What does professionalism look like in everyday practice for nurses and midwives? A new framework brings clarity on the subject and aims to help staff articulate and celebrate their value
A new framework commissioned by the chief nursing officers for England, Northern Ireland, Scotland and Wales and supported by the Nursing and Midwifery Council brings together evidence, experience and knowledge on professionalism. It demonstrates to nurses and midwives what professionalism looks like in everyday practice, and shows employers the key attributes of practice environments that support professional behaviours. The implementation of the framework will be an opportunity to shine a light on the unique contribution of nurses and midwives. This article explains how the framework came to be and what it contains.
Citation: Reed A, Dix A (2018) A framework to promote professionalism in everyday practice. Nursing Times [online]; 114: 3, 40-42.
Authors: Angela Reed is senior professional officer, Northern Ireland Practice and Education Council for Nursing and Midwifery; Ann Dix is a freelance healthcare journalist.
- This article has been double-blind peer reviewed
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Good health and care outcomes are highly dependent on the professional practice and behaviours of nurses and midwives. Professionalism, however, can mean different things to different members of the nursing and midwifery community, and has proved difficult to define (Morgan et al, 2014).
A new framework, Enabling Professionalism in Nursing and Midwifery Practice, aims to describe, for the first time, what professionalism looks like to support the everyday application of the Nursing and Midwifery Council’s code in practice environments across the UK (Chief nursing officers for the UK and NMC, 2017). For employers, it identifies key principles that will help them provide practice environments that support and encourage professionalism among nurses and midwives.
The framework was commissioned by the chief nursing officers (CNOs) for England, Northern Ireland, Scotland and Wales and is supported by the NMC. It helps practitioners to engage in conversations about what it is to be a nurse or a midwife, to understand and articulate their value as professionals, and to celebrate and challenge their own and others’ practice and behaviours to uphold professional standards.
The work brought together nursing and midwifery leaders across all levels of practice to draw on their experience and know-ledge. Working from the available evidence and significant work in each of the four UK countries, a project board chaired by Charlotte McArdle, CNO for Northern Ireland – supported by the Northern Ireland Practice and Education Council for Nursing and Midwifery – produced the framework.
Why was a framework needed?
Changes in healthcare include an increasing complexity of care in new models of service delivery where safety, quality and service user experience are core elements to improving practice. This refocuses the fundamentals of care, working from an important professional evidence base and body of knowledge, with compassion and caring being key components of the role of nurses and midwives.
Many countries have explored professionalism in nursing and midwifery with the aim of strengthening professional behaviours to enable practitioners to deliver the best possible care. In the UK, despite significant work, there has been no recognised definition of professionalism, the term being applied broadly and open to interpretation (Morgan et al, 2014).
Often the driver to consider the topic has been a perceived lack of professionalism. Some of the previous work was completed in response to national recommendations following high-profile institutional care failings – such those at Mid Staffordshire Foundation Trust (Francis, 2013) and University Hospitals of Morecambe Bay Foundation Trust (Kirkup, 2015). There was subsequently an effort to define, promote and measure professionalism to ensure consistently high standards of care.
In 2016, the NMC introduced a three- yearly revalidation process for nurses and midwives to demonstrate that they are fit to practise against a revised code of conduct. The 2015 code sets out a clear expectation of the practice, behaviours and attitudes required from nurses and midwives, including standards for upholding the reputation of the profession (NMC, 2015).
Revalidation comes at a time when nurses are taking on new and advanced roles, and when different ways of delivering services are raising new issues of professional accountability. The role of the healthcare assistant, aligned to the family of nursing and midwifery, also emphasises the professional responsibilities that lie in the delegation of care (NMC, 2015).
At the same time, financial and operational pressures on the NHS, and a prevailing culture of performance management, can have an adverse impact on resilience and professional identity. Difficulties recruiting and retaining nurses highlight the need to enhance the image of nursing, promote professional pride, support nurses to stay in the profession, and empower them to bring about better health and care outcomes (Gulzar et al, 2017).
It is in this context that the four CNOs saw an opportunity to address some of these challenges in the development of a single professionalism framework for the UK, showing how applying the code’s values and attributes is central to practice. The framework was produced to help nurses reflect on and articulate their value as autonomous, accountable and credible practitioners working collaboratively with other professions.
What does the evidence tell us?
Some authors suggest professionalism can change depending on the situation and environment nurses are in (Tanaka, 2014). How nurses and midwives express their thoughts on being professional varies based on their personal values system, which makes it hard to define professionalism (Scottish Government, 2012). Social media are associated both with promoting professionalism and highlighting a lack of professional behaviour (Oxtoby, 2014).
Professionalism has been linked to improving care safety, quality and experience (Dupree et al, 2011). It is cited as being underpinned by continuing professional development (Morgan et al, 2014) and defined by lifelong learning (Konukbay, 2014). Accountability and autonomy have been defined as attributes of professional behaviour when discussing the contribution of nursing and midwifery to health and care (Storfjell and Christiansen, 2010).
How was the framework developed?
In March 2016, the CNOs published a four-country statement of intent to explore what professionalism means in the context of the code, promoted through conferences, the nursing press and social media.
They nominated a project board of 16 nursing and midwifery leaders tasked with articulating the components of professionalism, the impact of the ‘autonomous, competent, accountable practitioner’, and the conditions for practice environments to support professional behaviours and provide safe, effective and person-centred care. The project board included CNO representatives; colleagues from the NMC, policy, service and education; service users; the independent and voluntary sectors; and staff-side and professional organisations.
The framework was tested and refined through one-to-one interviews with 11 practitioners across care and service, who were asked how they would use it, whether it had resonance and practical use, and what tools would be needed to support its use and implementation.
What is in the framework?
The framework includes:
- A definition of professionalism and its purpose;
- Attributes supporting professionalism;
- Organisational and environmental factors that enable professional behaviours;
- Individual responsibilities to enable practitioners to lead and support good-quality care, implement change and apply sound professional judgement.
It aims to:
- Strengthen and support nurses and midwives in their leadership roles;
- Help them articulate their effectiveness, demonstrate accountability and meet revalidation requirements;
- Provide practical examples of what the public can expect from a nurse/midwife.
What is professionalism?
Professionalism is clearly defined (Box 1) and its purpose described as “to ensure the consistent provision of safe, effective, person-centred outcomes that support people and their families and carers, to achieve an optimal status of health and wellbeing”.
Achieving the defined purpose will be demonstrated through a range of outcomes including:
- Consistent outcomes of care/services;
- People describing good experiences of care and services;
- Care settings that enable nurses and midwives to flourish;
- Improved health outcomes for populations.
Also listed are attributes that underpin professionalism. The framework recognises that “nurses and midwives practising at graduate level are prepared with the behaviours, knowledge and skills required to provide safe, effective, person-centred care and services”. The attributes are grouped under four headings and are aligned with the code: “being accountable”, “being a leader”, “being an advocate” and “being competent”.
Box 1. What is professionalism?
Professionalism is characterised by the autonomous evidence-based decision making by members of an occupation who share the same values and education. Professionalism in nursing and midwifery is realised through purposeful relationships and underpinned by environments that facilitate professional practice. Professional nurses and midwives demonstrate and embrace accountability for their actions.
Source: CNOs and NMC (2017)
Employers’ responsibilities are made clear, including “fostering a positive environment to raise concerns when issues arise that could compromise safety, quality and experience”. An environment that supports and enables professional practice and behaviours is defined as one that:
- Recognises and encourages leadership;
- Encourages autonomous innovative practice;
- Enables positive interprofessional collaboration;
- Enables practice learning and development;
- Provides appropriate resources.
Upholding individual professionalism
The framework describes how “the individual practitioner is responsible for upholding his or her own professional practice” through:
- Learning and developing continuously;
- Being a role model for others;
- Supporting appropriate service and care environments;
- Enabling person-centred and evidence-informed practice;
- Leading professionally.
Tools and implementation
Developing the framework took about a year and a half and was challenging, as there were many differing and strongly held views. Feedback from testing was extremely positive, suggesting the framework would be useful at all levels of practice and resonate well with the nursing and midwifery community. In particular, participants saw it as providing a basis for structured conversations about professionalism in practice and helping individuals reflect on their own practice for use as evidence for revalidation.
The framework and accompanying tools are now available on the NMC website. These include three animations demonstrating how nurses can use the framework to reflect on poor practice and challenge inappropriate behaviour in a constructive and non-confrontational way. There are also blogs from nurse leaders, as well as a portal for nurses to share their stories that attracted almost 500 submissions in the first 48 hours – the NMC has posted some as videos on social media (#professionalism).
Each UK country is now developing its own approach to taking the framework forward. The project board is exploring options for a robust review of how people are using the framework in practice, which will inform future implementation and tools. One of the first trusts to embrace the framework is University College London Hospitals Foundation Trust (Box 2). There is also interest from Australia and New Zealand.
Box 2. Enabling professionalism
Author: Vanessa Sweeney is assistant chief nurse, University College London Hospitals Foundation Trust.
My trust is planning to embed the professionalism framework across the organisation to make explicit the professional nursing and midwifery contribution and create a culture that encourages and inspires, with potential benefits for staff retention.
When I first read the framework, it really resonated. It felt like a much more positive way of looking at the professional code. We are saying we want to improve professionalism and support nurses to stay in the profession, but the dominant narrative relates to performance management, which can jar with what is core to nursing. This is our opportunity to change that narrative, promote professional pride and illuminate our unique contribution as nurses and midwives.
Creating a professional narrative could help resolve the disconnect felt by many nurses between the code and how they use it day to day, and strengthen nursing resilience and professional identity.
Starting in November 2017, the first six months are about scoping the framework, understanding it better and engaging staff. It is about articulating and making explicit the professional intention of new and existing activities or programmes of work and where this will add value to the profession. Some of the things we are doing already may slightly change course because we are thinking about the professional components.
For example, matrons are exploring how to align their successful matron rounds towards an ‘enabling professional’ model focused on leadership, evidence-based practice and critical thinking. Staff forums are giving junior nurses a platform to share their experiences and help take the professionalism agenda forward. Senior nurse leadership team meetings have been reorganised to create protected time to discuss professionalism and prevent operational issues taking over.
Other work streams include designing a supervision model and making explicit the nursing contribution to the development of a new electronic health record system for the trust. Professionalism will be the theme of an event in May celebrating International Nurses Day, when teams will report back on their work.
I have already noticed a change in language and dialogue, with more links and references to professionalism and nurses starting to develop their own initiatives. For example, the framework is being used by the deputies’ development programme to help sustain development from training. Student nurses have also used it in a new ‘mentor of the month’ award. We are also planning a piece of work linking professionalism to evidence around retention. There are components that will require investment at some point, so we need to be clear about why this is important.
We believe this framework will give nurses and midwives a voice to articulate what they intuitively know about their value and contribution within the multi-professional team, help them apply the principles of professionalism and incite them to stand proud as part of the nursing and midwifery professions.
- A new UK-wide framework describes professionalism in the context of the code of practice
- The framework draws on the experience of nursing and midwifery leaders across all levels of practice
- It shows nurses and midwives what professionalism looks like in practice to help them articulate their contribution
- It makes clear employers’ responsibilities to provide environments that enable professional behaviours
- The framework should promote leadership, strengthen resilience and improve staff retention
Chief nursing officers for the UK and Nursing and Midwifery Council (2017) Enabling Professionalism in Nursing and Midwifery.
Dupree E et al (2011) Professionalism: a necessary ingredient in a culture of safety. Joint Commission Journal on Quality and Patient Safety; 37: 10, 447-455.
Gulzar SA et al (2017) Empowerment among women nurses: a conceptual review of literature. Journal on Nursing; 6: 4, 20-29.
Kirkup B (2015) The Report of the Morecambe Bay Investigation.
Konukbay D et al (2014) Determination of professional behaviours of nurses working in an educational and research hospital. International Journal of Caring Sciences; 7:2, 633-641.
Storfjell LJ, Christiansen K (2010) Professionalism: nursing’s time is now. Journal of Illinois Nursing; 107: 1, 4-6.
Morgan J et al (2014) What does professionalism look like? Attitudes and behaviours derived from a Delphi Study. Nursing Management; 21: 7, 28-40.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Oxtoby K (2014) Student life – be sociable, but be careful. Nursing Standard; 28: 45, 66.
Scottish Government (2012) Professionalism in nursing, midwifery and the allied health professions in Scotland: a report to the Coordinating Council for the NMAHP Contribution to the Healthcare Quality Strategy for NHS Scotland.
Tanaka M et al (2014) Nursing professionalism: a national survey of professionalism among Japanese nurses. International Journal of Nursing Practice; 20: 6, 579-587.