Surface - Professional Identity: What it means to think, act and feel like a nurse – Part 1

This episode of the NLN Nursing EDge Unscripted Surface track is part 1 of 2 featuring guests Nelda Godfrey and Beth Phillips.

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Transcript

0:36

Welcome to this episode of the NLN podcast Nursing EDge Unscripted the Surface track and  thank you for joining us. This episode is entitled, "Professional Identity:  What it means to think, act, and feel like a nurse." Our conversation today will focus on  exploring professional identity what it is and what it isn't. We will also discuss the impact  of a strong professional identity and its impact on self-confidence workplace culture  job satisfaction and retention. To help us today we have two special guests. Dr. Beth  Phillips is an Associate Professor Emeritus and former Director of the Institute for Educational  Excellence at Duke University School of Nursing. Currently Beth is the Strategic Nursing Adviser  for ATI Ascend Learning. Dr. Nelda Godfrey is a Professor and Associate Dean for Innovative  Partnerships and practice at the University of Kansas School of Nursing their work with the  International Society for Professional Identity and Nursing is transforming the way nurses health  care professionals and society understand what it means to think act and feel like a nurse. This  work offers new language and new knowledge for the journey helping nurses heal flourish and expertly  care for others. So welcome Beth and Nelda. We are so excited to have you here for this conversation  on professional identity. So I'm going to kick it off to Rachel to get us going. Yeah and and  so before we even talk about professional identity, which I am really excited to have a conversation  about, you ladies are both doing really incredible important work and I just wanted to hold some  space for you both to be able to share what you're working on and what you're passionate about before  we kick off the conversation about professional identity. Well I'll go ahead and start. So it's a  real pleasure to be here with you and it's a great pleasure to be working with NLN. They have been our  longtime supporters and cheerers along the way and we really appreciate our friendship and our  relationship with them. Goodness, the projects that we are doing right now, we are actively working  with the National Student Nurses' Association.  That is a group of 60,000 nursing students and  we presented this notion of professional identity to them and the fact that there are four pillars  or four domains and they were all over it and said, oh yes, that's what we want. We want that to  be the pillars of our organization that those are the pillars of our Honor Society and their entire  leadership effort is moved around this so it's enormously important to have that kind of pipeline.  And the number of advisers for National Student Nurses' Association that are interested  is unbelievable. So that's, I say one of the most exciting areas. Secondly, I would say that you all  are aware that there's an organization called the Tri-Council, which is made up of major nursing  leaders in the country and the people in AONL have been working with our team in professional  identity to propose boldly propose a position statement on all nurses are leaders and so they  brought this position paper forward through AONL and the International Society for Professional  Identity and Nursing and then brought it to the attention of the Tri-Council. So we are in  the process of making sure we've got all of that information clarified for them and I think we're  going to have this communicated at the highest levels. There's a lot of advantage that comes  from that. I'll stop there on to back well I want to back us up because we wouldn't even be having  this conversation if it weren't for Nelda Godfrey. This has been Nelda's passion in Nelda's work for  years and years but a little under six years ago she had this idea of gathering thought  leaders from around the country to talk about professional identity and she invited 50 people  to Kansas to start this conversation and never and we've had this conversation, she and I never in her  wildest dreams did she think we would be where we're at today and we have repeatedly I had the  great pleasure and privilege of being invited to that first event, that first thing tank and have  been part of it ever since but we knew we were on to something but I don't think any one of us ever  saw the gravity that this actually had the power to change the profession or the need. We didn't  know the need was going to be as great as it is today, that we need a culture change. We need  it desperately in our profession and really in health care. It's way bigger I think than nursing  but I give credit to Nelda because it really she hasn't given up and she's continued to to drive  us and be positive and be open. Some of us and me I've been probably one of the big  push back people of the group and say, but wait, but wait, let's what about this. And she still  answers my calls and we still are friends, which is great. I think it's because we know ultimately  we all have the same goals and it's been just a wonderful addition to my career. I can't imagine  not being a part of this group. It's just been fabulous. I think, if you would let me  continue for a moment, what I want to say is I want you to understand who came together in that  first think tank. We had equal numbers of educators of regulators and practice people. You don't ever  get that in any group. They were representing every major nursing organization in the country. We had regulators from Canada and other people from Canada. We had undergrad students, graduate  students, CEOs for simulation companies. We had this marvelous mix of people and we posed to  

them: 7:20

we think professional identity is a thing. It is a real thing in every other discipline  besides nursing and if we are going to make this an active part of what we do, what is it going to  need, to how will it be defined, how will it be operationalized, and what do we need to do. So we  had Susan Luparell and Cindy Clark who are fabulous colleagues and very skilled at facilitation who  took us through a day and a half on this. And just to give you an example, Beth Phillips was invited  because one of my colleagues at Kansas had had her as a teacher in the online program at Duke and she  just couldn't quit talking about how fabulous Beth was as a teacher and so I'm calling her up and  saying, you don't know me but why don't you come to this thing. And so that as a result, so that  was the flavor of the whole thing and as a result after a day and a half 20% of the attendees said  we want to be on the steering committee and that then named itself the International society for  Professional Identity in Nursing and we are as I said around 650 strong from all over the globe.  That is impressive, isn't it? I'm sitting here first of all thinking about how Beth's account of your, Nelda, of your idea to do this. I mean, not just an idea, but your  passion and work and how it did start as one idea at some point. And I have about like 500 ideas a  day and I don't do anything about them. They just like swirl around in my head and some of them might get on paper, right. I might talk about some of them but to create an international  society, it's, it's really impressive. I'm just so...it's very exciting and I also wanted  to just make a really quick comment about how you talked about the people at the table and  how you had people from practice, administration, nursing education and you had this international  presence right from the start. Usually that comes after. That alone is just really impressive  to me because usually a group will meet and think they've got something going on  and who knows for how long and then be like, oh, who else should we have at the table? But the  fact that you had the table set and ready to go at that first conversation I think really says  something about the need. And then the only other thing I wanted to say real quick about Beth about  being the the push back buddy. Rachel and I have a very similar relationship where we  will help each other reframe, like in a very supportive, like loving way, honestly, but I think  that's important to have that balance of well, did you think about it this way? What  about this perspective? And we need that to I think keep our our conversations interesting  and addressing all the needs and seeing a different perspective. I agree with you. I think  that's because we can't all think alike.  We have people from I don't know if it's  every state that is on our Advisory Council but we're across the country and so what people are  seeing at different places is different and so I might say something from North Carolina  and somebody in California says, well, that's not how we do things here. And so we have to think of  it from a global perspective we can't think of it from what it is in my city or your city and  so it takes all of us collectively to think about how can we solve these problems on a global scale. And then when we talk international, my goodness, I mean some of the language issues, some of the  terminology, some of the... there's a lot of barriers and for a while we had a discussion  about maybe we pause our international folks and they just keep coming back and wanting to  be a part of it. We had our symposium in September and we had folks on there from overseas that did  amazing presentations about their work and they just want to be a part of it. One of our  colleagues champion who's in South Africa I think it was wasn't it like 4:00 a.m. He was on  the call all day, all our day, all his night just so he could be a part of this online symposium  because he knows it's so important to his profession and his work. You know, in listening  to this, to get a little metacognitive for a minute, it sounds like what I'm hearing is you  all were modeling key facets of professional identity while you were trying to define it  and articulate it which I think is really amazing. And I think this would be a great time for us  to dig into really the operational definition of professional identity because when we have these  big concepts that are hard to wrap our arms around I imagine lots of different people see it from  different perspectives and see it differently and I would love to hear a little bit more about the conversation that happened around that table as you were forming this shared mental model and  collective understanding of professional identity and where you are now with operationalizing  that definition. So I'll take up the definition and explain that for us and then I'll talk about  the four domains and then Beth is so good about explaining how all this fits together so we're  gonna let her do a lot of the talking, so there you are queued up Beth. The definition for professional  

identity in nursing is: 13:26

a sense of one's self and in relationship with others, that is influenced by the  characteristics, norms and values of the nursing discipline resulting in an individual thinking,  acting and feeling like a nurse. So I'm gonna get a little academic on you and talk about why this  is worded like it is, but there's a key phrase, "thinking, acting and feeling like a nurse," and that  is important because that was developed by Robert Merton in 1967 in the first book written about the  sociology of medicine and he talked specifically about professional identity being that which  results in the individual thinking, acting and feeling like a nurse. So in this interprofessional  world we are in we need to be connected with our fellow colleagues and I thought it was  only, we thought it was only fitting that it would sound like that. It is not an empirical definition  that you can test easily and that's one of the reasons we ended up with the four domains, but that example of thinking, acting and feeling like a nurse, that phrase resonates with everyone. It resonates with students, it resonates with the society, it resonates with faculty, it's very  important for us. The four domains are values and ethics, knowledge, nurse as leader, and professional  comportment. So I want to clarify a few of those areas. I serve currently as the chair of the  American Nurses Association's Ethics and Human Rights Advisory board so I have a keen interest  in values and ethics. This came very clearly through the work that we are doing. So values and  ethics - first domain. Second is knowledge. There's just, it's indisputable how much knowledge has to  be in place to think act and feel like a nurse, to provide the care we need to and that seemed  very clear cut for us but it's knowledge from all different areas. Thirdly, nurse as leader. Initially  we called it leadership and we realized because we have such a wide view that our colleagues in  practice thought that didn't apply to them because they thought that it only had to do  with a formalized leadership role and we quickly changed that to nurse as leader because, as I said  earlier, all nurses are leaders. And the fourth is professional comportment and this one has kind of  a checkered past. We had started with the term self-aware and our colleague Patricia Benner was  involved on these calls and she said, by the way, you can't measure self-awareness and she is  indeed correct. So we recast and rethought about it and went back to the literature and found the  concept of professional comportment, which is in the literature is a concept analysis by Clickner and  Shirey and we use that term to describe things you might not expect, things like self-aware, respectful, patient-centered. What it is not is it's nothing about the shoes you wear or where your stethoscope  hangs or what kind of a what color of a top you have on. In fact, we all say that we have looked at  all the literature, all the research literature on attire for nursing and it doesn't tell us anything.  It is six one way half dozen the other, so that is not where we're going with that. It is the definition  of professional comportment is a nurse's behavior through words, action and presence. We think it has  been adding these words to our discipline that has moved us forward and why we've had so many  people interested in the effort, Beth. You said that beautifully Nelda. I feel like we've pushed the  envelope with the idea of professional identity versus professionalism and we've presented  at conferences all over the country, actually internationally. Some of our folks went to Sigma and presented internationally the last couple years as well. Many people when they hear about  our group they think professionalism, they think uniforms or dress code or piercings or tattoos  and that comes up in the crowd all the time. So we end up having to have some discussions  about that, to the extent that a small group of us have just gotten...it should be coming  out in the next six months I believe...an article about the differences between professionalism and  professional identity because there is definitely a difference. Professionalism is a component of  one's professional identity. But before we even talk about that, we have a model that we share  when we present that has three concentric circles in it. The largest circle on the outside  is one's entire identity and then the next one within that one is their personal identity and the  smallest one in the center is their professional identity and we want nurses to recognize that they  don't separate and say, okay, now I'm going to work I have to put on this persona as a professional. It needs to be and that I believe is part of the problems we're seeing that  they don't own who they are as a nurse in their work setting. And so we've really emphasized that  you don't separate that. It is part of who you are and if you work on that professional  identity then the rest of it won't matter. The rest of it will come into play: your dress, your  behavior, all of those the attributes that we talk about within those four domains will make sense to  that individual. They'll strive for strong ethics and values, they'll strive for continuing education. One of our colleagues, Kristen Priddy, and I did a study a couple years ago. We weren't even planning  on actually doing a study. I had this brainstorm at a meeting and I said, you know, I'd love to know  what nurses think professional identity is. I think I posed that question Nelda and I said  I just want to create a little survey and see what people think so I crafted a few questions,  sent it to the group, we tweaked some of them, sent it out we got about 500 responses back. And then  we got a call from the director of a Board of Nursing in a western state and said we'd like  you to survey all of the nurses in our state. We want to see what they think so we decided,  well, let's go for IRB and let's really dive into this because maybe this is something that we need  to look at. We never once, I never once, I don't know Nelda if you had a crystal ball, but I did not ever  think that we would be directly linking what our work was to quality and safety, but oh my goodness  it came through so strongly and painfully. I would say we did a mixed method study and we had  about 700 responses, a little over 700 responses and just to give give you a taste of this we  asked a question, "how do you think having a strong professional identity impacts practice?" And we got  attributes like it gives me role clarity, it gives me pride in my profession, I have more confidence  in myself, I value lifelong learning, I have ethical practice behaviors, I have high practice standards, I have trust and respect for others and they have it of me, I look for innovation in practice which  is so critical, I see effective communication and teamwork in my practice setting, all of  those things lead to a safe, high-quality care for patients. And then this healthy work culture  that comes from it, leads to job satisfaction and retention. But then we asked the question, "how do  you think failure to form a strong professional identity impacts practice?" And this was what was  so disheartening and really heart-wrenching. They talked about a lack of unified value system, they  talked about lack of pride, they talked about it's just a job that they just get in there  to get a paycheck, it's just task centered, they talked about having unethical shortcuts,  sloppy practice, decrease motivation for growth, then this because of the no values and the lack of  role clarity it led to self-doubt, anxiety, they saw more isolation and bullying. All of those things  led to burnout, attrition, people leaving, all of the things we're hearing about today.  People just leaving by the droves and really dissatisfaction everywhere, all of these things  led to ineffective decision-making, which lead directly to poor quality care and unsafe care, really harm to our clients. There's decreased trust of patients. Patients don't trust us if  we don't really value the job that we're doing or if we just take it as just a job. There's less  engagement. There's really no desire for innovation or lifelong learning. I don't strive to look for  the evidence because I'm just going there to get a paycheck. Teamwork is non-existent.  These things all came out and it was like, oh my goodness this is not what we expected. All of these things pointed directly harm to patients and harm to nurses in such a big way and  it was really like a slap in the face. We knew that we had to continue to push ahead with this and  figure out a way to make sure every nurse, and this was Nelda's words, by 2025, every nurse in  the United States will know what professional identity is and will understand what those four  domains are. So that's one of our many goals. That was pretty lofty. Sorry about that. That's amazing.  So I have like, again like, I have 500 questions written down but I'll only choose like maybe two. My reflections based on listening to you both are really it seemed like in two different camps. One  is about nurse educator, identity professional identity and then more of a learner-centered  identity and how to navigate both. And so I guess I'll start with the learner-centered one because  you just ended on your goal of making sure the goal that every learner by  2025 understands what professional identity is. So my question is twofold, I suppose, how  do we teach it and how do we measure it? Because currently at least with regard the teaching part, I don't think is happening very intentionally, especially with this oneness you talk about. It  feels separate, like you have to step into when you go to clinical you're stepping into being a  nurse you're not walking around with this identity that's cohesive all the time so I don't think  that's being taught explicitly in many cases and then the evaluation piece. I think the clinical  evaluation tools put professionalism usually that ISM word there's some items under it and a lot of  times it's making sure your uniform doesn't look like you just took it out of your trunk and put  it on, which I've made some assumptions based on the uniforms I've seen from time to time, that's  what it looks like has happened. So I'm curious what are your thoughts about teaching it and  evaluating it? Yeah Beth, why don't you take teaching I'll take evaluate. Yeah,  so a couple things. We can't assume that because educators are educators they understand it either.  So I think that's that's one hurdle is that our educators need to know about professional  identity formation for themselves and with all the new educators that we are getting now and in  the future because of the shortage and because many of our newer educators I'm seeing across  the country don't necessarily have a background in nursing education they're probably very strong  clinicians and they're thrown into it they may not have any kind of support in that way so we  are very busy in again preparing presentations and we've done some conferences where we've done  three hour pre-conferences about professional identity formation we're also in the process  of crafting some modules that Sigma is going to put up on their website for nurse educators  specifically about how do you learn about this and teach about this so that the educators can first  of all educate themselves and then be ready for students. We've also made a very concerted effort  to target the journals that we publish our work in as well as we've reached out to many of the  maybe Nursing 101 type texts or Professionalism 101 books and offer to write chapters in those  books and we've got a couple yeses so far but we feel like that's a start as well to get them  out there so that educators can understand this. And then probably the biggest and I don't know if  I don't want to steal your thunder, go, go ahead, we have been very successful in having  people on all three of our major accrediting body work groups both CNEA with NLN, CCNE with AACN  and ACEN and our professional language is now in all of those standards so that is I hate to say  forcing educators but they are going to see this language so when they're working on self studies  for accreditation they're going to have to think about now how do we measure this? We want to be  conscious of our time boundaries this conversation could go on and it will we will pick up with our  conversation with Beth and Nelda discussing professional identity in nursing on our next episode. Thank you for joining us on this episode of NLN Nursing EDge Unscripted  Surface. We hope you join us next time. And until then, remember, whether your  water is calm or choppy, stay connected, get vulnerable and dare to go beneath the surface.