A qualitative study on nursing professionalism: safeguarding life through a conceptual model

Abstract

Objective

The aim of this study was to clarify and develop a conceptual framework for nursing professionalism.

Background

Nursing professionalism serves as a guide for nurses in all aspects of their work. Nurses with strong professionalism are key to safeguarding the health of all people. However, the concept of nursing professionalism remains ambiguous.

Methods

This study used Charmaz's Constructing Grounded Theory. Thirty-eight participants, including nursing students, clinical nurses, nursing managers, doctors and patients in China, were interviewed from May 2021 to August 2022. We used purposeful sampling and theoretical sampling. By exploring stakeholders’ understanding of the concept of nursing professionalism, the researchers clarified its conceptual components.

Results

The conceptual framework of nursing professionalism encompasses four components: altruism, dedication, caring, and professional competence. Altruism includes putting patients-first and benefiting others. Dedication includes sacrifice, patience, tolerance, and expecting nothing in return. Caring reflects reverence for life, empathy, compassion, and concern. Professional competence includes sensitivity, responsibility, excellence, self-discipline, and collaboration.

Conclusion

This study clarifies the conceptual framework of nursing professionalism, providing guidance for cultivating professional values in nursing education and clinical practice. The framework also enables the development of precise assessment tools to systematically evaluate nursing professionalism.

Introduction

As nurses represent the largest group in the health care industry, the level of their professionalism is crucial for stabilizing the nursing team and enhancing patient outcomes [1]. Several studies have shown that professionalism plays a crucial role in enhancing nurses'sense of professional identity and overall job satisfaction [2]. By embodying professionalism, nurses not only gain public recognition for the core values of nursing but also experience personal fulfillment [2]. Nursing professionalism plays a crucial role in nursing practice, and it is essential for nurses to undergo long-term, continuous professionalism training [3] and provide a culture of professionalism to meet clinical demands [4]. To cultivate nursing professionalism, it is imperative to establish a systematic and scientific conceptual framework as a foundation and support.

Nursing professionalism refers to the belief in nursing as a profession, encompassing nurses’ cognition, attitudes, and behavior during practice [5]. It serves as the primary force behind nursing practice. In 1982, Styles [6] proposed that the foundation of nursing professionalism lies within individual registered nurses. To provide a clearer definition of professionalism, she introduced the term'professionhood'. Styles advocated for convincing nurses of the value of nursing, nurturing professional attitudes, and establishing models of nursing professionalism. She also emphasized the importance of three fundamental professional attitudes for nurses: (1) fulfilling commitments and striving for excellence in their work; (2) recognizing the shared responsibility and authority within the profession while maintaining professional integrity; and (3) recognizing the significance of their work, having a sense of mission, and seeking social recognition and a clear sense of purpose.

In 1984, Miller’s [7] Wheel of Professionalism in Nursing defined professionalism from a behavioral perspective. According to this theory, nursing professionalism involves eight aspects: competence and continuing education; adherence to professional ethics; membership in major professional associations; academic discourse and communication skills; community service; development, application, and evaluation of theoretical knowledge; advancement, application, and evaluation of research; and autonomy and self-regulation. However, Moloney [8] suggested that individual self-shaping of professionalism plays a minimal role, while nurses in a collective setting can influence and even enhance the professionalism of their peers. Moloney's study provided a new perspective on the study of professionalism. The concept of nursing professionalism currently lacks a unified definition, with various scholars offering different perspectives on its interpretation. Yoder [9] suggested that the definition of professionalism consists of six components: (1) serving the interests of patients, (2) possessing high standards of competence and knowledge, (3) demonstrating high ethical standards, (4) exhibiting a humanistic spirit, (5) practicing social responsibility, and (6) demonstrating sensitivity to people’s culture and beliefs. Other scholars have defined nursing professionalism through concept analysis, identifying three pillars: nursing principles, communication principles, and ethical principles [10]. Sullivan's study define professionalism as a multidimensional construct [11] and identify three distinctive dimensions of nursing professionalism, building upon prior research [12]: (1) the utilization and contribution of nursing knowledge; (2) professional autonomy; and (3) the responsibility to meet social needs. A literature review conducted by Cao et al. [13] concluded that professionalism is characterized by multidimensionality, dynamism, and abstraction, and proposed that the conceptual components of nursing professionalism include care, professionalism, and altruism.

These previous studies have laid an important foundation for the development of the concept of nursing professionalism. The current conceptual framework remains broad and unrefined, primarily outlining general dimensions without delineating the specific attributes underlying each component of nursing professionalism. To effectively guide the assessment and cultivation of professional competencies, a more precise and operationalized framework is required.

Furthermore, nursing professionalism evolves with professional development and is influenced by culture and context; thus, to cultivate nursing professionalism, it is crucial to understand the perspectives of nursing staff and develop a conceptual framework to create more targeted and effective strategies for fostering professionalism. In this regard, qualitative research can provide deeper insights into the concept of nursing professionalism. Therefore, this study aims to explore the following questions: 1. What is the conceptual content of nursing professionalism? 2. How can we distinguish the concept and components of nursing professionalism from those of medical professionalism?

Methods

Design

The interpretive nature of Charmaz's Constructing Grounded Theory allows researchers to incorporate both professional and personal experiences, along with existing knowledge, to inform their studies [14]. Therefore, it is appropriate to use Constructing Grounded Theory to explore the complex concepts of nursing professionalism. Constructivist grounded theory is an optimal method for explaining social processes and human behavior and has been widely used in nursing, education and sociology [15]. The concept of nursing professionalism was not predetermined but emerged from the interactive process among the researcher, the subjects, and the data.

Participant recruitment, sampling and data collection

Researchers conducted semi-structured interviews to collect data from May 2021 to August 2022, utilizing purposeful sampling and theoretical sampling.Sampling was initially through purposeful and convenience by participant self-selection [16]. The researcher selected people with nursing professionalism (e.g., nurses who have been recognized with the Nightingale Award as interviewees) to be interviewed through purposive sampling. Analyses commenced immediately upon interview completion. Based on the results of the analyses, the sampling proceeded from convenience to theoretical on the basis of the emergent finding.

Theoretical sampling constitutes a defining characteristic of grounded theory research. This methodology emphasizes concurrent data collection, coding, and analysis, where subsequent sampling decisions are guided by emerging codes and conceptual requirements as the theory progressively develops. For instance, during this investigation, textual analysis revealed that constructing a comprehensive conceptual framework of nursing professionalism necessitated inclusion of practitioners at various career stages. Consequently, the research team strategically expanded participant recruitment to incorporate nursing students and junior nurses in subsequent interview phases to satisfy theoretical saturation requirements.

The research team, based on the need for theoretical sampling, successively included different interviewees such as nursing administrators, clinical nurses, nursing students, physicians, and even patients. Data collection continued until theoretical saturation was attained in both manifest and concealed core categories after conducting interviews with 38 participants.

The inclusion criteria were as follows:

① The participants included individuals associated with nursing practices, including nursing managers, nurses, nursing students, nursing educators, physicians, administrative staff, patients, and their family members. Qualifications such as relevant certificates were required for nursing managers, nurses, nursing students, nursing educators, physicians, and administrative staff. Participants (patients and/or family caregivers) met inclusion criteria: age ≥ 18 years, documented hospitalization or caregiving history, and communicative competency confirmed by researchers.

② The participants volunteered, provided informed consent, and agreed to have the interviews recorded.

Exclusion criteria were as follows:

• ①Individuals with communication barriers.

• ②Participants who withdrew prematurely.

Researchers prepared an interview outline (as shown in Table 1) before conducting the interviews. Informed consent was obtained from the participants, explaining the purpose and process of the interview, and seeking permission to record the conversation. By employing effective interview techniques, researchers explored the research questions in depth. The interviews were recorded using audio recording tools, supplemented by note-taking. Information about the interviewees is provided in Table 2.

Table 1.

Interview outline

Interview outline
	Introduction
1	Why did you choose to be a nurse?
2	How long have you been in clinical nursing? What makes you stay in your job?
	Discussion on the concept content of nursing professionalism:
1	How do you understand nursing professionalism?
2	What qualities or behaviors do you consider to be indicative of nursing professionalism?
3	Are there any good nurses around you? What are their characteristics? Can you give me some examples?
4	What do you think nursing professionalism consists of?

Table 2.

General information of the study subjects (N = 38)

Category	Number	Gender	Age	Working years	Title/Occupation	Education	Number of interview sessions	Average interview time/min	Region
Nursing manager	DN1	Female	63	43	Chief Nurse Practitioner	Master's degree	4	225	Shanxi Province
	DN2	Female	32	6	Nurse in charge	Master's degree	1	94	Shanxi Province
	DN3	Female	60	39	Chief Nurse Practitioner	Master's degree	1	46	Shanxi Province
	NM1	Female	40	15	Associate chief nurse	Doctor of Medicine	1	35	Shanxi Province
	NM2	Female	42	17	Associate chief nurse	Master's degree	1	62	Shanxi Province
	NM3	Female	34	10	Nurse in charge	Undergraduate	1	72	Tianjin City
Clinical nurse	N1	Female	37	15	Nurse in charge	Master's degree	2	60	Shanxi Province
	N2	Female	36	15	Nurse in charge	Technical secondary school	1	67	Shanxi Province
	N3	Female	28	4	Nurse in charge	Master's degree	1	90	Shanxi Province
	N4	Female	29	2	Nurse practitioner	Doctor of Medicine	1	82	Sichuan Province
	N5	Female	28	3	Nurse practitioner	Master's degree	1	38	Shanxi Province
	N6	Female	32	11	Nurse in charge	Master's degree	1	50	Shanxi Province
	N7	Female	64	43	Chief Nurse Practitioner	Technical secondary school	1	88	Shanxi Province
	N8	Female	34	10	Nurse in charge	Undergraduate	1	81	Chongqing City
Teacher of nursing	NT1	Female	32	2	Lecturer	Doctor of Medicine	1	94	Sichuan Province
	NT2	Female	33	5	Lecturer	Master's degree	1	79	Shanxi Province
	NT3	Female	30	5	Lecturer	Master's degree	1	44	Shanxi Province
	NT4	Female	41	16	Associate professor	Doctor of Medicine	1	67	Tianjin City
	NT5	Female	63	40	Professor	Master's degree	1	62	Shanxi Province
	NT6	Female	33	5	Lecturer	Master's degree	1	60	Shanxi Province
	NT7	Female	33	5	Lecturer	Master's degree	1	45	Shanxi Province
Nursing student	DrS1	Male	37	/	/	Doctor of Medicine	1	90	Inner Mongolia
	DrS2	Female	32	/	/	Doctor of Medicine	1	68	Liaoning Province
	MS1	Female	23	/	/	Master's degree	1	87	Liaoning Province
	MS2	Female	23	/	/	Master's degree	1	45	Shanxi Province
	US1	Female	22	/	/	Undergraduate	1	45	Shanxi Province
	US2	Female	22	/	/	Undergraduate	1	54	Shanxi Province
	US3	Female	19	/	/	Technical secondary school	1	43	Shanxi Province
Medical doctor	Dr1	Male	38	10	Physician in Charge	Master's degree	1	62	Shanxi Province
	Dr2	Male	31	1	Resident physicians	Doctor of Medicine	1	91	Shanxi Province
Administrative staff	Oth1	Female	50	29	Chief Nurse Practitioner	Master's degree	1	67	Shanxi Province
	Oth2	Female	31	6	Nurse in charge	Master's degree	1	42	Shanxi Province
Patient	P1	Male	56	/	Renal adeninoma postoperative/workers	High school	1	32	Shanxi Province
	P2	Female	59	/	Acute drug-induced liver poisoning/workers	High school	1	40	Shanxi Province
	P3	Female	32	/	Thyroid cancer postoperative/Staff	Technical secondary school	1	43	Shanxi Province
	P4	Male	63	/	Type 2 diabetes mellitus/Farmer	Junior high school	1	36	Shanxi Province
	P5	Female	67	/	After breast cancer/bank clerk	High school	1	40	Shanxi Province
	P6	Male	82	/	Coronary heart disease/Teacher	Technical secondary school	1	36	Shanxi Province

Data collection was concluded when no new information could be gleaned, and data saturation was reached. Two trained assistants independently inputted baseline characteristics into password-protected Excel spreadsheets, followed by cross-verification to ensure data integrity.

All materials related to the study subjects'information were encrypted and securely stored by the researchers. Interview questions were formulated based on the literature and group discussions. To ensure the accuracy and comprehensiveness of the information, the researchers transcribed the interviews and then returned the transcripts to participants for review or correction.

Additionally, this study employed the artifact collection method as a supplementary means of data gathering. The primary focus was on collecting physical items, such as images provided by the interviewees, and relevant texts, including books related to the subject. Media data collection primarily included news reports, television interviews, and images posted on social platforms. This study collected two books,"Florence Nightingale in China"and its sequel"Continuation of Florence Nightingale in China,"to complement the exemplary stories of individuals embodying nursing professionalism. Additionally, 29 media reports related to nursing professionalism, 219 images provided by the interviewees, and 15 short videos were collected. The recorded interviews were transcribed using the"iFlytek Listening System,"resulting in over 500,000 words of transcribed text.

Data analysis

This study employed Charmaz's Constructing Grounded Theory, which involves the coding process of initial coding, focused coding, and axial coding. Initial coding assigns labels to each word, sentence, or segment of the data [14], using methods such as word-by-word coding, line-by-line coding, and event-by-event coding. Initial coding facilitates the researcher's immersion in the text for analysis without making interpretive leaps. Focused coding utilizes the most significant and/or frequently occurring initial codes to sift through large volumes of data. Axial coding [14] connects categories and subcategories, clarifying their attributes and dimensions, and reorganizing fragmented data from the initial coding phase, thereby providing coherence to the analysis. Although Charmaz's approach does not strictly require axial coding, Charmaz emphasizes the importance of developing subcategories for the identified categories and illustrating their relationships.

In this study, the researchers conducted detailed initial coding of the transcribed texts, as exemplified in Table 3. Through textual analysis, numerous initial codes related to"sensitivity"were generated. These codes were iteratively synthesized into two focused codes: sensitive to patient’s need and sensitive to patient’s condition. The two representatives further focused on forming a more central code: sensitivity.

Table 3.

Initial and focused coding

Interviews text	Initial coding	Focused coding1	Focused coding2
R: Actually, nurses must possess a sensitive disposition1. They need to be attuned to everything—what does sensitivity mean2? It means that when you see a patient suffering or in pain, as a nurse, you’re acutely aware of it3. The worst thing for a nurse is insensitivity4. That’s why nursing theorist Watson emphasized the concept of sensitivity. (DN1)	1. Sensitivity is an essential nursing quality 2. Comprehensive sensitivity to patient conditions 3. Sensitive to patient suffering 4. Nurse insensitivity constitutes clinical risk	1Sensitive to patient suffering	Sensitive to patient’s condition
R: You need to be sensitive to both yourself and others1. For instance, I’m highly sensitive—if a teacher criticizes me for being late or gives me a disapproving look, I self-reflect and ask,"Did I do something wrong?"Then I take corrective action2. Nurses must have a high level of sensitivity, much like Nightingale herself3. If you’re insensitive—seeing a patient in pain but remaining indifferent—that’s outright apathy4. Ultimately, sensitivity should be an inherent trait of nurses5. (DN1)	1. Be sensitive to yourself and others 2. Sensitivity helps correct behavior 3. Nurses need to be highly sensitive 4. Be sensitive to patients'pain 5. Sensitivity is a unique quality of nurses	Sensitive to patient suffering	Sensitive to patient’s condition
I adjust my working approach based on my nursing shifts. For example, if I’m assigned to a general ward shift, my tasks are more routine—I simply focus on completing daily responsibilities like standard patient care1. But when working in the ICU, I need to stay sharp. ICU patients often have critical, rapidly changing conditions2, so I must mentally keep track of every medical tube, monitor their vital signs closely, and stay updated on their status throughout the shift3. (N6)	1. Routine work 2. Reasons for alertness in the intensive care unit (need for high sensitivity/rapid change of condition) 3. Sensitive manifestations: Observe the pipeline: observe the changes of the disease throughout the day	Sensitive to patient's condition	Sensitive to patient’s condition
R: Why do nurses need to be sensitive? Because your profession demands it1. Just like this mother—if you weren’t a mother, you wouldn’t need that sensitivity. But once you become a mother, you notice immediately if your child eats less today or seems quieter than usual, right? Normally they come home chattering away, but today they’re withdrawn. You’d sense something’s off without even knowing exactly why—that’s maternal sensitivity2. (DN1)	1. Sensitivity is required by the nursing profession 2. Mothers are sensitive to their children	Sensitive to the patient's mood	Sensitive to patient’s need

With progressive analytical refinement, five focused categories emerged—sensitivity, responsibility in patient care, excellence, self-discipline, and collaboration—which collectively constitute the thematic dimension of professional competence within the nursing professionalism. Concurrently, additional categories of nursing professionalism were identified(Altruism, Dedication, Caring), ultimately integrated under the overarching core category of"Safeguarding Life", which encapsulates the essential component of nursing professionalism (Table 4).

Table 4.

Theme, sub-theme and example quotes

Theme	Sub-theme	Interviewee	Example quotes
Altruism	Putting patients-first	NM1	Altruism doesn't necessarily mean always sacrificing oneself, but nursing professionalism requires constantly emphasizing that the patient's life is paramount, and their interests come first. Nursing should always be altruistic, always revolving around the patient.
	Benefiting others	Oth1	In the ICU, preventing vascular embolism is crucial. You know, things like making sure patients move regularly or wear compression stockings—those are all carried out by nurses. But here's the thing: if you don't have the proper medical knowledge about these precautions, you might implement them incorrectly or miss important details. That's where true professionalism comes in—using our specialized expertise to genuinely help patients benefit from these preventive measures.
Dedication	Sacrifice	DN1	Why work overtime? On the one hand, it's due to insufficient staffing, and on the other hand, it's because of the complexity and variability of the job. Nursing is ever-changing, and its complexity and individual variations pose considerable challenges. That's why doctors and nurses must embody a spirit of dedication. For instance, if it's time for you to finish your shift, but a patient experiences severe bleeding or an emergency arises, what do you do? You have to sacrifice your own time to assist the on-duty nurse in handling the patient.
	Patience	DN1	Nurses deal with all sorts of things, you know. Blood, vomit, secretions, or patients who look like something out of a horror movie—twisted limbs, disfigured faces, especially in cases like trauma patients from accidents. What you're faced with are situations like these—it affects your mood, but as a nurse, it's what we do.
	Tolerance	NM2	Patients complain, they may not treat you well or anything. When we interact with patients, we often face their dissatisfaction. You really have to rise above it, you know? Sometimes you just have to learn to deal with the unfairness. A bit of patience, acknowledging their emotions.
	Expecting nothing in return	N6	Doctors and nurses aren't only in it for the money; our calling is to save lives, not prioritize profit. Healthcare is altruistic; the primary goal is to ensure people's lives and health before anything else.
Caring	Reverence for life	DN1	Our job is really different from others, it's so unique. A little slip-up, and a patient lost their life. That's why we respect the value of each patient's life, cater to their needs. With that understanding, we take our job seriously, never slacking off.
	Empathy, compassion, and concern	DN1	The crux for psychiatric nurses lies in establishing a ‘soul-to-soul’ connection with the patient. The nurse‒patient relationship transcends mere contractual obligations; focusing instead on companionship and attentive listening. Guarding the patient requires being bedside, being present, and observing with sensitivity. If you're not present—what good is it?
Professional competence	Sensitivity	N2	Nurses need to have good judgment. For instance, with a patient experiencing significant bleeding, if there's not much vaginal bleeding but excessive sweating, fatigue, and a pale complexion, and there's no bleeding from the vagina, you have to consider the possibility of internal bleeding, right? You have to have the ability to assess these issues.
	Responsibility in patient care	P5	I believe responsibility is more important than capability. Some nurses may not have the strongest skills, but they have a strong sense of responsibility. This sense of responsibility drives them to provide excellent care for their patients. For the sake of the patients, they naturally push themselves to improve their skills.
	Excellence	N3	To be a good nurse, you need to keep learning in the clinical setting, reflect on work experiences, continually enhance yourself, and hone your skills
	Self-discipline	N8	Nurses need to be cautious. A lot of work in nursing practice is done alone without human supervision. If you set the bar very low, the quality of care may be low, and patient safety may not be guaranteed.
	Collaboration	N7	New nurses are not familiar with the nursing workflow, so experienced nurses will mentor them. For example, when a patient's condition suddenly changes and requires first aid near the end of work, some nurses may still stay and cooperate to complete the patient's first aid.

The researchers extracted collection information about perceptions of nursing professionalism and followed the grounded theory textual analysis to determine how many aspects of professionalism are included, what specific elements are included, and what combination of these aspects explains nursing professionalism. After the textual analysis, members of the group discussed the aspects and elements included to ensure that these aspects explained nursing professionalism and that there was as little crossover as possible between the various sections.

Theoretical saturation refers to the point at which collecting fresh data no longer yields new theoretical insights[14]. In our study, researchers conducted a total of 40 interviews with 38 participants, with two respondents interviewed multiple times. The participants ranged in age from 19 to 63 years, with educational backgrounds ranging from high school to the doctoral level. Geographically, participants were distributed across various regions such as Jiangsu, Guangxi, Liaoning, Shanxi, and Inner Mongolia in China, among others. The interviewees represented diverse roles, including nursing managers, clinical nurses, nursing educators, nursing students, doctors, administrators, and patients. Additionally, this study supplemented data collection with both image and text materials.

Throughout the data collection and analysis process, researchers maintained memos to document potential biases [14]. Regular team meetings were conducted to review textual analysis outcomes, with focused discussions on emerging categories and themes requiring resolution of discrepancies. All identified themes underwent rigorous cross-validation to ensure analytical consistency.

Rigor and trustworthiness

Researchers contacted participants through diverse channels, including email, mobile messages, and WeChat. Ethical standards were rigorously upheld, with all participants completing informed consent documents. The rigor of the data analysis process was ensured by maintaining the trustworthiness of the data, which included credibility, confirmability, transferability, and dependability [17].

Credibility: Credibility was ensured by audio-recording and transcribing all conversations to maintain the accuracy of the data. Additionally, this study employed various data collection methods to increase credibility, such as collecting physical items (e.g., images provided by the interviewees), relevant texts (e.g., books related to the subject), media reports, and short videos.

Confirmability: To ensure confirmability, the interview transcripts were returned to participants for review and correction. Additionally, the research team met regularly to discuss findings, plan future data collection, review transcripts, and evaluate the collected data [18].

Dependability: The development of the interview questions originated from a comprehensive review of the relevant literature. Subsequent modifications and validations were undertaken collaboratively by the research team, further enhancing the methodological rigor of the study. To ensure dependability, the research team meticulously reviewed the interview transcripts, compared the extracted codes to the original data, and repeatedly cross-checked the analysis with participants’ views to maintain reflexivity and prevent researcher bias from influencing the study data. Drawing on the researchers’ clinical nursing and management experience, the data analysis was conducted reflectively, ensuring that any preconceived assumptions did not influence the analysis or results of the study [19].

Transferability: This study adhered to the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [20]. Regular discussions were conducted among the researchers to analyse emerging categories and themes. Throughout data collection and analysis, researchers maintained memos to document any potential biases. The qualitative research analysis considered the compatibility of opinions collected during individual interviews. Additionally, transferability was enhanced by demonstrating that the richness of the interview conversations increased the vividness of the report.

Ethical considerations

The Ethics Committee of the First Hospital of Shanxi Medical University (Approval number 2020K061) approved this study, ensuring participant confidentiality through a signed agreement. To protect privacy, all personal information was anonymized. Participation was voluntary, and participants retained the right to withdraw at any point.

Findings

In this study, interview data from 38 participants were analyzed in depth and supplemented with textual and visual material from books in order to derive the conceptual components of nursing professionalism. Nursing professionalism is a complex concept that includes four main conceptual components: altruism, dedication, caring and professional competence. These four components of this concept and the richness of attributes it contains work together to explain the content of the concept. Each of these attributes encompasses rich subcontent, as illustrated in Fig. 1.

Fig. 1.

Conceptual framework for nursing professionalism

Altruism

In contrast to self-interest, altruism is defined as actions that benefit others [21]. Respondents in this study noted that altruism represents a fundamental component of nursing professionalism. The conceptual content of altruism contain prioritizes patients first and acting in ways that benefit others.

Putting patients-first

The results of the textual analysis of this study show that the most prominent aspect of altruism is the patients-first in nursing. Some interviewees believed that patient-first was encapsulated in the maxim"nurses should refrain from actions detrimental to patientsencapsulated in the maxim"nurses should refrain". One participant noted this concept in the following passage:

"To be a good nurse, the most crucial thing is what Florence Nightingale's pledge emphasizes—'I will abstain from whatever is harmful or mischievous,'You mustn't engage in anything unethical; this should be the very foundation of being a good nurse". (NT1).

Altruism emphasizes prioritizing the interests of patients, consistently placing their needs at the forefront of care. Participants believed that nurses should prioritize patients'life, health, and safety, as well as their economic well-being.

NM1 pointed out that" altruism doesn't necessarily mean always sacrificing oneself, but nursing professionalism requires constantly emphasizing that the patient's life is paramount, and their interests come first. Nursing should always be altruistic, always revolving around the patient."

Benefiting others

The notion benefit others is a manifestation of altruism. Respondents considerd that the altruistic component of nursing professionalism is evident through the specialized care that nurses provide to benefit patients. For instance, nurses provide health education, routine screening, disease management services, and psychological support. Facilitating equitable access to health care resources has become a significant aspect of benefiting others.

Furthermore, respondents believed that when specific disasters such as earthquakes, tsunamis, infectious diseases, or even war, threats to people's lives, health, and safety necessitate that nurses, as guardians of health, extend their assistance. This study also collected images of respondents participating in the fight against COVID-19, reflecting the altruistic spirit of nurses who, despite personal risks, contributed selflessly when confronted with the threat of infectious diseases.

Dedication

Textual analyses of the respondents revealed dedication is a crucial concept in nursing professionalism. Text analysis displays sacrifice, patience, tolerance, expecting nothing in return are all part of a nurse's dedication.

Sacrifice

Text analysis showed that sacrifice of nurses encompasses dedicating time, compromising one’s health, and relinquishing aspects of personal or family quality of life. Engaging in nursing work requires a willingness to make sacrifices, reflecting a commitment to the profession that includes time, health, and aspects of personal or family life.

"Why work overtime? On the one hand, it's due to insufficient staffing, and on the other hand, it's because of the complexity and variability of the job. Nursing is ever-changing, and its complexity and individual variations pose considerable challenges. That's why doctors and nurses must embody a spirit of dedication. For instance, if it's time for you to finish your shift, but a patient experiences severe bleeding or an emergency arises, what do you do? You have to sacrifice your own time to assist the on-duty nurse in handling the patient."(DN1).

Furthermore, due to the unique demands of the nursing profession, nurses may find themselves compelled to sacrifice a degree of their own well-being to ensure their patients'health and lives.

Most respondents mentioned,"Disrupted circadian rhythms are a common health challenge for clinical nurses. Due to the nature of nursing work, we just can't avoid taking night shifts, and in the long run, it messes with our sleep, you know…".

Several interviewees also mentioned that nurses encounter negative emotions such as anxiety, depression, fear, and grief from patients and their families. Emotional labor is recognized as an integral aspect of the dedication involved in nursing work [22].

Patience

Nurses predominantly encounter individuals who are in a state of illness. Embracing and enduring these situations, including the difficulties associated with disease and disability, are integral components of the dedication inherent in the nursing profession.

"Nurses deal with all sorts of things, you know. Blood, vomit, secretions, or patients who look like something out of a horror movie—twisted limbs, disfigured faces, especially in cases like trauma patients from accidents. What you're faced with are situations like these—it affects your mood, but as a nurse, it's what we do."(DN1).

The unique nature of nursing is reflected in in the fact that nurses often undertake tasks for patients that those patients would typically handle themselves if not for the limitations imposed by illness.

Nursing work is also intricate. To meet the various needs of patients, nurses must invest significant amounts of mental, physical, and emotional energy. Compared with other professional groups, nurses face greater hardships, highlighting the increased necessity for dedication in their roles.

Tolerance

Our understanding of life and health remains limited. Many diseases, even with advanced technological means, cannot be definitively diagnosed, effectively treated, or cured. In such circumstances, some patients may experience dissatisfaction due to unmet expectations in medical care.

"Patients complain, they may not treat you well or anything. When we interact with patients, we often face their dissatisfaction. You really have to rise above it, you know? Sometimes you just have to learn to deal with the unfairness. A bit of patience, acknowledging their emotions." (NM2).

Moreover, some patients may exhibit inappropriate behaviors, such as manic aggression, due to cognitive impairment caused by illness. Several participants considered appropriately accepting and understanding patient behavior as an integral part of nursing work. However, N6 raised concerns, stating,"While accommodating patient behavior is necessary, it must be within certain limits. Acts that harm healthcare providers or disrupt the therapeutic nursing environment cannot be tolerated."

Expecting nothing in return

Expecting nothing in return means that nurses provide health care to patients without seeking financial or emotional rewards. Participants believed that the core of nursing work is caregiving, assistance, and compassion, without expecting personal gains in exchange for their efforts.

"Doctors and nurses aren't only in it for the money; our calling is to save lives, not prioritize profit. Healthcare is altruistic; the primary goal is to ensure people's lives and health before anything else."(N6).

Emotion is a subjective attitude and experience, representing an individual's foundational response to whether objective stimuli align with their needs [22]. In this study, most respondents felt that a sense of value from positive emotional feedback, such as patient gratitude, could derive professional satisfaction. However, most participants also believed that the dedication of nurses signifies altruism and selflessness, without seeking emotional rewards in return.

"On an individual level, though, when a nurse is facing a patient, it's not about seeking returns; it's about ensuring a speedy recovery for them."(NT5)

Caring

Respondents in this study noted that caring is an integral aspect of nursing professionalism that involves reverence for life, as well as empathy, compassion, and concern.

Reverence for life

Reverence for life entails approaching life with awe while actively aiding and safeguarding it. This principle serves as the foundation for nurses to care for others, embodying a profound respect for the sanctity of life.

"Our job is really different from others, it's so unique. A little slip-up, and a patient lost their life. That's why we respect the value of each patient's life, cater to their needs. With that understanding, we take our job seriously, never slacking off."(DN1).

One interviewee emphasized,"Only by valuing life can we truly respect patients and cultivate compassion."The interviewee noted that a significant challenge in nursing was providing assistance, and caring for strangers. Furthermore, participants in this study believed that nurses must understand and embrace the unknown and uncertain aspects of life, striving to ensure the safety of life to the best of their abilities.

Empathy, compassion and concern

This study point out that"empathy, compassion, and concern"represent the purest and most integral aspects of nursing professionalism. Compassion in nursing refers to expressing sympathy for the pain and suffering experienced by patients. Empathy is defined as"placing oneself in the patient's position, considering their perspective, while concurrently upholding one's caregiving responsibilities and role."Concern denotes nurses'caring for patients. Most respondents believed that, traditionally, an"excellent nurse"is one who embodies qualities such as"kindness, concern, and sympathy towards patients."

"The core essence of nursing lies in caring and compassion. Caring is the natural expression of emotions, even a therapeutic action. When helping with certain elderly individuals, technicalities become less crucial, even medications take a back seat, but the significance of genuine concern becomes particularly paramount."(DN1).

Nurses need to approach patients with constant companionship and presence. Renowned sociologist Erving Goffman contends that presence allows caregiving to be truly effective [23].

The crux for psychiatric nurses lies in establishing a ‘soul-to-soul’ connection with the patient. The nurse‒patient relationship transcends mere contractual Obligations; focusing instead on companionship and attentive listening. Guarding the patient requires being bedside, being present, and observing with sensitivity. If you're not present—what good is it?"(DN1).

Proactive assistance was a coded theme identified in this study."Proactive"signifies the nurse's awareness of the patient's needs and represents the tangible actions of assistance provided after empathizing with the patient's situation and expressing kindness, concern, and sympathy.

Professional competence

Nurses must undergo systematic learning and possess proficient technical skills in applying professional knowledge to fulfill their significant responsibility of safeguarding health. Professional competence encompasses five key aspects: sensitivity, responsibility, excellence, self-discipline, and collaboration.

Sensitivity

Nurses require heightened sensitivity to provide high-quality care, which involves a keen awareness of both the patient's medical condition and their individual needs. This study posits that only nurses who have undergone specialized training can perceptively detect changes in a patient's condition. Such nurses are equipped to articulate issues accurately to physicians, prompting timely interventions and ultimately fulfilling the goal of safeguarding patient health.

"Nurses need to have good judgment. For instance, with a patient experiencing significant bleeding, if there's not much vaginal bleeding but excessive sweating, fatigue, and a pale complexion, and there's no bleeding from the vagina, you have to consider the possibility of internal bleeding, right? You have to have the ability to assess these issues."(N2).

In addition, nurses need to be sensitive to patients’ needs. The interviewees believed that nurses primarily interact with patients who require professional care during critical periods of their lives, and their needs differ from those of healthy individuals. Therefore, sensitive nurses are able to meet the needs of patients based on the varying stages of life they are in.

Responsibility in patient care

Nurses encounter living individuals, and responsibility in patient care extends beyond just addressing the immediate health needs to encompass the overall well-being. Responsibility in patient care is a crucial aspect of nursing professionalism, including nurses'initiative to identify and address both existing and potential health problems.

"I believe responsibility is more important than capability. Some nurses may not have the strongest skills, but they have a strong sense of responsibility. This sense of responsibility drives them to provide excellent care for their patients. For the sake of the patients, they naturally push themselves to improve their skills." (P5).

Text analysis indicated that nurses need to proactively identify issues rather than merely completing tasks passively. They should be able to actively address various concerns raised by patients.

Excellence

"Excellence"is a fundamental aspect of nursing professionalism. It is achieved when nurses continuously assimilate and apply medical knowledge, engage in ongoing learning, and update their knowledge and skills.

N3 stated,"to be a good nurse, you need to keep learning in the clinical setting, reflect on work experiences, continually enhance yourself, and hone your skills."

The interviewee emphasized that achieving professional excellence should ultimately benefit patients. By keenly observing changes in the patient's condition and identifying potential risks through professional knowledge, nurses can ensure timely treatment and care. This, in turn, promotes better health outcomes for patients.

Self-discipline

Self-discipline is crucial aspect of nursing professionalism, encompassing both image discipline (nurses who have professional image) and work discipline. Some interviewees believe that nurses must maintain a professional image, which includes adhering to appropriate work attire, practicing good nursing etiquette, and demonstrating a positive service attitude. Nurses who adhere to these norms in their professional conduct become role models for patients, highlighting disciplined living and working habits that contribute to a healthy lifestyle.

"Nurses have a professional image, and sometimes, even small actions unintentionally reflect her professional competence. This [nursing] image leaves a certain impression on patients. For example, maintaining sterile practices, changing fluid bottle caps, and avoiding unnecessary contact with sterile areas while disinfecting wounds—all contribute to a professional image. When patients sense this level of professional, it builds trust not only in the nurse but also in the hospital."(N5).

Nursing self-discipline involves punctuality, working in a planned and organized manner, and maintaining self-discipline during work. Punctuality is fundamental to ensuring the smooth delivery of medical services to patients. Additionally, a planned and organized approach to tasks is not only a good work habit but also a for a critical aspects of nursing self-discipline. In nursing practice, self-discipline refers to a nurse's ability to meticulously follow operational procedures and regulations, even during solitary shifts or periods without direct supervision. Self-discipline is a voluntary and conscientious behavior guided by internal beliefs, that represents the noble qualities required by nursing professionalism.

N8 said,"Nurses need to be cautious. A lot of work in nursing practice is done alone without human supervision. If you set the bar very low, the quality of care may be low, and patient safety may not be guaranteed."

Collaboration

Collaboration in nursing practice encompasses interactions among nurses, between doctors and nurses, and across various departments to deliver health services to patients. Effective collaboration is essential for truly understanding patients'needs and assisting them in achieving favorable health outcomes.

"New nurses are not familiar with the nursing workflow, so experienced nurses will mentor them. For example, when a patient's condition suddenly changes and requires first aid near the end of work, some nurses may still stay and cooperate to complete the patient's first aid."(N7).

Discussion

Interpretation and analysis of the conceptual framework for nursing professionalism

This study employed Charmaz's Constructing Grounded Theory to analyze and derive the conceptual framework of nursing professionalism. The conceptual content of nursing professionalism includes the themes of'altruism','dedication','caring', and'professional competence'. Altruism involves the notions patient-first and benefits others. Dedication includes sacrifice, patience, tolerance, and expecting nothing in return. Caring reflects reverence for life, empathy, compassion, and concern. Professional competence include sensitivity, responsibility, excellence, self-discipline, and collaboration.

A clear conceptual definition of each component of nursing professionalism provides a foundation for its assessment and cultivation. This study’s conceptual framework aligns with existing scholarship but exhibits divergence in specific perspectives.

Altruism was identified as the most critical component of nursing professionalism. Although some researchers have raised doubts, suggesting that altruistic care equates to self-sacrifice, self-denial, and one-way unconditional care, this study presents a differing viewpoint [24]. It proposes that altruism does not necessarily imply self-sacrifice. Instead, altruism should be viewed as an ideology or mindset within the context of nursing professionalism. Nurses should consider self-care and altruism dialectically, as self-care and caring for others are not mutually exclusive concepts [25]. While attending to one’s own needs is equally important, nurses should also be able to prioritize patient care when the life and health of the patient are at risk [26].

This study proposes"dedication"as an important concept in nursing professionalism. In contrast to Western cultural emphases on contractual principles, this study posits that the concept of"dedication"reflects Confucian values—such as humility, altruism, and benevolence—embedded in Chinese caregiving practices. Dedication inherently transcends self-interest. However, this level of dedication has also faced scrutiny, may imply moral coercion. Despite this, this study contends that due to the specific nature of nursing work and the diverse needs of patients, nurses’ commitment to prioritizing life and patient care inevitably leads to a sense of dedication in critical situations.

Caring is considered a core value of nursing professionalism. Some studies suggest that care is driven by responsibility, where caring for others'well-being is seen as a moral responsibility [27].

This study highlights that care in nursing professionalism is valuable but difficult to achieve, mainly due to 1) nurses providing care to patients who are unfamiliar to them, making it challenging to establish emotional connections within a short time. 2) Nursing requires presence and companionship. Being present refers to nurses using all mental, physical, and emotional resources to create a caring environment that facilitates patient healing [28].

Nursing involves a connection between the patient and the nurse, requiring the expression of kindness, concern, love, sympathy, support, and participation far beyond mere professional duties. If nursing deviates from the essence of caring, its professionalism risks becoming akin to a cold machine, which can make it difficult to provide warmth and compassion to patients.

Professional competence is a critical attribute of nursing professionalism. Freidson [29] noted that only professionals who are trained and experienced can apply specific, implicit, and profound knowledge to their work. Nurses must use extensive nursing knowledge to care for vulnerable patients and address their unique needs [30]. This requires a deep understanding of complex medical knowledge and the ability to apply it effectively in practice rather than merely performing tasks mechanically. Our findings indicate that professional competence attribute can empower nurses to better assist patients. It has been proven that professional nursing can lead to increased patient satisfaction and positively impact patient outcomes [31].

A comparison of the concepts of nursing professionalism and Nightingale's professionalism

Some scholars have noted a relationship of universality and particularity between nursing professionalism and Nightingale's professionalism [28]. Nightingale's professionalism epitomizes nursing professionalism by emphasizing nurses’ ability to improve the health and lives of individuals, families, communities, and nations. It also acknowledges their knowledge, skills, compassion, and bravery in providing care, especially in challenging situations.

Hence, the Florence Nightingale Medal, established by the International Red Cross as the highest honor in the nursing field, recognizes individuals who have made outstanding contributions to the nursing profession and embody the following qualities [32]: 1) Courage and dedication demonstrated in natural disasters and armed conflicts, providing care with positive empathy to the injured, sick, and other vulnerable groups; and 2) Exemplary service in public health or nursing education and a pioneering spirit that innovatively enhances the quality of nursing health care or training.

Some scholars propose a conceptual framework for Nightingale professionalism comprising four components: cherishing life, wholehearted dedication, loyalty to duty, and exemplifying leadership [28]. This aligns with our study's proposed conceptual framework for nursing professionalism, encompassing the four core elements of altruism, dedication, caring, and professional competence. This suggests a convergence in the essential nature of the Nightingale professionalism and the nursing professionalism identified in our study.

A comparison of the concepts of nursing professionalism and medical professionalism

There are commonalities between the concepts of medical professionalism and nursing professionalism. Doctors and nurses belong to the main bodies of medical and health practice and share the responsibility of serving the public and caring for people's health. Lijuan Bu [33]summarized the concept content of medical professionalism as: benevolence (spiritual guidance), preciseness, sincerity (professional identity), and trustworthiness (behavioral guidance). The concept content of nursing professionalism in this study includes altruism, dedication, caring, and professional competence. The concept content of"caring"in nursing professionalism is akin to the advocacy of"benevolence"in medical professionalism. Meanwhile, while the concept content of"professional competence"in nursing professionalism aligns with the emphasis on"preciseness"in medical professionalism, reflecting the professional differences between doctors and nurses. Additionally, the concepts of"altruism” and “dedication"in nursing professionalism show a semantic intersection with"sincerity” and “trustworthiness"of medical professionalism.

Notably, this study highlights the distinct"nursing characteristics"within nursing professionalism. For example, concepts such as"being present and providing companionship,""sensitivity to the patient's condition,""sensitivity to the patient's needs,""proactively identifying problems,""advancement in patient care,"and"the nurse's image of self-discipline"are all elaborated upon. These elements emphasize the differences between nursing professionalism and medical professionalism. The unique aspects of nursing professionalism are shown in Fig. 2.

Fig. 2.

Unique aspects of nursing professionalism

Strengths, limitations and future study

This study employed a grounded theory approach to explore the conceptual content of nursing professionalism, refining and deepening the conceptual framework to a significant extent. The findings also highlight the distinctive characteristics of the nursing profession. However, this study exclusively included participants from China, potentially limiting its generalizability. Despite this, the concept of nursing professionalism may extend to diverse cultural contexts. Due to COVID-19, in-person interviews were challenging, leading to a combination of phone and WeChat interviews for some participants. To address this limitation, researchers conducted multiple in-depth interviews with select participants.

Future research will facilitate the cultivation and assessment of nursing professionalism in academic and clinical settings. We will develop educational programs based on the conceptual framework of nursing professionalism, such as constructing teaching cases using four components with sub-thematic content to enhance students’ professional development. Hospital administrators can utilize findings from this study to implement regular staff training. Additionally, scenario-based assessment tools aligned with nursing professionalism components will be designed to evaluate clinical nurses’professional competence.

Conclusion

This study has developed a conceptual content model for nursing professionalism, comprising four components: altruism, dedication, caring, and professional competence, each encompassing rich content. This model can serve as a reference for assessing and cultivating nursing professionalism. Nursing educators, policymakers, and hospital administrators can take evidence-based actions informed by these findings, thereby enhancing clinical service quality and advancing the nursing profession. In future research, we will conduct longitudinal studies to track the developmental trajectory of nursing professionalism, along with interventional studies to systematically evaluate the efficacy of educational reforms.

Authors' contributions

HL,C : Investigation, Resources, Writing - Original Draft, Writing - Review & Editing, Data collection ZX,C: Investigation, Resources, Formal analysis, Writing - Original Draft, Writing - Review & Editing YM: Software, Investigation, Writing - Original Draft LB, L: Supervision YJ,S：Methodology XY, H: Project administration YM, W: Project administration YJ, C: Project administration QH, W: Supervision HY (Corresponding author): Methodology, Project administration.

Funding

Linfen Soft Science Research Program Project (NO.2432).

Data availability

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

Declarations

Ethics approval and consent participate

This study was approved by the Ethics Committee of the First Hospital of Shanxi Medical University (Approval number 2020K061).

No human or animal research was involved in the preparation of this manuscript.

Consent for publication

Ethical standards were rigorously upheld, with all participants completing signed informed consent documents. To protect privacy, all personal information was anonymized. All participation was voluntary, and participants retained the right to withdraw at any point.

Competing interests

The authors declare no competing interests.