In this study, an in-depth analysis of data from 38 participants' interviews, supplemented by textual and visual materials from books, was conducted to derive the conceptual content of the Nursing Professionalism. The nursing professionalism is a complex concept comprising four major conceptual components, namely altruism, dedication, caring, professional. Each of these attributes encompasses rich sub-content, as elucidated in Figures 1.
3.1 Altruism
Altruism is defined as actions that are beneficial to others, in contrast to self-interest[20]. Altruism constitutes the core values of healthcare practices and represents the primary significant dimension of the nursing professionalism. The conceptual content of altruism within the nursing professionalism encompasses patient-first and benefiting others.
3.1.1 Patient-first
Some interviewees believe that adhering to the fundamental principle of patient-first altruism is encapsulated in the maxim "nurses should refrain from actions detrimental to patients.
"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 them at the forefront of care. Participants believe that nurses should ensure the paramount consideration of patients' life, health, and safety, followed by safeguarding the economic well-being of patients.
NM1 points out: "Altruism doesn't necessarily mean always sacrificing oneself, but the nursing professionalism requires constantly emphasizing that the patient's life is paramount, and their interests come first. Nurse always altruism, always revolving around the patient."
3.1.2 Benefiting Others
The altruistic component of nursing professionalism is evident as nurses employ their specialized care to benefit patients. For instance, nurses provide forms of healthcare such as health education, routine screening, disease management services, and psychological support to patients. As the nursing profession advances, coupled with increased recognition from both the nation and society, nurses will play an increasingly vital role in promoting and advancing public health. Facilitating equitable access to healthcare resources becomes a significant aspect, emerging as a new imperative within the spirit of nursing professionalism, with the core aim of benefiting others.
Furthermore, respondents believe that when facing specific disasters such as earthquakes, tsunamis, infectious diseases, or even war, threats to people's lives, health, and safety require nurses, as guardians of health, to extend a helping hand for assistance. This study also collected images of some respondents participating in the fight against COVID-19, reflecting the altruistic spirit of nurses who, despite personal risks, contribute selflessly when confronted with the threat of infectious diseases.
3.2 Dedication
Dedication is a crucial concept in nursing professionalism. Fawcett[21] proposed the core foundational concepts of nursing as individuals, environment, health, and nursing. Since nurses care for living individuals involving physical, psychological, intellectual, social, and spiritual aspects, nursing becomes a complex and intricate profession. Consequently, nursing personnel need to possess a spirit of dedication.
3.2.1 sacrifice
Sacrifice is a component of dedication. Data analysis indicates that sacrifice encompasses dedicating time, compromising health, and relinquishing personal/family life quality. Engaging in nursing work implies a willingness to sacrifice, involving the commitment of time, health, and aspects of personal or family life.
"Why work overtime? On 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 nature of the nursing profession, nurses, in certain circumstances, find themselves compelled to sacrifice a certain degree of their own well-being to ensure the preservation of patients' health and lives.
Most of the 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, throws off our hormones, you know..."
Some interviewees also mentioned that nurses, encounter negative emotions such as anxiety, depression, fear, and grief from patients and their families. Emotional labor is acknowledged as an integral aspect of nurses' dedicated work[22].
3.2.2 Patience
Nurses predominantly encounter individuals in a state of illness. Embracing and enduring in the face of disease, disability, and ugliness 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 nurses often undertaking tasks for patients that they would typically handle themselves but are unable to due to the limitations imposed by illness.
Nursing work is intricate. Achieving the fulfillment of various patient needs requires nurses to invest significant amounts of mental, physical, and emotional energy. Nurses, compared to other professional groups, endure greater hardships, underscoring the heightened necessity for a spirit of dedication.
3.2.3 Tolerance
Our understanding of life and health is limited thus far.Many diseases, even with current 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. Some participants consider appropriately accepting and understanding patient behavior as an integral part of the nursing work. However, some respondents raise questions, 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."
3.2.4 Expecting nothing in return
Expecting nothing in return implies that nurses provide healthcare to patients without seeking financial or emotional rewards. Participants believe that the core of nursing work is caregiving, assistance, and compassion, without expecting personal gains in return for their efforts towards patients.
"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[23]. In this study the majority of respondents thought a sense of value from positive emotional feedback can derive professional satisfaction, such as patient gratitude. Most participants believe that the dedication of nurses signifies altruism and selflessness, without seeking emotional returns.
"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)
3.3 Caring
Caring is an integral aspect of nursing professionalism which involves reverence for life and empathy, compassion, and concern.
3.3.1 Reverence for life
Reverence for life entails approaching life with awe, while actively aiding and safeguarding it. It 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)
The interviewee emphasized, "Only by revering life, can the willingness to respect patients and cultivate compassion emerge." The interviewee perceived the challenge in nursing as the encounter with unfamiliar patients, providing assistance, and care for strangers. Furthermore, the participants in this study believed that nurses need to comprehend and embrace the unknown and uncertain aspects of life, striving to ensure the safety of life to the best of their abilities.
3.3.2Empathy, compassion, and concern
This study posits that "empathy, compassion, and concern" represent the purest and most integral aspects of the 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. The majority of respondents believe that, in the traditional sense, 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, offering 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 'battle companion' connection with the patient. The nurse-patient relationship transcends mere contractual obligations; it's more about patient companionship and attentive listening become especially crucial. Guarding the patient requires being bedside, being present, observing with sensitivity. If you're not present—what good is it? "(DN1)
Proactive assistance is 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.
3.4 Professional
Nurses must undergo systematic learning and possess proficient technical skills in applying professional knowledge to fulfill the significant responsibility of safeguarding health. Professional, as a vital component of the nursing professionalism, primarily encompasses five key aspects:sensitivity, responsibility, excellence, self-discipline, collaboration.
3.4.1 Sensitivity
Nurses require a heightened sensitivity to provide high-quality care, encompassing 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. They 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 the patients’ needs. The interviewees believed that most of the people nurses face are patients, that is, those who need professional care in special periods of life, and their needs are different from those of healthy people. Therefore, sensitive nurses will meet the needs of patients according to the different stages they are in.
3.4.2 Responsibility in Patient Care
Nurses encounter living individuals, and responsibility in patient care is reflected not only in patient care but also in the overall life and health of patients.
Responsibility in patient care is a manifestation of nursing professionalism, including nurses' initiative to identify existing and potential health problems and actively solve patients' 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 actively address various concerns raised by patients.
3.4.3 Excellence
"Excellence" is a key manifestation of the nursing professionalism wherein nurses achieve professional excellence by assimilating and digesting medical knowledge, continuously learning, and updating nursing knowledge and skills.
N3 believes, "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 emphasizes that achieving professional excellence should ultimately benefit patients. By keenly observing changes in the patient's condition and identifying potential risks through the knowledge gained professionally, patients can receive timely treatment and care.This, in turn, promotes better health outcomes for the patients.
3.4.4 Self-discipline
Self-discipline is considered a manifestation of the nursing professionalism, which encompasses both image discipline( nurse who has professional image) and work discipline.
Some interviewees believe that nurses with nursing professionalism need to take responsibility for their professional image which reflected not only in appropriate work attire, good nursing etiquette, and service attitude. For example, nurses who adhere to norms in their professional conduct also become role models for patients, showcasing disciplined living and working habits that contribute to a healthy lifestyle.
"Nurses have a professional image, and sometimes, even small actions unintentionally reflect her professionalism. 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 professionalism, 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 the fundamental aspect of work self-discipline, ensuring the smooth delivery of medical services to patients. Additionally, having a planned and organized approach to tasks is not only a good work habit but also a requirement for nursing self-discipline. In the nursing practice, self-discipline refers to the nurse's ability to meticulously carry out nursing tasks in accordance with operational procedures and relevant regulations, especially during solitary shifts or periods without direct supervision. Self-discipline is a voluntary and conscientious behavior guided by internal beliefs, representing the noble qualities required by the nursing professionalism.
Nurse8 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."
3.4.5 Collaboration
Team collaboration in nursing practice encompass interactions among nurses, between doctors and nurses, and across various departments. Nursing as a team to deliver health services to patients. The care provided by nurses involves cooperation with various healthcare professionals. Effective collaboration between teams and communication between nurses and patients are essential to truly understand patients' needs and assist them in achieving favorable health outcomes.