Factors influencing professionalism among nurse educators: A qualitative study

Abstract

BACKGROUND:

Nurse educators require to exhibit specialized behaviors that demonstrate the beliefs of the nursing profession. The aim of the study is to explore the factors influencing professionalism among nurse educators in the selected nursing educational institutes of Indian States.

MATERIALS AND METHODS:

Qualitative approach was adopted where multiple focus group discussions were planned and conducted. The study was carried out among nurse educators from the Northern Indian states. Thematic analysis, using the argumentative interactions approach was used. The consolidated criteria for reporting qualitative research (COREQ) guide were followed.

RESULTS:

Three types of factors, that is, individual (micro-level), organizational (meso-level), and external professional occupational (macro-level) were explored, where individual factors emerged as having a strong positive impact on nurse educators’ professionalism as compared to other factors. Poor organizational infrastructure, privatization of educational institutions, and other related factors were reported as having a negative influence on nurse educators’ professionalism.

CONCLUSION:

Most of the educational institutions included in the present study, lacked basic infrastructure/facilities for the professional development of nurse educators and professionalism.

Introduction

The only way to develop good students in the current dynamic environment is to create a well-developed education system and provide life-long learning opportunities. It is important to understand that students’ professionalism is significantly related to the professional values and preparation of teachers.[1] Nursing professionalism needs nurses to exhibit behaviors that demonstrate the beliefs of the nursing profession.[2] The professional values must reinforce the education and nursing practice as well. Nurse educators are in the inimitable place to deliver students with professional insight and values that inculcate professionalism[3]

Professionalism is the active demonstration of the traits of a professional.[4] In 1984, Barbara Kemp Miller described the “Wheel of Professionalism in Nursing” that was helpful for the nurses to recognize attributes and behaviors essential for professionalism in nursing.[5,6] Further a “behavioral inventory for the assessment of a professionalism” was developed, based on the wheel of professionalism.[7]

High professionalism is related to enhanced nursing performance and autonomy, capability to think critically, and empowerment.[8] Progression in knowledge and technology are placing pressure on nursing professionals to have vast quantities of information and requirement of continuity.[7] Transformational leaders transform organizational cultures in such a way that creates a conducive culture to achieve optimum professionalism.[9]

As the healthcare system moves toward more modernized and corporate industrialism, it is the responsibility of every nurse to ensure the integrity and maintain a high level of professionalism.[10] Nurse educators can illustrate behaviors and attitudes that influence the development of professionalism among their students.[11]

The aim of the study is to explore the factors influencing professionalism among nurse educators of the selected nursing educational institutes in the Indian States. Insights from this study are likely to extend the base for understanding, that is, necessary for the nurse educators, nursing leaders, and policymakers to do measures that enhance the professionalism in nursing.

Materials and Methods

Study design and setting

This was a qualitative exploratory study using an emergent–systemic focus group; the design was adopted where multiple focus group discussions were planned and conducted withdrawing on template analysis based on the Flexner criteria of professionalism. The study was carried out in eight nursing educational institutions in selected Northern Indian states that were selected using purposive sampling[12]

Study participants and sampling

Nurse educators, who wanted to participate, were assertive to share their views, were willing to volunteer, and were available for 2 h were selected using the purposive (maximum variation) sampling technique.

Data collection tools and techniques

The focus group discussion was selected as a method of data collection as it provides in-depth and interactive descriptions of the participant's experiences.[13] In total eight focus group discussions were conducted with eight participants (n = 64) in each session. The researcher performed the role of facilitator, moderator, and interpreter to facilitate the discussion. A comfortable room was arranged within the campus of the selected Institutes.

All the focus group sessions were audio-recorded. The sessions lasted between 60 and 100 min. An argumentative interactive approach was used where the researcher adequately covered all prepared questions. Immediately after each session, the moderator and assistant moderator debriefed the session and a short transcript of each discussion was prepared.

Data analysis

Thematic analysis was carried out where all the transcripts were observed for relevant categories and codes were applied. Descriptive analysis was done with the help of SPSS V. 22

Ethical consideration

The research was approved by the Institutional Ethics Committee (IEC) of Saraswati Nursing Institute, Punjab. All participants signed an informed consent form, and anonymity and confidentiality of data were ensured.

Methodological rigor

The methodological rigor of the study was determined based on the criteria described by the Lincoln and Guba for qualitative research, that is,[14]

The credibility of the study was ensured where focus group discussions adequately covered all predeveloped questions and an argumentative interactive approach was used. Emerged themes could be verified easily as in the present study audio records and written verbatims of the participants were used. A consensus approach was used.

Dependability was ensured by preparing a short transcript of each discussion, which was helpful to focus on the research questions and provide a rich description of emerging themes. All the changes were documented and kept a trackable record of when and how changes were implemented.

Confirmability of the emerged categories and themes was attained by the Investigator triangulation. A consensus approach to integrating the categories and themes emerging from the data was performed.

Transferability was enhanced by ensuring data saturation. Thoroughness was determined by organizing multiple focus group sessions in different states to explore the diverse responses of participants.

Results

Participant's characteristics

A total of 64 nurse educators (participants) were included in eight focus group sessions (Punjab: n = 3, Haryana: n = 3 and Rajasthan: n = 2). No one refused to participate. Characteristics of participants are shown in Table 1. Participants’ professional characteristics according to the Flexner criteria of professionalism were collected and depicted in Table 2.

Table 1.

Characteristics of participants n=64

Characteristics	State			Total
	Punjab	Haryana	Rajasthan
	Number of participants
Gender
Male	04	02	09	15
Female	21	21	07	49
Age in completing years
21-25	07	07	04	18
26-30	14	11	06	31
31-35	03	02	06	11
36-40	00	01	00	01
41-45	00	02	00	2
Above 45	01	00	00	01
Professional qualification
BSc	07	11	09	27
MSc (MSN)	18	12	07	37
College of final degree attainment
Private	22	22	14	58
Government	03	01	02	06
Professional experience (in years)
0-1	05	08	02	15
2-5	14	10	08	32
6-8	03	02	02	07
8-12	02	02	04	08
Above 12	01	01	00	02
Current designation
Clinical instructor	07	11	09	27
Lecturer	14	10	06	30
Associate professor	04	01	01	06
Professor	00	01	00	01

Table 2.

Participant’s professional characteristic n=64

Professional characteristics	State			Total
	Haryana	Punjab	Rajasthan
	Number of participants
Advance course in nursing skills
Yes	06	02	03	11
No	19	21	13	53
Workshop conferences attended in last 1 year
Yes	20	09	06	35
No	05	14	10	29
Research publication/s
Yes	14	09	03	26
No	11	14	13	38
Membership of professional organization/s
Yes	13	10	04	27
No	12	13	12	37
CNE attended in last 1 year
Yes	03	01	00	04
No	22	22	16	60
Subscription of research journal/s
Yes	05	02	02	09
No	20	21	14	55

Abbreviations: CNE, “Continuing nursing education”

Explored factors influencing professionalism among nurse educators

The comprehensive conceptual model for healthy work environments for nurse educators was used to categorize and the emerged themes are as depicted in Table 3.

Table 3.

Factors influencing professionalism among nurse educators

Domain	Code	Factor level	Emerged factors
			Positive	Negative
Physical/structural policy components	1A	Micro (Individual factors)	No factor emerged	Physical characteristics of educators
	1B	Meso (Organizational factors)	Rules and regulations Monitoring/supervision Institute having postgraduate/PhD programs Parental hospital Work autonomy	Lack of resources High work burden Poor salary structure Management policies
	1C	Macro (External factors)	Accreditation bodies Technological advancements. Monitoring	Privatization Mushrooming of nursing educational institutions Poor implementation of policies Poor infrastructure of government hospitals.
Cognitive/psycho/social/cultural components	2A	Micro (Individual factors)	Desire for professional recognition/gain Personal characteristics; interests, personality traits, etc.	Lack interest. Brain drains
	2B	Meso (Organizational factors)	Professional culture of organization Professional mentor Performance evaluation	Management attitude Incompetent colleague Unprofessional culture of organization Student’s characteristics Lack of discipline sloppy academic behavior Irregularity or poor attendance Male students
	2C	Macro (External factors)	No factor emerged	No factor emerged
Professional/occupational components	3A	Micro (Individual factors)	Participation in conferences/workshops Research publication Pursue higher education College of degree attainment and teachers	Poor professional knowledge of nurse educators
	3B	Meso (Organizational factors)	Privatization of nursing education	Non-availability of professional up-gradation program
	3C	Macro (External factors)	Advancement of other professions Philosophy of the nursing profession	External professional environment Poor quality of conferences/workshops

Factors having a positive influence on professionalism

Rules and regulations: Rules and regulations followed within the organization emerged as a strong positive factor. Participants expressed themselves openly with statements such as “Strict discipline followed by my principal impact our professionalism positively”; “My organization has certain rules to be followed that compel teaching faculty to behave professionally.”

Monitoring/supervision: Intensive and regular monitoring/supervision especially in private colleges, helps teachers to perform in a way to deliver their best. Participants’ statements such as “CCTV monitoring of classes make teachers more conscious about their duties”; “Monitoring/supervision is very important because it helps you to maintain an expected behavior”; “Private management frequently takes student's feedback about teachers’ efficiency.”

Institute with postgraduate courses: Key supporting statements made by the participants includes “PG courses running in our institution help us groom professionally”; “PG colleges organize more professional activities such as conferences/workshops and also have more senior staff, which helps faculty members to groom professionally.”

Parent hospital: Significant statements made by the participants were: “parental hospital is essential for any college to provide clinical exposure for the students”; “Nurse educators find it easy to implement the curriculum if the college has a parental hospital.”

Work Autonomy: If adequate authority is given to make decisions, then it may enhance the sense of responsibility and professionalism among nurse educators. Key statements are “I have work autonomy in my organization and that makes us more accountable”; “If management allows you to work freely, you can perform better”.

Role of accreditation bodies: Participants’ significant statement includes: “We usually do the plan (lesion, unit, master rotation, and clinical plans) before inspection of accreditation bodies,” “Regular inspection of nursing institutions oblige institution's management to maintain standards and practices.”

Technological advancements: Key supportive statements of participants includes: “Number of research journals available these days help us to update with recent advancements”; “Use of computer technology (indicating PPTs and other digital aids) improve the quality of teaching and learning activities.”

Role of individual nurse educator (self): Personality characteristics of nurse educators such as interest in the profession, self-motivation, self-discipline, and personal values/belief shape their professionalism. Significant statements include “I am interested in teaching, love to teach with different methods”; “My own interest and satisfaction help me to groom myself professionally”; “My personal belief and own value system influence my personal and professional dealings.”

Role of a family: Family members influence professionalism positively. Significant supportive statements include: “My parents are my role model”; “My husband is a research scholar who always encourages me to read and conduct research studies”; “My sister is a PhD scholar, she always encourages me to update knowledge.”

Professional recognition/gain: Various statements made by the participants to justify include: “With research publication, you can improve your value in the organization”; “I do the publication and participate in other professional activities to get professional recognition”; “I want people should know me (desire to improve professional image).”

Organizational culture: Emerged factors include the professional expectations of the management and seniors and available support from colleagues and other people in the organization. Some of the key statements of participants were: “My organization is supportive and everyone helps each other professionally as well as personally”; “My organization and colleagues are always supportive to do research studies.”

Professional mentor(s): Significant statements made by the participants were “My seniors always motivate me to do research publication”; “My senior colleagues encourage me to participate in conferences and other professional activities.”

Performance evaluation/appreciation: Study participants perceived student feedback, peer evaluation (colleagues), academic goals of the individual teacher, and organizations’ goals as strong positive factors influencing professionalism. Key statements include: “I try to improve my professional behavior and skills with the help of student's feedback”; “I like it when students and colleagues appreciate me for my professional skills and competency”; “Evaluation of academic performance by the students and teachers increase accountability in achieving those goals.”

Professional grooming: Participation in conferences/workshops, doing research publication, and desire for higher education—all emerged as the ways of professional grooming. Significant statements include: “I can upgrade my knowledge by participation in conferences”; “I want to upgrade myself professionally and hence actively participate in professional activities”; “Research publications will help to improve myself professionally.”

College of degree attainment: Significant statements include, “I think my college of final degree attainment positively helped me to maintain professional ethics in my dealings”; “The way I was trained in my post-graduation helps me to maintain professionalism in my behavior.”

Privatization of nursing institutes: Participants expressed their views on the privatization of nursing education such as “Private college, management monitors teaching activities more intensively”; “Major things happened here for student admission” (college management is result-oriented).

Advancement of other professions: Key statements include: “Use of technology in teaching results in the better professional outcome”; “Trends have changed now; everyone is adding research in their teaching”; “Trends of evidence-based practice (EBP) also enhance the needs for conducting and dissemination of researches.”

Professional values: Nursing is a noble profession and at the same time, professional values have been expressed as having a positive influence on nurse educators’ professionalism. A key statement to justify this includes—”Philosophy of nursing profession helps to maintain professional ethics.”

Factors having a negative influence on professionalism

Personal characteristics of educators: Significant statements include—”I am old enough to learn computer that is required for research”; “Research is a recent trend, it was not there when I did post-graduation, and we are old generation people”; “I am lacking the experience to carry out an independent research project”; “I do not have much experience related to research and publications.”

Lack of resources: Poor infrastructure, insufficient clinical facilities, inadequate teaching faculty, and high staff turnover were the major concerns expressed by most of the focus group participants. Significant statements include—”Poor clinical experience facilities for the students”; “Lack of Audio Visual (AV) Aids and insufficient time makes it difficult for us to maintain standards of teaching”; “We have inadequate laboratory facilities”; “Available books in our library are insufficient and substandard.”

High work burden: Key significant statements made by the participants include: “Do not have much time to prepare lecture properly”; “Too much filing work and records, no time for the library”; “Allotted lecture hours are too much, no time for preparation”; “Lack of adequate teaching faculty increases workload”; “High staff turnover puts more burden on teaching staff and affect quality.”

Poor salary: Significant statements include- “No appraisal, increment or other incentives; salary structure is also very poor”; “I am being paid a very low salary and it is frustrating to work with this salary; I am losing my interest”; “Lack of motivation because of the existing appraisal system is worst in this institution”; “There is a high registration fee for conference participation, I can not afford it with the present salary.”

Inadequate facilities, leave benefits, and working conditions in the institute: Most of the participants were not satisfied with the facilities provided to them. Some of the statements made by the participants include—”My organization is not conducive for research and other professional activities”; “Management doesn't provide leaves for participating in these (professional) activities (conferences/workshops); “My organization does not organize this kind of activities (indicating about conferences).”

Mushrooming and privatization: Some of the major concerns due to private management expressed by the participants include: “Poor curriculum implementation, deceitful student evaluation system, admission crisis in private colleges, job insecurity among faculty, issues with job stability (instability), and poor infrastructure in these institutions.” Key significant statements of participants include: “Mushrooming of the nursing institutions has resulted in an unhealthy competition among private colleges and is promoting unethical practices”; “In private jobs, if you do not do what management says then go home (you may lose your job)”; “Job is not secure in private colleges.”

Lack of interest in the profession: Significant statements include, “I am not even interested in the professional development of self”; “I do not have any interest in doing research and publications”; “I do not read research journals”; “I am not interested in these activities (talking about conferences participation/publications).

Brain drains: Key supportive statements include: “Once you plan to go abroad, you start losing interest in all these professional development activities (participation in conferences, CNEs)”; “I am going abroad so fully focused on filing process (showing no interest in activities of current organization).”

Private Management: Profit-oriented attitude, ethical violation, and academic interference have emerged. Supporting key significant statements include: “Management role in my organization is very unprofessional”; “Management working style does not value and support research activities”; “Management's role is unprofessional (profit orientation)”; “We make bogus attendance of students (fake attendance)”; “My management always compels us to manipulate student's evaluation.”

Role of colleagues and organization's culture: Key statements includes: “I face resistance while talking/sharing innovative ideas with colleagues”; “My senior always degrades me”; “Here the staff is not taking any interest in faculty development activity; (professional activities such as conferences).”

Student's characteristics: Key significant statements include: “Many students do not attend classes regularly”; “Students do not have interest in learning”; “Absenteeism among students is a very common issue”.

Poor professional knowledge of teachers: Significant statements include: “I had poor quality research and clinical training during my graduation (only name's sake)”; “I got my education from private college” (questioning the training she received being a student)”; “I have a lot of theoretical knowledge but there is no application of it” (lacking practical implications).

Non-availability of professional up-gradation program: Continuous learning and knowledge up-gradation are one of the parameters (components) of professionalism. Significant statements include: “Here we do not have availability of skills development programs”; “We do not get any information related to conferences/workshops and continuous nursing education programs are not available.”

External professional environment: Verbatims include: “There is nothing to learn with academic research”; “No utilization and I do not find any use of these things (publications)”; “Most of the people publish for formality, no serious efforts”, “Most of the researches has no actual implementation.”

Role of a professional organization(s): Key statements include “Conferences/workshops are only fundraising events (indicating high registration fee)”; “Actually no one participates to learn from these organizations”; these are only social gatherings (doing word); “I do not think these professional organization(s) improve knowledge.”

Discussion

The present study explored individual (micro), organizational (meso), and external (macro) environmental factors influencing nurse educators. It is consistent with the study done by Gha Ghardian et al., (2014)[15] where demographic, educational, environmental, and attitudinal factors were observed to affect nurses’ level of professionalism.

In the present study, the professional knowledge and competency of the nurse educators were perceived to be influencing their professionalism positively. It is consistent with the study done by Ahmed and Hussain (2012)[16] where subject mastery (competency) was perceived by the participants at the highest level among the four factors of teachers’ professional performance. The present study revealed that the professional values and attitudes of individual nurse educators have a positive influence on their professionalism Brehm et al., (2006)[17] also stated that specific knowledge, attitudes, and values are the professional requirements for optimal professionalism.

The impact of idol professional/mentor was perceived as having a positive influence on nurse educators’ professionalism. It is consistent with the findings of the study conducted by Felstead and Springett (2016)[11] where role model professional attributes were described as crucial to developing professionalism among nursing students.

Professional/personal commitment was perceived as having a positive influence on professionalism. A study conducted by Hus (2006)[18] also described that the teaching commitment (professional identity and giving of self) and teacher's competence enhance the quality of nursing education. Female nursing students were perceived as more professional and easy to deal with as compared to male students, similarly, Lui et al., (2008); Martin et al., (2003)[19,20] also found that female students had higher professional values as compared to male students. Rognstad (2004)[21] also stated that in recent years’ young women select nursing as a profession because of paying attention to the value of altruism.

Findings revealed that teaching and role modeling (mentor) of nurse educators and senior colleagues are always important in strengthening professionalism among nursing students. In concurrence with this finding, Weis and Schank (2002)[22] have also reported that education does make a difference in the formation of professional values and they are going to be developed through instructors’ role modeling behaviors.

The present study revealed that the professionalism and professional values of nurse educators are influenced by their social culture. Konishi et al., (2009)[23] also write that although professional values are a global issue, culture gives them shape and emphasizes differences. Every culture has individual ethics with different emphasis and importance.

Findings of the present study revealed workload/burden, lack of teaching faculty, the role of a professional organization(s), and poor curriculum implementations (planning) as having a negative influence on nurse educators’ professionalism. These results are in line with the findings of a research by Fantahun et al. (2014)[24] which identified characteristics that negatively impacted nurses’ professionalism, including a heavy workload, a lack of professional foresight, and poor functioning of nursing association. Kwon et al.,(2010)[25] stated that the nursing shortage is becoming a more and more problematic issue for professionalism in this era.

Poor working conditions of the organization, job insecurity, non-availability of jobs, non-availability of other benefits for faculty (holidays, rewards, vacation), and low salary have also emerged as negative factors. Similarly, Hampton and Hampton (2000)[26] also described the relationship between reward structure, education levels of nurses, and level of professionalism.

The study revealed that lack of autonomy and role clarity in a job as factors influencing professionalism negatively. Chnug and Ko (2004)[27] reported that autonomy in a job and a well-defined job description enhance professionalism. The study further revealed that poor job satisfaction is a negative factor of professionalism.

Limitations and recommendations

Several limitations to this study deserve consideration. First, focus group sessions were conducted at workplaces of the nurse educators, which may influence and inhibit their responses, moreover, it can lead to social desirability bias. Second, despite rigorous research design and maximum variation- sampling, most of the study participants were young and belonged to private organizations thus, findings might have limited generalizability. The present study recommends that future studies are needed to replicate and extend the findings by using a larger sample from a wider professional range. Researches need to be conducted to develop a theoretical framework for professionalism in nursing.

Conclusion

Three types of factors, that is, personal, professional, and organizational have emerged as factors influencing nurse educators’ professionalism. Findings can be used by the governing/regulating authorities to make policies that improve professionalism in nursing. Moreover, the study will also help accreditation bodies to identify major concerns and challenges and finally determine their focus area to ensure the quality and uniformity of nursing education.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.