The review found that identified studies were conducted in Europe, the United States and Asia, and no studies emerged from other countries and continents. All seven identified studies were conducted in a hospital setting, and none were from the PHC setting. The absence of studies in the PHC settings could be argued that all studies are from high-income countries where health care is well established. Major neonate, infant and under-5 child health concerns in these countries are not related to preventable diseases like in low-middle income countries (18), where PHC is considered the first level of care for most of the population.
The studies focused on nursing professionalism related to the nurse-parent, nurse-nurse or multi-disciplinary interactions. In all seven studies, none of their research focused on the interaction or provision of basic and direct nursing care of the PN in neonate, infant or under-5 child care. The aim and purpose of the review were to explore, synthesise, and identify the published evidence of literature on professionalism attributes required by the PN to provide quality care to neonates, infants and under-5 children. Five themes with their respective sub-themes were identified from the seven studies. Knowledge, accountability, advocacy, collegiality and collaboration, and ethics and values were the five themes that emerged in the reviews that are related to the eight attributes of Registered Nurses’ Association of Ontario (6) nursing professionalism attributes in the quality of care to the neonates, infants and the under-5 childcare.
Knowledge determines the competency of PN and contributes to patient safety, efficient use of resources, and interpersonal and professional relationships. It is one of the determinants of the quality of care that will be provided and the level of nursing professionalism (38, 39). It was established in this review that the PNs had an emotional intelligence knowledge deficit on how to handle disruptive behaviours, control emotions, communicate with parents and make ethical decision making which can be a threat to neonatal, infant and under-5 child quality of care (33–36). The finding is consistent with the studies conducted with student nurses that low levels of emotional intelligence can cause physical and psychological negative impacts and jeopardise the ability to perform and provide patient quality care in this context of the study (40, 41). To counteract the emotional intelligence deficit, the PNs need education and training, which according to (42), requires ambition and can be started at any point in their nursing profession. Training workshops and coaching can be cost-effective results for increasing the PN with emotional intelligence at any age (43, 44). The PNs in the review studies relied on previous experiences and understanding of patients for their interventions and management of their patients. There is no clear indication of why the PNs relied on their previous experiences, but this is consistent with the integrative review findings that nurses used the previous experience to manage their patients because they find protocols are not designed for individualised care (45, 46).
Accountability protects the patients against the harmful actions of the nurse by ensuring that the nurse refers to legal frameworks and learns from actions and omissions (47). PNs in the neonate, infant, and under-5 child care interaction with parents/caregivers may blur professional boundaries and integrity due to the emotional support needed by the parent/caregiver and the child. Consistent with the finding of the review, one of the challenges against the quality of care in the neonatal and paediatric intensive care units was moral distress which questioned the professional integrity of the PNs. Conflicting roles ensued when PNs felt restricted by the organisation and the profession in using their personal and professional abilities to care for the child (48). Self-regulation is key to maintaining professional integrity and accountability. Organisations need to design and implement frameworks that will alert the PNs of their emotional and professional balances change in the workplace (49).
The role of nursing advocacy is to identify and report concerns about the patient’s well-being (50). The safety of children was a concern for the PNs in the findings of the review studies (22, 36), and interventions were necessary. The PN’s advocacy roles were challenged by multi-disciplinary, legal and organisational challenges, such as being unrecognised by social workers, fear of testifying in court and no support from the hospital. This was consistent with the review findings of (51, 52), that such barriers discourage nurse advocacy. Another support of the findings is that closed communication and punitive effects in operative nursing care were again identified as barriers, and the PNs felt intimidated to advocate for the vulnerable patients who cannot speak for themselves (53). Nursing advocacy is not the sole role of the nurse. Healthcare organisation needs policy change to recognise the multi-disciplinary team involved and parent empowerment in the healthcare decision-making of their children (54, 55).
Collegiality and collaboration are multi-disciplinary team members supporting each other in the essence of effective teamwork to provide quality care (56–58). Role confusion and ignoring team members’ strengths and weaknesses were found to destabilise teamwork (56)(Campbell et al., 2020). This is consistent with the review finding on bullying, incivility, social worker-nurse miscommunication and role confusion (33, 36), resulting in poor quality care. Communication, training, simulation activities, and a supportive work environment has the capacity to resolve poor working environments. The PNs did not give specifics of the training required, but it was highly recommended that simulation stood out to be the best approach across all disciplines of nursing, which could be a choice for neonates, infants and under-5 child care settings (56, 59).
The ethics and values attribute of professionalism in this review was more focussed on the nurse-parent interactions. These findings are not surprising, noting that the nursing care of the neonate, infant and under-5 child involves family dynamics. These interactions pose a need for the PN to be able to communicate, respect, trust and consider the value systems of the parent/caregiver, which may be different from the PNs values (60, 61). The parents’ observation of PNs on effective communication involved acknowledging their presence, introducing self, spending time with parents, explaining and saying thank you (22, 34, 36). Consistent with (60, 62), it was not clear to the nurses in Saudi and the United States of America which information to communicate with parents and the appropriate time to communicate. Making unnecessary comments and not protecting the child’s privacy was one of the ethical aspects that the parents were concerned about from the nurse questioning the PNs competency and safe practices (22, 63). The PNs referred to objective and documented information sharing as important when reporting patient care, while parents said that written information is easily accessible. The findings are what is referred to as multi-format of communication, which enhances effective communication to reach all types of persons involved in the care of the child (62, 64).
Participation of parents/caregivers involves receiving support from the PNs and the hospital. Separation from the baby can cause stress on the parent and child and need to be avoided. From the studies of this review, parents need flexible visiting hours, accommodation for lodging and emotional support from the hospital and the PNs (22, 34). The findings of this review are in line with previous studies that identified strategies that parents had minimal depressive symptoms when they were involved in their neonatal care during admission and gained knowledge to care for the baby at home (65–67).
Limitations
Nursing professionalism of infants, neonates and the under-5 child has not been explored, published or described in the found literature, indicating research gap in this context. The use of search keywords of nursing professionalism could have limited results of more publications that focused on individual attributes of professionalism. The limiters on this review was peer-reviewed, English, full articles through the university databases. However, articles that did not match limiters were filtered, that may indicate limitations with the search limiters. Only peer-reviewed articles were used. More reviews that include grey literature may be conducted in the future for more publications that may be beneficial to guide future research on nursing professionalism.