with the topic of study and who had experience working in nursing homes and providing end-of-life care to residents; therefore, a purposive sample was chosen. In this study, a heterogeneous sampling was employed, which involved including participants from different nursing homes with varying lengths of employment and diverse experiences in providing end-of-life care to residents. This approach was chosen to gather data rich in information [ 40 ]. Furthermore, when recruiting participants, the first author was guided by Malterud et al.’s [ 41 ] pragmatic principle, suggesting that the more ‘information power’ the participants provided, the smaller the sample size needed to be, and vice versa. Therefore, the sample size was not determined by saturation but instead by the number of participants who agreed to participate. However, participants were chosen because they had particular characteristics such as experience and roles which would enable understanding how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The inclusion criteria for the participants were as follows: (i) to be a registered nurse, (ii) had a minimum work experience of two years employed at a nursing home, and (iii) had clinical experience with end-of-life/palliative care. To recruit participants, the first author sent a formal application with information about the study to four nursing homes. After approval had been given, the participants were asked and recruited by the leadership from each nursing home. The participants were then contacted by the first author by e-mail and scheduled a time for meeting and conducting the interviews.

Ten nurses from four different nursing homes were invited to participate, but only nine agreed. The participants were all women, aged between 27 and 65 and their work experience ranged from 4 to 21 years. Two participants had specialist education in palliative care, and one was currently engaged in a master’s degree in nursing science. Characteristics of the participants are presented in Table  1 :

Data collection methods

Data were collected through five semistructured individual and one focus group interviews. Both authors conducted the interviews together. The study was carried out between April and September 2022. Due to the insecurity related to the situation caused by the post-SARS-CoV-2 virus pandemic and concerns about potential new social distancing regulations imposed by the Norwegian government, four participants from the same nursing home opted for a focus group interview format. This decision was motivated by a desire to mitigate the potential negative impact that distancing regulations might have on data collection. The interviews were guided by an interview guide developed after reviewing relevant literature on end-of-life care and ethical dilemmas. The development of the interview guide consisted of five phases: (i) identifying the prerequisites for using semi-structured interviews; (ii) retrieving and using previous knowledge; (iii) formulating the preliminary semi-structured interview guide; (iv) pilot testing the interview guide; and (v) presenting the complete semistructured interview guide [ 42 ]. The interview guide was developed by both authors prior to the onset of the project and consisted of two demographic questions and eight main open-ended questions. The interview guide underwent initial testing with a colleague employed at the same nursing home as the first author. After the pilot phase in phase four, minor language revisions were made to specific questions to bolster the credibility of the interview process and ensure the collection of comprehensive and accurate data. The same interview guide was used to conduct individual interviews and focus group (Table  2 ).

The interviews were all conducted in a quiet room at a nursing home. Each interview lasted between 30 and 60 min and were digitally recorded. The individual interviews were transcribed verbatim by the first author. The focus group interview was transcribed by the second author.

Ethical perspectives

Prior to the onset of the data collection, ethical approval and permission to conduct the study were sought from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 360,657) and from each leader of the nursing home. The study was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association [ 43 ]: informed consent, consequences and confidentiality. The participants received written information about the aim of the study, how the researcher would ensure their confidentiality and, if they chose to withdraw from the study, their withdrawal would not have any negative consequences for their employment at nursing homes. Data were anonymised, and the digital records of the interviews were stored safely on a password-protected personal computer. The transcripts were stored in a locked cabinet in accordance with the existing rules and regulations for research data storage at Oslo Metropolitan University. The participants did not receive any financial or other benefits from participating in the study. Written consent was obtained prior to data collection, but verbal consent was also provided before each interview. None of the participants withdrew from the study.

Data analysis

The data were analysed by employing a qualitative deductive content analysis, as described by Kyngäs and Kaakinen [ 44 ]. Both researchers independently conducted the data analysis manually. The empirical data consisted of 63 pages (34,727 words) of transcripts from both individual and focus group interviews. The deductive content analysis was performed in three steps: (i) preparation, (ii) organisation and (iii) reporting of the results.

During the first step—preparation—each researcher, individually, read the transcripts several times to get an overview of the data and select units of analysis by searching for recurring codes and meanings and to carefully compare the similarities and differences between coded data. These codes were labelled independently by both researchers and placed into an analysis matrix.

During the next step—organisation—the researchers met and discussed and then compared and revised the labels several times until they agreed about the preliminary findings. During the interpretative process towards developing an understanding of the empirical data, the content of the labels referred to nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with the five phases of Tronto’s theory of ethics of care [ 32 , 33 ], thus assigning them to the five phases of the theory. Following this final refinement, one main category and five categories, each supported by several subcategories, were identified, as presented in Table  3 .

Reporting the results was the last step in the analysis. To enhance the understanding of the study’s findings, the findings are presented with supporting excerpts from the participants.

In qualitative studies, trustworthiness is the main parameter for appraising the rigour of the study [ 45 ]. To enhance the trustworthiness of the study, four criteria—credibility, transferability, dependability and confirmability, as described by Lincoln and Guba [ 46 ]—were applied.

To support credibility, a detailed description of the sample and the sampling process was provided. Furthermore, the interview guide and the questions that the participants were asked during the interviews are made available to the readers. Moreover, although the data were collected from five individual interviews and one focus group, triangulation of two data collection methods allowed researchers to ensure that the study is based on diverse perceptions and experiences, strengthening the credibility and impact of the study’s findings [ 47 ].

Detailed information about the sample and setting supports the assessment of the transferability of the findings. In this way, the readers can recognise and evaluate whether the findings would be applicable to similar contexts with a similar sample. Quotes from the participants’ statements are given to support the findings. Each quote ends with a number representing the code that each nurse was given before conducting the interviews (i.e., Participant in interview 1, PI1 or participant 6 in focus group interview, P6FG).

To increase dependability, the same interview guide was used to ask all participants the same questions. Dependability was also increased by the researchers reading and analysing the interviews independently and then checking the consistency of the data analysis technique with each other and discussing the analytical process until a consensus was reached.

To enhance confirmability, excerpts from the participants’ statements were included when presenting the findings, thus verifying the concordance of findings with the raw data. This demonstrates that the data were not based on preconceived notions.

Trustworthiness was also supported by member checking, meaning that the researchers sent the participants the transcripts of the interviews immediately after data collection; then, the interviews were transcribed. The participants were asked to review the transcripts and check the accuracy of the data; hence, they had the opportunity to add, remove or clarify their statements. Only one participant answered this request, stating that the transcripts were accurate, and she did not have any further comments. Despite encountering a suboptimal response from participants, the authors remain confident in the trustworthiness of the study. Rich data, derived from a combination of individual and focus group interviews, yielded diverse and nuanced responses from participants, reinforcing the credibility of the findings.

Reflexivity is the researcher’s reflection on their position during the research process [ 48 ]. Both researchers have clinical experience in providing end-of-life care to nursing home residents. Therefore, it was critical to be aware of the impact that their clinical backgrounds might have on the research process from information seeking during the analysis of data and discussion of the findings. To avoid early interpretation of the data, the researchers were aware of their preunderstanding and tried to put it on hold. Both authors engaged in discussions regarding apprehensions and reflections, actively participating in the triangulation process throughout the study to prevent potential bias during data collection, analysis, and interpretation. The theoretical framework was brought in the end of the analysis process, which helped label the emerged findings.

The analysis of the empirical data combined with an ethical reflection helped researchers to identify and understand the moral dimension of nurses’ experiences with end-of-life care provided to nursing home residents. During the analysis, an overarching category emerged– ‘The moral dimension of the provision of end-of life care’– describing nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. The participants agreed that end-of-life care is a care process that undergoes several phases, with each phase having its own ethical quality or its own element of care, here according to Tronto’s moral qualities [ 34 ]. In the following section, the findings are described using Tronto’s identified moral qualities for each of the five phases of the care process [ 32 , 33 , 34 , 35 ].

Caring about—being attentive

For the participants, being autonomous was perceived as a feature that increased their awareness of the resident’s caring needs during their last days of life. The participants agreed that the caring process involves paying attention, listening and recognising residents’ unspoken needs. Moreover, it implies nurses being able to make autonomous decisions when deciding which needs to care about at one particular moment.

The participants agreed that the core values of providing end-of-life care were to alleviate suffering, maintain dignity and provide comfort care. The participants perceived caring about as having sufficient knowledge, along with the experience and autonomy in practice, as well as providing comprehensive end-of-life care for residents. For the participants, caring about during the end-of-life process means them being present and dedicated. This implies nurses carefully observing, autonomously acting, and making decisions based on their judgements, and thus, they can decide and choose their course of action promptly based on resident’s condition or side effects. Moreover, caring about involved participants being attentive to perceiving the residents’ needs when the residents could no longer articulate themselves. The participants expressed their worries about resident’s bodily deterioration, leading them to lose their ability to express needs, as shown by the following quote:

There is not much communication when residents go into their last stage of life. Well… some of them are consciously until their death, but most are sedated; therefore, it is necessary to use your knowledge and experience to assess not only their needs for food and liquids or bodily hygiene, but also, we have to monitor their response to pain killers and other medication, and if it’s too much or too little, we need to do what’s needed to reduce or increase the medication and not let them suffer (PI3).

Some of the participants expressed that attentiveness to the residents’ care needs was a skill based on their clinical gaze developed during their careers. Other participants discussed that building a close relationship with the residents while they still could walk and talk was a precondition that helped them develop a clinical gaze, hence facilitating the nurses’ being attentive. Attentiveness allowed the participants to do what was needed when knowing the residents’ needs during the provision of end-of-life care. This may be interpreted as the moral or ethical quality of caring about during the end-of-life caring process, as demonstrated by the following statement:

We have time to know the resident before their health condition worsens… We previously knew what they wanted and how they wanted… their stay at nursing home gives us the opportunity to know their preferences and needs. Morally, we are obliged to provide the same quality of care they received when they could express themselves (PI4).

Caring for—taking responsibility

According to several participants, another phase within the end-of-life caring process was taking responsibility to care for. The participants agreed that monitoring the residents in their last days implies assuming responsibility. Assuming responsibility was perceived as an autonomous caring activity. They also discussed taking this responsibility seriously, which is a moral dimension of the end-of-life caring process and, ultimately, of the nursing profession. Usually, this responsibility was taken by a nurse, but it also involved other healthcare personnel or even next-of-kin. Among these responsibilities, the participants mentioned that the end-of-life caring process included not only caring for the resident’s physiological and psychosocial needs, but also assigning permanent healthcare personnel to continuously monitor the resident. Although the participants were aware that they share responsibilities for the caring process, ‘who does what…’, they ultimately had the overall responsibility for the whole end-of-life caring process.

Another responsibility included communication, which included listening, providing information, and supporting the residents’ next-of-kin. One of the participants expressed this as follows:

When I observe that the resident’s health worsens, I inform the next-of-kin and invite the spouse or the children to a meeting together with the responsible doctor and I, and we inform the next-of-kin what they might expect. The end-of-life care is not only about the resident and their last days, but also is to care for their next-of-kin to meet their needs and to overcome guilt feelings, anger or sadness.… (PI1).

Another way to care for patients was to deliberately increase opportunities to exercise autonomy during the caring process. For instance, the focus group participants discussed issues around advanced life support during the resident’s last days of life. Being prepared and having knowledge were the preconditions that gave them the authority to identify and make decisions about residents’ needs in here-and-now moments, hence exercising their autonomy. Some participants shared their experiences with controversies between next-of-kins’ and nurses’ assessments of what is the best care for the residents during their last days of life. Therefore, the importance of taking the initiative to discuss and clarify the resident’s needs and preferences was emphasised during the focus group interview, as shown in the following quote:

Some next-of-kins express wishes for advance life support and hospitalisation for their loved ones… and sometimes, to meet their needs, we try this, but the resident is suffering. The resident comes back to us after one or two days… To avoid this, clear guidelines, and a dialogue between the resident, their next-of-kin and us at the very beginning [when the resident enters the nursing home] is important… I think that minimalising the occurrence of difficult or conflictual situations and relieving the sufferance is care for both resident and their next-of-kin (P8FG).

Care giving—knowing what, why, how and when

During the interviews, the participants also discussed the caregiving process and provided concrete examples of what their caregiving encompassed. Spending extra time with the resident, choosing to be in the room and holding their hand to maintain physical contact was perceived as an autonomous caring act and a deliberate choice. One participant described this as follows:

For me, it is important that the dying person feels or hears that I am here with him or her… how he or she feels in these moments matters to me. I do it because I want to do it.… (PI5).

Other participants said that being autonomous when they actually provided caregiving to residents helped them make continuous assessments based on knowledge about what , how , how much , when and why to care. Knowledge and skills were decisive factors in providing competent care and making autonomous decisions during the caregiving phase; hence, competence was perceived as a moral dimension of caregiving. One of the participants said the following:

Caregiving at end-of-life is not only about giving morphine according to the doctor’s prescription… it involves all the judgements you have to make, all the skills you have… from preventing the occurrence of bedsores to knowing when to stop feeding but preventing thirst… think about all this knowledge and experience you must have to be able to make autonomous bedside judgements about when , why and so on.… (PI2).

Care giving at the end-of-life was described as all the necessary activities a nurse does to provide comfort and compassionate care to a dying resident. Among these activities, providing fundamental care and keeping residents comfortable and free of pain were seen as parts of the caregiving process. Moreover, adequate pain relief and symptom management were described as the moral dimension of care giving at this stage of end-of-life care, as one of the participants from the focus group interview said:

You cannot be passive when you see that the resident is suffering. I cannot go home and think that I should have done one or the other. It is against the nurses’ code of ethics and my personal moral and ethical principles. You have to act… I have to do what is needed… first thing first… pain relief and then personal hygiene! (P9FG)

Some of the participants mentioned some challenges they encountered during the care giving process. They said that care giving implies also standing in demanding situations. The lack of healthcare personnel with necessary knowledge or formal palliative care education or handling ethical dilemmas was seen as demanding situations that influenced the provision of care giving. Most of the participants felt that they were alone during the decision-making processes, which increased their awareness of their professional autonomy:

Sometimes, during weekends or evenings, I am the only nurse among the healthcare staff, and I have an overall responsibility for all nursing home residents. I have to prioritise who gets my attention and who needs me the most. Things can happen, regardless of whether it is Friday evening or weekend. I have to make a decision and do what is needed: to be with the dying resident and to support his or her next-of-kin in that moment. (PI5)

Care receiving—assessing caregiving

Several participants stated that, during the care-giving process, it was important to assess how the resident receive the care provided at the end-of-life stage. This was possible by monitoring the resident’s state of being but to also assess the outcomes of their care giving activities. They also reflected on their assessments and how they subsequently dealt with those assessments.

All the participants were confident in their knowledge and with their care giving at the end-of-life stage. They were aware that their care activities had consequences for the residents’ physiological and psychosocial needs. The assessment of the resident’s state of being was made by nurses listening, observing and interpreting resident’s response to care giving as signs of comfort or discomfort. One of the participants explained this as follows:

When providing personal care, if the resident presents any signs that can be interpreted as discomfort, I think that priority number one is me not causing more pain or suffering. However, I also understand that this person needs more pain killers, so I have to make sure that this person receives adequate medicine. (PI5)

Some participants also discussed the importance of assessing their care giving activities. They mentioned the importance of their assessments of the benefits of all care giving against the burden of all interventions and treatments. Their professional autonomy allowed them to make decisions about how to eschew care giving that was inappropriately and burdensome and choose the best comforting care for the resident. The participants stated that knowledge and experience were important in making such decisions, and their professional autonomy facilitated making choices of the best and less burdensome care giving. One of the participants said the following:

We have to assess whether the care giving provided meets the resident’s needs or not, whether the care comforts or perceives it as a burden and how the resident responds to this provision of care. (PI4)

During the interviews, some of the participants revealed a feeling of guilt when assessing that care giving altered the resident’s state of being, thus leading to new needs for care. They also discussed that the moral obligation and intention to relieve the suffering of the resident should override the foreseen but unintended harmful effects of care giving, including medication or other care interventions. One of the participants shared her experience as follows:

I still remember the attitude some of us had for a while ago… too much or too often morphine depresses the respiration and leads to death… I was struggling with feelings of guilt and even moral distress when I observed residents were still suffering because the medication they received had little or maybe no effect. I called the doctor and explained the situation… usually, the experienced doctors listen to us… and he [the doctor] prescribed more morphine.… (PI3).

Documentation of the response to care giving was also an issue discussed during the interviews. Some participants emphasised the importance of keeping detailed reports for a proper assessment of the care giving and medication and its outcomes. All reports were digitally written. Informal discussions between nurses and next-of-kin were also documented, especially when next-of-kin evaluated the care their loved ones received. The participants indicated that the more written information there was, the better. One participant acknowledged the following:

There is no such thing as ‘too much information’… being open about the morphine’s side effects and what to expect in the next hours or days is important for them [next-of-kin]. It helps them understand that end-of-life care is a process, not a quick fix procedure. (PI5)

Caring with—It is a teamwork process

During the interviews, most of the participants reflected upon the end-of-life caring process and its occurrence within the context of care in nursing home. The participants discussed that end-of-life care is not only about the responsibilities nurses have towards residents and their next-of-kin, but also the responsibilities of others who may influence the caring process. They perceived the caring process as an interplay between residents, next-of-kin, and themselves, along with how they relate to each other, which influences the caring process. However, as several participants asserted, this process did not occur in a vacuum: it occurred within an organisational context, which then influenced the caring process from the very beginning. One participant emphasised the importance of stable healthcare personnel within a caring organisation:

High staff turnover does not facilitate good end-of-life caregiving. Both residents and their next-of-kin need continuity and predictability in caring for and among healthcare personnel. They need somebody they know and trust… being exposed to new people every day increases their stress levels. (PI1)

Other participants discussed the importance of the leadership style and how the leader’s support influenced the culture of end-of-life care at the ward. The participants revealed that, within a caring context where their natural potential was enhanced through an enabling leadership style, they felt that they could provide competent and compassionate end-of-life care. One of the participants from the focus group stated that a positive leadership style supports nurses’ professional autonomy, thus helping them control the caring process, to have independence and to increase their ability to make clinical decisions and competent judgements regarding resident’s end-of-life care. One participant shared her experience as follows:

My leader gives me the freedom to make decisions when it comes to deciding what is best for the resident… She [the leader] enables me to be autonomous during the caring process, and this makes me aware of what and how to care.… (PI2).

The participants from the focus group interview also discussed how the nursing home’s caring culture influences care practice. They perceived the nursing home’s caring culture as positive, enabling good end-of-life care but also defective and an obstacle to care. They emphasised the importance of providing dignifying end-of-life care for residents. During the focus group interview, two of the participants engaged in a dialogue:

End-of-life care is providing care to the most vulnerable people, and it should be dignified… To do so, I have to provide care in a ‘caring room’ filled with dignity. (P7FG) Although next-of-kin and I have different perspectives of what good end-of-life care might be, we care together, we are a caring team which ensures in our own way that the resident receives competent care.… Yes, you [P7] mentioned this ‘caring room’… maybe we should open the door more often into this room and invite next-of-kin. (P6FG)

The aim of the present study was to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. In the following, we discuss these perceptions in relation to Tronto’s [ 32 , 35 ] ethics of care framework and other supporting literature. To identify the moral dimension of these perceptions, we have related them to the moral qualities corresponding to each phase of the care process, as described by Tronto [ 33 , 35 ].

In the first phase of the care process—caring about—the participants discussed the importance of being attentive to which type of care needs to be provided, which is the moral quality of the first phase of care. Similar to findings from another study [ 49 ], findings from the present study revealed that some participants perceived autonomous practice as carrying out actions based on their decisions. Caring about entails detecting the resident’s needs, hence obliging nurses to ‘do something’ [ 50 ]. This particular skill was seen as an autonomous caring activity, that is, the nurses’ deliberate choice of putting on hold their self-interest and/or agenda and ‘a capacity genuinely to understand the perspective of the other in need’ [ 35 ] (p.34) , here nursing home resident.

In Tronto’s view [ 33 ], nurses’ attentiveness contributes to building up a caring relationship with a patient. The findings from the current study reveal that nurses perceived the provision of competent and compassionate end-of-life care as a result of their clinical gaze developed through certain activities, attitudes and knowledge of the patient, and through mutual relationships between the residents, next-of-kin and them. These results are supported by findings from previous studies that emphasise the importance of the nurse’s past experiences with the resident [ 51 ] and the significance of developing a good relationship with the resident and their next-of-kin [ 8 , 23 , 52 , 53 , 54 ] to provide adequate care. Moreover, similar to findings from other studies [ 55 , 56 ], the present study reveal that, to respond to the resident’s end-of-life care needs, nurses must bring not only their professional knowledge, clinical experience and ability to work autonomously but even ethical sensitivity. These findings enforce Gastman’s [ 50 ] view on caring, in which caring should respond to the patient’s care needs. This involves nurses having empathy, capacity of judgement and the ability to see what is required in a specific situation (here, end-of-life care), which, according to Gastmans [ 50 ], is inherent in the moral dimension of nursing practice.

The second phase of care—caring for—refers to nurses taking on the burden of meeting the needs identified in the first phase, that is, caring about. There was no ambiguity, and the participants had no doubts regarding who had the responsibility for the provision of end-of-life care to nursing home residents. The nurses’ responsibility was seen as a moral dimension of care. In line with Pursio et al.’s study [ 30 ], the present findings indicate that the freedom to make patient care decisions and work independently has a positive impact on the moral dimension of end-of-life care for nursing home residents. However, nurses’ work was not only about meeting residents’ needs, but also to create a safe milieu, a communicative space together with each other and with the resident’s next-of-kin, thus sharing power and control over the care process. Similar findings are displayed in an integrative literature review [ 53 ], demonstrating that a positive culture of collaborative and reciprocal relationships, a willingness to engage and become engaged and nurses communicating with intent to share and support rather than inform all lead to facilitating decision-making in nursing homes. According to Tronto [ 35 ], to facilitate end-of-life decision-making, nurses must take the initiative to allocate responsibilities; otherwise, the nurses withdraw themselves from their responsibility. By exercising their professional autonomy to assign responsibilities, nurses strive to mitigate the power imbalance among residents, their next-of-kin, and themselves, thereby preventing the occurrence of potential power struggles in their relationships [ 34 ]. This proactive approach helps prevent the emergence of end-of-life care dilemmas that could undermine the moral dimension of end-of-life care.

The third phase of care—care giving—requires, according to Tronto [ 35 ], the moral quality of nurses’ competence, meaning nurses directly engaging with care. The findings revealed that the nurses provided end-of-life care, and to do so, they needed to have competence, which implies the nurses having the knowledge, skills and values necessary to know what, why, how and when to provide end-of-life adequately. In addition, good end-of-life care requires the competence to individualise care—to provide competent care based on the resident’s physical, psychological, cultural and spiritual needs [ 57 ] while considering the resident’s context of care. Nurses’ competence is crucial for their autonomy; however, to effectively utilize their competence, nurses must be capable of assessing care needs and responding promptly [ 30 ]. Otherwise, delays in assessing residents’ care needs could undermine the moral dimension of end-of-life care. To provide individualised competent care, it is necessary that nurses make continuous assessments. As the findings reveal, the nurses were concerned with providing competent care, that is, adequate pain management. If the care provided was incompetent and led to more pain for the resident, the nurses perceived psychological distress—a state of being that resulted in response to a variety of moral events—leading to the nurses feeling anger, frustration, guilt, powerlessness and stress [ 58 ]. According to Tronto [ 34 ] (p.17) , ‘incompetent care is not only a technical problem, but a moral one’; however, as the findings reveal, the provision of competent care also depends on the nurses’ ability to prioritise decision-making when standing alone. Although nurses’ professional autonomy enabled them to make decisions and choose the right what , how , how much , when , and why , the lack of adequately educated healthcare personnel make the decision-making process a technical problem, which could weaken the moral dimension of end-of -life care.

The fourth phase—care receiving—involves the moral quality responsiveness. This means nurses being responsive to the reaction of the nursing home residents to end-of-life care process. As the findings have revealed, nursing home residents are vulnerable to nurses’ act of care or lack of care. According to Gastmans [ 59 ], care is a reciprocal practice that occurs within the framework of a relationship between the care provider (nurse) and care receiver (resident). The reciprocity consists of nurses assessing that the care provided actually meets the resident’s needs for pain management and other physiological and spiritual needs. The nurses had to make autonomous end-of-life care decisions to meet the resident’s needs. This involved the nurse’s attention to care giving to not be perceived as power abuse, which could have negative consequences for the moral dimension of end-of-life care provision.

According to Tronto [ 33 ], vulnerability may lead to unequal relationships where power abuse may occur. Nursing home residents are in a vulnerable position because they rely on nurses’ competence and ability to alleviate suffering and assess and reassess the residents’ responsiveness to pain management. To avoid an unequal relationship between resident and nurse, nurses must assess whether the care provided is competent or incompetent. Besides assessing and documenting the care provided and its outcomes, informal discussions between the resident’s next-of-kin and nurses were also assessed as important for next-of-kin perceiving a balanced power and equal position within the relationship. However, because each end-of-life act of care may alter the resident’s state of being, responsiveness requires more attentiveness [ 34 ]. Nurses must therefore meet the resident’s new needs for care with compassion and a commitment to maintaining the highest quality of life throughout the evolving stages of the resident’s end-of-life journey.

The final phase of care—caring with—requires that solidarity and trust are the foundation of all care giving to meet caring needs [ 35 ]. The moral quality of this caring phase is solidarity. The findings from the present study suggest that the nurses felt solidarity with both the residents and their leaders. The nurses felt that they were given the support and freedom to act autonomously when making decisions regarding end-of-life care, but similar to findings from a previous study [ 22 ], they also recognised the impact that organisational factors, such as leadership and care culture, may have on the justice and equality of the care provided when they prioritise care to whom needed it the most. Similar to findings from another study [ 49 ], participants in the present study described autonomy as the ability to make independent decisions and prioritise care for those who needed it most. However, according to Tronto [ 35 ], all nurses have a responsibility to help determine how care activities and responsibilities should be allocated. Residents, their next-of-kin and other healthcare personnel may have different views on how they may perceive appropriate, compassionate and dignified end-of-life care [ 20 , 21 ].Therefore, it is important to have transparency in nurse–resident–next-of-kin relations if the element of power within the relationship should be replaced by trust. Otherwise, the nurses’ autonomy may negatively influence the moral dimension of end-of-life care provided to nursing home residents. By opening the door of the “caring room” and inviting next-of-kin to participate in the care process, nurses may contribute to a greater reflectiveness around what may constitute ‘good’ end-of-life care.

Strengths and limitations

One of the strengths of the study is the use of Joan Tronto’s theory of the ethics of care [ 32 , 34 , 35 ] and its five phases and elements of care to discuss the study’s findings. This allows a deeper understanding of how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. Another strength lies in the utilisation of two distinct methods of data collection: individual and focus group interviews. These approaches provided diverse datasets that shed light on various aspects of how nurses’ professional autonomy impacts the moral dimension of end-of-life care. Furthermore, the inclusion of participants with varying work experiences from four nursing homes enhances the richness and depth of the data generated from the interviews, further strengthening the quality of the study. Member checking ensures that the researcher’s interpretations accurately reflect the participants’ experiences and perspectives, thereby enhancing the validity of the study. This practice can be considered one of the methodological strengths of the study.

The current study has also some limitations that need to be considered. First, a limitation may be related to the size of the participant sample. The sample consisted of only nine nurses, a number that may be seen as a limitation in data collection. To challenge this limitation, the researchers posed follow-up questions during the interviews, thus offering the participants the opportunity to provide rich descriptions of their experiences with end-of-life care. Even though the sample consisted of only nine nurses, these participants reflected on and described their everyday work experiences. The participants’ rich descriptions were evaluated as possessing sufficient information power [ 41 ], thereby enhancing the overall quality of dialogues during interviews– a notable strength.

Second, the findings are limited to these nine participants and their personal work experiences in four different Norwegian nursing homes. This means that the sample is small and context dependent, which may limit the transferability and generalisability of the findings.

A third limitation pertains to the potential influence of the chosen theoretical framework on researchers’ preunderstanding during data analysis. To avoid bias, the theoretical framework was introduced at the end of the data analyses and after the coding process was conducted. The theoretical framework contributed to situating the knowledge from the empirical data into theoretical knowledge and vice versa. However, to be certain about interpretations and knowing that the qualitative nature of the study cannot completely exclude the impact of the preunderstanding on the analysis of the data, both researchers were aware of their theoretical preunderstanding and tried not to make conclusions beforehand.

The ethics of care framework provides opportunities for nurses to analyse their own caring activities during the provision of end-of-life care to nursing home residents. The exploration of the moral dimension of the provision of end-of-life care, utilising Tronto’s theory, revealed that moral qualities, such as attentiveness, responsibility, competence, responsiveness, and solidarity are influenced to a certain extent by nurses’ autonomy. What is crucial for the provision of competent end-of-life care is the nurses’ awareness of acting properly in accordance with the moral qualities to each of the phases of caring. Therefore, to provide competent end-of-life care nurses must be attentive to residents’ care needs, take on the responsibility for the care provided to ensure that residents’ needs are met, provide competent care based on knowledge, skills and values and assess how residents respond to the care provided. In other words, this is the basic nursing process in action, and this problem-solving approach is needed for the provision of competent end-of-life care.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Oslo Metropolitan University.

Abbreviations

Participant in interview [number of the individual interview

Participant [number] in Focus Group interview

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Acknowledgements

We would like to express gratitude to the nurses who participated in this study, thereby contributing to the data collection. Additionally, we extend our thanks to the Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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Rachel Gilbert & Daniela Lillekroken

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D.L. contributed to the study conception, data collection, and analysis, and wrote the main manuscript text. R.G. was involved in data collection, analysis, reflection, and manuscript writing. D.L. was responsible for administrative work related to journal submission and was also involved in reviewing and editing the manuscript. R.G. and D.L. have read and approved the manuscript before submission.

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Correspondence to Daniela Lillekroken .

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The Norwegian Agency for Shared Services in Education and Research approved the study protocol (Sikt/Ref. number 360657) and concluded that the study was not subject to the Norwegian Health Research Act (LOV-2008-06-20-44; https://lovdata.no/dokument/NL/lov/2008-06-20-44 ). An English version of the Norwegian Health Research Act can be found at: https://www.uib.no/en/med/81598/norwegian-health-research-act . This study does not aim to get insight into participants’ health status, sexuality, ethnicity, and political affiliation (sensitive information), therefore, no additional approval from a local ethics committee or institutional review board (IRB) was necessary to be obtained to conduct the study. This study was performed according to principles outlined in the Declaration of Helsinki, and in accordance with Oslo Metropolitan University’s guidelines and regulations. Data were kept confidential and used only for this research purpose. The researchers provided verbal and written information about the study. Informed consent was obtained from all participants prior data collection.

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Gilbert, R., Lillekroken, D. Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study. BMC Nurs 23 , 216 (2024). https://doi.org/10.1186/s12912-024-01865-5

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Received : 06 December 2023

Accepted : 13 March 2024

Published : 28 March 2024

DOI : https://doi.org/10.1186/s12912-024-01865-5

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Nursing Home Basics: Who Qualifies, Who Pays, and Other Helpful Facts

Why it matters.

Understanding how nursing homes work can be confusing because standards for eligibility, insurance coverage, etc. vary from state to state in the US.

In this second article in our series on nursing homes ( read Part I here ), we answer some commonly asked questions about nursing home structures and functions.

Who Is Eligible to Enter a Nursing Home?

People qualify for nursing home/facility level of care (NFLOC) if they are unable to live alone safely in the community. There is no federal definition of NFLOC and the exact rules governing level of care vary from state to state. Despite this lack of consistency, the following four areas are commonly considered when a state determines a person’s level of care need: physical functional ability; health issues/medical needs; cognitive impairment; and behavioral issues. In many states, there has been significant rebalancing toward home and community-based services and away from nursing home care. Check state websites for updated information on specific eligibility requirements.

Who Pays for Nursing Home Care?

Medicare is the federal health insurance program for people in the US who are 65 or older, some younger people with disabilities, people with End-Stage Renal Disease. A common misconception is that Medicare will pay for all nursing home costs. This is not true.

Post-acute care (PAC) or skilled nursing facility (SNF) care is usually covered by Medicare or private insurance up to 100 days (100 percent for 20 days and then 80 percent for 80 days based on certain criteria). Long-term care (meals, room and board, and basic health services) is often paid for privately until funds are spent down. A “ spend down ” is how someone with Medicare may qualify for Medicaid — a joint federal and state program that provides health coverage to some people with limited income and resources — even if their income is higher than a state's Medicaid limit. Under a spend down, a state lets the person subtract their non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) from their available income. Each state’s Medicaid program covers approximately 70 percent of nursing home care.  Long-term care insurance can also pay for nursing home care, but relatively few people have it.

The average cost of a nursing home is over $90,000 per year but this varies state to state. Multiple organizations provide information about nursing home costs and Medicaid daily rates online, including the  American Council on Aging .

Who Oversees and Regulates Nursing Home Quality and Safety?

The Centers for Medicare and Medicaid Services (CMS) oversees nursing home quality and safety at the federal level. Several divisions have regulations that pertain to nursing homes. 

The CMS Division of Nursing Homes develops and oversees most nursing home regulations. CMS delegates nursing home surveys and inspections to a designated organization in each state, usually the State Survey Agency (SSA). SSAs conduct annual, recertification, and complaint surveys and assess compliance with regulations. There is also a Special Focus Facility program for a small number of low-performing nursing homes that receive more intensive oversight and guidance on quality improvement in each state.

How Do We Measure Nursing Home Quality?

Because definitions of quality may vary, there are different methods used by federal, state, or private organizations to collect and analyze quality data. Here are a few examples:

• Minimum Data Set (MDS) is a standardized assessment tool required by CMS that measures health status in nursing home residents. All nursing homes that accept Medicare or Medicaid must submit the MDS regularly for each resident to receive payment.
• National Healthcare Safety Network is an electronic system for infection reporting, including COVID and other data that goes to CDC.
• CMS Five Star Quality Rating System gathers information from inspections (surveys), quality measures, and staffing from each nursing home and makes this information publicly available on the CMS website.
• Medicare’s Care Compare   allows users to locate and compare data from nursing homes.

What are Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs)?

QIN-QIOs focus on working with nursing homes, states, and regions to improve quality of life and quality of care across settings, including nursing homes. QIN-QIOs have their own separate line item in the US federal budget to support the national program which covers  all 50 states and US territories . QIN-QIOs are not part of state survey agencies or the survey process. Their focus is on quality improvement, support, education, and training, which are often provided free or at very low cost.

Who Works in Nursing Homes?

Women make up most of the nursing home workforce, particularly direct care workers such as certified nursing assistants (CNAs). ( Almost 90 percent of nursing assistants are female). Many are single parents.  People of color comprise most of the US nursing assistant workforce.

Most nursing assistants are low-income wage earners. Many live at or near the federal poverty level and almost half receive some type of public assistance. Nursing homes typically pay CNAs the minimum wage, but this is not necessarily a livable wage depending on where they live. For this reason, CNAs often work in multiple settings and have multiple jobs. For many CNAs, English is not their first language, and they may have limited English proficiency. Many are immigrants.

What Are Some Challenges Faced by the Nursing Home Workforce?

There are many issues facing nursing home CNAs today and some new opportunities. The National Association of Health Care Assistants (NAHCA) conducted a survey of 1,420 CNAs in July 2023. When asked about their jobs, many CNAs reported that low wages and benefits would be the primary reasons they intend to seek another type of employment. They also cited unstable or inadequate hours, lack of supervisor’s/manager’s support, lack of career advancement or professional development, and feeling under-valued.

High rates of turnover (in some cases over 100 percent in a year) and the need for stronger, stable leadership are important reasons to better support CNAs and other direct care workers. Creating and testing standardized career ladders or lattices and providing more training and education on topics of interest to CNAs represent opportunities to promote better retention and reduce turnover. Another way to respond to CNA concerns is by becoming an  Age-Friendly Health Systems Nursing Home .

Alice Bonner, PhD, RN, is IHI’s Senior Advisor for Aging. Amanda Meier, BSW, MA, is IHI’s Project Manager, Age-Friendly Health Systems. If you have any questions or ideas about nursing homes or related policy issues, please feel free to reach out to Alice Bonner ( [email protected] ) or Amanda Meier ( [email protected] ).

You may also be interested in:

The Basics We (and Policymakers) Should Know about Nursing Homes

Centering What Matters: The Core of Age-Friendly Care

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