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The Nurse Leader’s Role:

A Conduit for Professional Identity Formation and Sustainability
Published:November 05, 2020DOI:https://doi.org/10.1016/j.mnl.2020.10.001
      The development of professional identity in nursing (PIN) is essential to the education, advancement, and brand image of nursing, and to demonstrate the impact on patients’ health and well-being. Unfortunately, the construct of PIN has not been well-established. To further shape and distinguish the concept, 3 think tanks were held between 2018 and 2020, resulting in the recognition that nursing leadership is a primary conduit to influence PIN. How leaders role model, improve practice environments, and foster lifelong learning greatly contributes to the formation and sustainability of the professional identity of nurses and the next generation of leaders.
      Key Points
      • A clear understanding of the construct of professional identity in nursing is needed
      • The 4 domains for professional identity are values and ethics, knowledge, leadership, and professional comportment.
      • Nursing leadership is the visible conduit to cultivate professional identity in nursing.
      What is a nurse and what is their role? To whom does a nurse turn to for answers? Nursing is at a pivotal point in its trajectory and is not alone in the quest of defining its professional identity. From the 1870s to 1950s, nursing was a virtue-based profession focusing on moral behaviors; from the 1960s to present, nursing transitioned to a competency model focusing on skills, knowledge, and behaviors. Today, nursing is transforming into a combination of virtue, competency, and identity formation.
      • Godfrey N.
      Professional Identity in Nursing: Science, Strategy and Call to Action for 2018 Think Tank.
      Benner and colleagues
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      recommended that nursing education “shift from an emphasis on socialization and role-taking to an emphasis on formation.” However, no grassroots movement has followed among nurse educators to clarify and potentially standardize a discipline-wide focus on professional identity formation in education, practice, or regulation.
      Nursing continues to be plagued by a myriad of issues, primarily due to an incoherent perception, image issues, and stereotyping of nursing within society.
      • Godfrey N.
      • Young E.
      Professional identity.
      • Bennett C.L.
      • James A.H.
      • Kelly D.
      Beyond tropes: towards a new image of nursing in the wake of COVID-19.

      Mao A, Lu S, Lin Y, He M. A scoping review on the influencing factors and development process of professional identity among nursing students and nurses [e-pub ahead of print]. J Prof Nurs. https://doi.org/10.1016/j.profnurs.2020.04.018. Accessed September 10, 2020.

      In a 2020 study with a sample of 286 participants, researchers examined factors contributing to inconsistencies with nursing’s brand image.

      Mao A, Lu S, Lin Y, He M. A scoping review on the influencing factors and development process of professional identity among nursing students and nurses [e-pub ahead of print]. J Prof Nurs. https://doi.org/10.1016/j.profnurs.2020.04.018. Accessed September 10, 2020.

      The authors reported 8 themes including that image is not a priority, there is a lack of leadership development, and nurses experience inappropriate treatment and labeling by other professional colleagues.

      Mao A, Lu S, Lin Y, He M. A scoping review on the influencing factors and development process of professional identity among nursing students and nurses [e-pub ahead of print]. J Prof Nurs. https://doi.org/10.1016/j.profnurs.2020.04.018. Accessed September 10, 2020.

      Understandably, the lack of clarity about nurses’ identity and influence compounds these misperceptions among other disciplines, nurses themselves, and society at large.

      Mao A, Lu S, Lin Y, He M. A scoping review on the influencing factors and development process of professional identity among nursing students and nurses [e-pub ahead of print]. J Prof Nurs. https://doi.org/10.1016/j.profnurs.2020.04.018. Accessed September 10, 2020.

      Nurses’ professional identity is part of their overall identity and is influenced by their interactions with others and their perceived experiences.
      • Godfrey N.
      Professional Identity in Nursing: Science, Strategy and Call to Action for 2018 Think Tank.
      Professional identity may not be a familiar term to all nurse leaders, but it is an important topic in medicine, veterinary medicine, and pharmacy, to name a few.
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      ,
      • Armitage-Chan E.
      • May S.A.
      Identity, environment and mental well-being of the veterinary profession.
      Professional identity in nursing (PIN) is defined as “a sense of oneself, in relationship with others, that is influenced by characteristics, norms and values of the nursing discipline, resulting in an individual thinking, acting and feeling like a nurse.”
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      ,
      • Fitzgerald A.
      Professional identity: a concept analysis.
      Academic leaders are increasingly becoming motivated to build learning environments that actively help form students’ PIN. Research findings demonstrate that a stronger sense of professional identity leads to greater satisfaction in a field
      • Bennett C.L.
      • James A.H.
      • Kelly D.
      Beyond tropes: towards a new image of nursing in the wake of COVID-19.
      and that professional identity and psychological well-being are linked.
      • Thoits P.
      Self, identity, stress and mental health.
      ,
      • Wald H.S.
      • Anthony D.
      • Hutchinson T.A.
      • et al.
      Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.
      A recent article revealed that some leaders contribute to the negative brand and image of nursing when they lack leadership development, did not have role models, and did not advocate for themselves.

      Godsey JA, Houghton DM, Hayes T. Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession [e-pub ahead of print]. Nurs Outlook. https://doi.org/10.1016/j.outlook.2020.06.005. Accessed September 20, 2020.

      However, in an earlier article, researchers reported that Generation Y nurses were cautious yet optimistic about their future leadership roles and the future of nursing.
      • Dyess S.M.
      • Sherman R.O.
      • Pratt B.A.
      • Chiang-Hanisko L.
      Growing nurse leaders: their perspectives on nursing leadership and today’s practice environment.
      Thus, mid-level and senior nurse leaders are in a unique position to model behaviors to foster and sustain professional identity in nursing.
      • Dyess S.M.
      • Sherman R.O.
      • Pratt B.A.
      • Chiang-Hanisko L.
      Growing nurse leaders: their perspectives on nursing leadership and today’s practice environment.
      The purpose of this article is to discuss the influence of leadership on nurses’ professional identity, provide supportive evidence from 3 think tanks, and discuss implications of this new knowledge for nursing leadership and the formation and sustainability for PIN.

      Think Tanks In 2018, 2019, and 2020

      In 2018, approximately 50 nurse leaders from practice, education, and regulation were invited to participate in a think tank at the University of Kansas School of Nursing to provide ideas for further developing the concept of PIN because it has not been a well-established construct. This group is now named the International Society for Professional Identity in Nursing (ISPIN).
      Many of the nurse leaders represented major nursing organizations, including the American Organization for Nursing Leadership (AONL). Over the span of 1 and half days, strategies and inductive processes were employed to uncover construct domains that resulted in 4 newly identified domains of professional identity in nursing (Figure 1).
      Momentum grew and a second think tank was convened in 2019. Many of the participants were from 2018, with some new participants who joined the group to extend the work. Domains and key elements were refined, and exemplars of professional identity in nursing were developed. Additionally, work began on the development of a conceptual model.
      • Joseph M.L.
      • Edmonson C.
      • Godfrey N.
      The conceptual model for professional identity in nursing. International Society for Professional Identity in Nursing (ISPIN) Advisory Council.
      In 2020, the third think tank occurred, and members created resources for using the exemplars in practice, regulation, and education.
      KU Medical Center School of Nursing
      Professional Identity in Nursing.
      The 4 domains and key characteristics established for professional identity in nursing to maximize health and wellbeing either in a direct care nursing or non-direct care nursing role are values and ethics, knowledge, leadership, and professional comportment (Figure 2).
      KU Medical Center School of Nursing
      Professional Identity in Nursing.
      ,
      • Brewington J.
      • Godfrey N.
      The professional identity in nursing initiative.
      Because professional identity in nursing is fostered in all settings and all roles requiring nursing knowledge, this insight poses implications for nursing leadership.
      Figure thumbnail gr2
      Figure 2Definitions for Professional Identity in Nursing.

      Nurse Leaders’ Influence

      In the 2018 think tank, a Tree of Impact was generated through consensus methods. Thematic analysis was used to examine themes around PIN. Two key themes emerged with leadership implications. These included fostering of professional identity in all settings and fostering lifelong learning.
      • Joseph M.L.
      • Edmonson C.
      • Godfrey N.
      The conceptual model for professional identity in nursing. International Society for Professional Identity in Nursing (ISPIN) Advisory Council.
      ,
      KU Medical Center School of Nursing
      Professional Identity in Nursing.
      It is clear that both the academic setting and clinical settings are poised to play a key role in professional identity formation and sustainability, specifically with role modeling, clinical placements, transitioning into practice, jobs, implementing healthy work environments, and supporting the evolving role expectations of nurses.
      • Godfrey N.
      • Young E.
      Professional identity.
      ,
      • Joseph M.L.
      • Edmonson C.
      • Godfrey N.
      The conceptual model for professional identity in nursing. International Society for Professional Identity in Nursing (ISPIN) Advisory Council.
      ,
      KU Medical Center School of Nursing
      Professional Identity in Nursing.
      One major area of impact by nurse leaders is on retention. There is a plethora of literature that has shown that career choice, job satisfaction, and positive nursing image are associated with nurse retention. Additionally, negative career perceptions and achievement have been shown to be associated with attrition.
      • Armitage-Chan E.
      • May S.A.
      Identity, environment and mental well-being of the veterinary profession.
      Godsey and colleagues

      Godsey JA, Houghton DM, Hayes T. Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession [e-pub ahead of print]. Nurs Outlook. https://doi.org/10.1016/j.outlook.2020.06.005. Accessed September 20, 2020.

      revealed that leaders contributed to the brand image of nursing and called for greater leadership support, increasing advocacy by leaders, the need to speak up for nursing, and the need to demonstrate more confidence in the nurse leader’s role.
      The current pandemic has highlighted nursing’s influence on the health care experience. Nurses have voiced a lack of influence with regard to health policy, but the pandemic has provided us with a stronger voice to influence future policy and practice. The lasting impact of this pandemic will be determined in part by how leaders respond individually, organizationally, and societally. Nurse leaders’ responses will influence future leadership practice and society’s perception beyond this current generation.
      • Bennett C.L.
      • James A.H.
      • Kelly D.
      Beyond tropes: towards a new image of nursing in the wake of COVID-19.
      This applies to leaders in both education and practice.

      The Nurse Leader as a Conduit for Professional Identity

      A strong, confident, and flexible professional identity is essential for nurses and nurse leaders to function optimally and influence change. This benefits not only nurses themselves, but also patients, other members of the health care team, and society.
      • Brewington J.
      • Godfrey N.
      The professional identity in nursing initiative.
      To enable professional identity, nurse leaders need to optimize role modeling, foster professional identity in all work settings, and promote lifelong learning.

      Modeling of Foster Professional Identity in Nursing

      Nurses’ personal beliefs and identities may be distinct upon entry into nursing school and during clinical experiences. However, nursing formation calls for alignment to established ethical standards of the profession. This will occur over time, enabling identity construction and deconstruction for the formation of PIN.
      • Hite A.
      • Godfrey N.
      Professional identity in nursing: why does it matter?.
      Formal development will begin in academia and then transition into practice. This ongoing formation will require modeling of PIN. Modeling may occur through daily interactions and communication efforts to ensure that nurses “think, feel, and act like a nurse.”
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      ,
      • Hite A.
      • Godfrey N.
      Professional identity in nursing: why does it matter?.
      ,
      • Johnson M.
      • Cowin L.S.
      • Wilson I.
      • Young H.
      Professional identity and nursing: contemporary theoretical developments and future research challenges.
      Coaching nurses to be clear about their significance and how their role contributes to the health care team, patient care, and society, will be a critical strategy for identity formation in nursing.
      • Sherman R.O.
      The Nurse Leader Coach: Become the Boss No One Wants to Leave.
      A call in the published literature for all nurses is to demonstrate self- confidence.
      • Stajkovic A.D.
      • Luthans F.
      Self-efficacy and work-related performance: a meta-analysis.
      ,
      • Gilmartin M.J.
      Variations in clinical nurse leaders’ confidence with performing the core role functions.
      There are many factors that may impede nurses’ ability to consistently exuberate a reliable and positive nurse identity and nurse leader image. However, research has shown that self-confidence is associated with work outcomes such as successful career transitions, job satisfaction, job performance, and voluntary turnover.
      • Gilmartin M.J.
      Variations in clinical nurse leaders’ confidence with performing the core role functions.
      Self-confidence is trusting one’s own judgment and abilities, and acknowledging that one values themselves and feels worthy, regardless of what others may think.
      • Johnson M.
      • Cowin L.S.
      • Wilson I.
      • Young H.
      Professional identity and nursing: contemporary theoretical developments and future research challenges.
      The increasing complexity of practice environments calls for ongoing intellectual stimulation, new educational tools, and assets such as clinical reasoning and educational preparation to enable optimal collaboration to improve patient care outcomes.
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      ,

      Godsey JA, Houghton DM, Hayes T. Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession [e-pub ahead of print]. Nurs Outlook. https://doi.org/10.1016/j.outlook.2020.06.005. Accessed September 20, 2020.

      ,
      • Godfrey N.
      Proceedings of the Professional Identity in Nursing: Science, Strategy and Call to Action Think Tank.
      Practice environments need to be conducive and stimulating for learning by modeling best practices. In that way, nurses can replicate these practices in future leadership roles or seek environments to practice that enhance their professional identity.
      • Joseph M.L.
      • Edmonson C.
      • Godfrey N.
      The conceptual model for professional identity in nursing. International Society for Professional Identity in Nursing (ISPIN) Advisory Council.

      Fostering PIN in all Work Settings

      Leaders need to foster professional identity in all work settings regardless of whether it is in acute care or elsewhere. To work with others within any setting requires the execution of professional identity domains of values and ethics, knowledge, leadership, and professional comportment (Figure 2).
      Enabling an environment that is civil, nurturing, and intellectually stimulating empowers nurse’s PIN.
      American Society for Quality. W
      Edwards Deming’s 14 Points for Total Quality Management.
      ,
      Robert Wood Johnson Foundation
      Charting Nursing's Future Brief: Patient Safety Through Workplace Transformation.
      A leader’s responsibility is to promote and encourage a healthy work environment. Leaders need to embrace their influence to impact cross-functional and interdisciplinary teams, assist in identifying educational needs, promote effective communication, and incorporate conflict resolution skills.
      American Nurses Association
      American Nurses Association Position Statement on Incivility, Bullying, and Workplace Violence.
      As a discipline, there needs to be a strict zero-tolerance policy for incivility, bullying, microaggressions, and harassment. As role models, it is essential for every leader to uphold this policy consistently in all work settings. The American Nurses Association (ANA) states nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect.”
      American Nurses Association
      American Nurses Association Position Statement on Incivility, Bullying, and Workplace Violence.
      Leaders need to nurture themselves first so they can advocate and promote healthy behavior in work environments, personal lives, and throughout communities.

      Promoting Lifelong Learning

      Knowledge, as a concept in the Conceptual Model of PIN is lifelong learning. Lifelong learning was first introduced by Knowles as a transformation from formal education being primarily for those with resources in formal settings to those needing ongoing education. This paradigm shift is now a standard.
      Reflections on Lifelong Education and the School.
      Lifelong learning is the process of acquiring and enhancing enlightenment in the domains of formal and informal opportunities throughout the lifespan, based on a need for continual inquiry. The Future of Nursing Report emphasized the foundational element of lifelong learning as a key driver of transforming the nursing profession.
      Institute of Medicine
      The Future of Nursing: Leading Change, Advancing Health.
      Subsequently, in a 2017 systematic review, the authors identified 9 themes for lifelong learning and stated that if the profession truly adopts a lifelong learning philosophy the need for continuing education would become irrelevant.
      • Qalehsari M.Q.
      • Khaghanizadeh M.
      • Ebadi A.
      Lifelong learning strategies in nursing: a systematic review.
      Strategies to model lifelong learning include the capacity to grow, utilizing multiple ways of knowing, having a desire for excellence, having a growth mindset, and engaging in reflections. Nurse leaders can model and foster these strategies.
      The holistic nature of the nursing profession is the integration of the personal, professional, and environment aspects. These dimensions are crucial, as the whole person is expected to care for others and care for self, which require continual development.
      • Godfrey N.
      Professional Identity in Nursing: Science, Strategy and Call to Action for 2018 Think Tank.
      The complexities of the environment have required us to become intentional, focused, and open, with an ongoing quest to seek additional educational opportunities. Over time, this often takes nurses back to nursing school for career changes beyond the bedside.

      Future Implications for Nursing Leadership

      Visible, consistent, and effective nursing leadership will be vital to convert the enhanced attention and positive discourses about nursing into action.
      • Benner P.
      • Sutphen M.
      • Leonard V.
      • Day L.
      Educating Nurses: A Call for Radical Transformation.
      ,

      Godsey JA, Houghton DM, Hayes T. Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession [e-pub ahead of print]. Nurs Outlook. https://doi.org/10.1016/j.outlook.2020.06.005. Accessed September 20, 2020.

      ,
      • Johnson M.
      • Cowin L.S.
      • Wilson I.
      • Young H.
      Professional identity and nursing: contemporary theoretical developments and future research challenges.
      A strong PIN supported by a new brand image will take us forward through the 21st century and build on our history.
      • Bennett C.L.
      • James A.H.
      • Kelly D.
      Beyond tropes: towards a new image of nursing in the wake of COVID-19.
      Change begins with each nurse, who widens and then influences other levels.

      Individual Level

      Nurse leaders need to engage in self-leadership. The theory of self-leadership stresses the importance of creating and maintaining a constructive thought pattern. One who uses a growth mindset believes that with effort and experience, new knowledge can be learned and useful skills developed for future pursuits. Other techniques to reframe thinking include positive self-talk, visualization, challenging beliefs and assumptions, and finding a mentor who can model strong self-leadership skills and emotional intelligence. Having an experienced mentor can improve conversational skills with others when they turn to you for direction.
      • Goldsby E.A.
      • Goldsby M.G.
      • Neck C.P.
      Self-leadership strategies for nurse managers.

      Organizational Level

      Nurse leaders may design an internal brand to occupy a distinct presence in the minds of stakeholders (patients and families, physicians, executives, and other disciplines). This may be accomplished through a brand campaign. An effective brand campaign with a management strategy communicates a message that is clear, relevant, and consistent, while also articulating meaningful goals. To execute this campaign, the nursing team and supportive personnel must design an image so that it creates a distinct and valued place in the minds of all. This maximizes the brand to fit the image. Brands include consumer values, thoughts, feelings, perceptions, images, experiences, beliefs, and attitudes.
      • Godsey J.
      • Perrott B.
      • Hayes T.
      Can brand theory help re-position the brand image of nursing?.
      The nurse leader’s challenge is to articulate nurses’ value, for example in innovations to address a pandemic.

      Societal Level

      Nurse leaders need to spread the vision and work from organizations to a broader context within society. In a recent study, Australian authors spoke about tensions that continue to plague the field of nursing and used the metaphor of Newton’s Cradle.
      • McAllister M.
      • Madsen W.
      • Colin H.
      Newton cradle: a metaphor to consider the flexibility, resistance, and direction of nursing’s future.
      This metaphor represents energy and momentum, and describes the significance and interconnections between all the tensions plaguing the profession. When the tensions within nursing are contained, understood, and developed, they remain in alignment, and energy is conserved, and not misdirected. The metaphor suggests that awareness and attention to these challenges, as well as taking a broad-based approach to systematic improvements, may help nursing become more effective, progressive, and proactive in shaping its future.
      • McAllister M.
      • Madsen W.
      • Colin H.
      Newton cradle: a metaphor to consider the flexibility, resistance, and direction of nursing’s future.
      This analogy supports work that is occurring now regarding the image of nursing and PIN.
      • Godfrey N.
      • Young E.
      Professional identity.
      ,

      Godsey JA, Houghton DM, Hayes T. Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession [e-pub ahead of print]. Nurs Outlook. https://doi.org/10.1016/j.outlook.2020.06.005. Accessed September 20, 2020.

      ISPIN

      Although much needed and overdue, ISPIN continues to solidify our understanding of what PIN is, what it looks like, how it is taught, and how it is evaluated. We have been intentional with our approach to create change. We are currently using a 6-step intervention strategy for change.
      • Wight D.
      • Wimbush E.
      • Jepson R.
      • Doi L.
      Six steps in quality intervention development (6Squid).
      • Step 1: define and understand the problem and its causes
      • Step 2: identify which causal or contextual factors are modifiable
      • Step 3: decide on the mechanisms of change
      • Step 4: clarify how these will be delivered
      • Step 5: test and adapt the intervention
      • Step 6: collect sufficient evidence of effectiveness to proceed to a rigorous evaluation
      Through the first 2 think tanks, steps 1 and 2 have been accomplished. The mechanisms of change have been established from Think Tank 3 through concrete competency development. Nurse leaders are being called to support, model, and guide others in order to ensure all nurses learn about, find, and form their PIN. As the concept of PIN becomes clearer with measurable attributes and actionable strategies, nurse leaders will have an opportunity to test the processes developed to teach, evaluate, and address PIN in all nurses. With the increasing participation of nurse leaders, steps 5 and 6 can also be evaluated and improved upon.

      Conclusion

      A primary conduit for professional identity in nursing is nursing leadership. Current leaders are poised to influence the next generation of nurse leaders. The time is now. Members of Generation Y are optimistic about their future roles as leaders and the nursing profession.
      • Dyess S.M.
      • Sherman R.O.
      • Pratt B.A.
      • Chiang-Hanisko L.
      Growing nurse leaders: their perspectives on nursing leadership and today’s practice environment.
      Therefore, how nurse leaders lead, model, improve practice environments, foster lifelong learning, and test new interventions from ISPIN will impact brand image and the next generation of leaders to form a stronger professional identity.

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      Biography

      M. Lindell Joseph, PhD, RN, FAAN, is Clinical Professor and Director Health Systems/Administration Program at the College of Nursing, The University of Iowa, in Iowa City, Iowa. She currently serves on the AONL Foundation Board of Directors. She can be reached at [email protected] . Beth Cusatis Phillips, PhD, RN, CNE, CHSE, is Associate Professor and Director of the Institute for Educational Excellence at the School of Nursing, Duke University, in Durham, North Carolina. Cole Edmonson, DNP, RN, NEA-BC, FACHE, FAONL, FNAP, FAAN, is Chief Experience and Clinical Officer at AMN Healthcare, Dallas, in Dallas, Texas. Nelda Godfrey, PhD, ACNS-BC, RN, FAAN, ANEF, is Professor and Associate Dean, Innovative Partnerships & Practice at the School of Nursing, University of Kansas, in Kansas City, Kansas. Debra Liebig, MLA, BSN, NPD-BC, is Program Manager at the Accreditation & Regulatory Readiness Department, Children Mercy, in Kansas City. Susan Luparell, PhD, RN, CNE, ANEF, is Professor at the College of Nursing, Montana State University, in Great Falls, Montana. Karyanne Weybrew, MSN, RN, WHNP, is Campus Assistant Director, ADN Program at American Career College in Los Angeles, California.