Study of Nightingale’s nursing professionalism: a survey of nurses and nursing students in China

2020 marks the 200th anniversary of the birth of Florence Nightingale, who is the founder of modern nursing. Since she rescued nursing from the ‘sludge’, nurses have gradually taken root in healthcare and have been playing an increasingly important role all over the world. Nurses have been irreplaceable during the COVID-19 outbreak. The World Health Organization (WHO) announced 2020 ss the International Year of Nurse and Midwife to recognize the important contributions of these two communities to global healthcare. All these pronouncements are based on nurse professionalism, which is a key factor in the competence of nurses.

Nevertheless, historians, sociologists and nurses are attempting to determine whether professionalism is still present in this profession [1]. For a long time, nurses have been described as mere executors of doctors’ orders, while their professional skills have not been recognized. Nursing knowledge and skills in nursing science that have accumulated over a long period have been ignored. This phenomenon has been repeated in the media and received much exposure. In other words, most bedside nursing and clinical skills are viewed as byproducts of medical knowledge and judgment. This stereotype results in the belief that nursing requires dedication and following instructions instead of knowledge and skills. Even worse, this stereotype has been strengthened by some practical behaviors of nurses to meet the expected image of public [2].

Indeed, nursing has been developing as a science since the establishment of modern nursing education. Nursing professionalism has existed since the foundation of modern nursing, and it has been continuously developed and improved. In China, it is also known as “Nightingale’s Spirit”. However, a deviation in understanding the connotation of Nightingale’s nursing professionalism has been observed. For example, most people in China believe that Nightingale’s nursing professionalism refers to dedication and sacrifice and that nursing involves serving as a reputable caregiver. This may be related to the internationally renowned Nightingale Medal that emphasizes sacrifice and dedication [3, 4]. Owing to Florence Nightingale's far-reaching influence on modern nursing and her irreplaceable role, most people picture Florence Nightingale whenever nurses are mentioned.

However, in 2003, the American newspaper the Washington Post published an article entitled Good night, Florence: with nursing in crisis, some say it's time to retire Nightingale as a symbol [5]. Is Florence Nightingale no longer the flag of caregivers? Is Nightingale’s nursing professionalism out of date? Substantial efforts have been invested in studies of nursing professionalism. Researchers [6‐8] have investigated and practiced the professional scale from different perspectives, which provide models and methods to measure nurse professionalism. Nevertheless, the recognition of nursing professionalism by nurses should be clarified, and nurses themselves should rid themselves of this stereotype first, since nursing professionalism reflects the attitude of nurses toward their work and serves as a guide for their behaviors. Previous studies have shown that the job satisfaction of nurses is proportional to the professionalism level of nursing [9]. A study on the internet image of nurses indicates that nurses are typically described as workers who are responsible for comforting patients and recording data [10]. Florence Nightingale has been described as a lantern goddess, which does not reflect the professionalism of nursing. This would appear to have a negative impact on the development of nursing professionalism. In particular, the public tends to ignore the professional value of nurses, resulting in negative influences on the recruitment of nursing staff, allocation of resources and awareness of nursing professionalism. It has been demonstrated that the simple view of nursing plays a dominant role if the image of nursing is based only on the stereotype [11]. Therefore, a change in the perception of nursing may be as necessary today as in the Nightingale Era. Additionally, it is necessary to review the concept of nursing professionalism to provide a conceptual definition for the twenty-first century. This is particularly necessary since professionalism is a complex and multi-dimensional structure, which differs with historical and cultural backgrounds [12]. Similarly, Nightingale’s nursing professionalism should currently be re-examined to explore its enduring essence in nursing. In this study, the current impacts of Nightingale's professional values on nurses were investigated with Nightingale’s nursing professionalism as the starting point. Recognition of the connotation of Nightingale's nursing professionalism by nurses and nursing students in China was investigated.

This study aims to explore the connotation of Nightingale’s nursing professionalism and the recognition of nurses and nursing students in China. A statistical analysis of the survey of different populations and their characteristic indicators revealed that nurses and nursing students in China have a consistent understanding of Nightingale’s nursing professionalism, and the average scores of all items exceeded 7, indicating that all the indices in Nightingale’s nursing professionalism are of equal significance.

Some studies proposed that nurse interns feel frustrated about the public view that nurses primarily provide ‘care’ and do not merit recognized professionalism [15]. Moreover, clinical teachers help students to acquire professional values by acting as an example in practice [16]. Therefore, it is assumed that nurses have a deep understanding of Nightingale’s nursing professionalism compared with nursing students owing to their clinical experiences. However, the survey results indicated no difference in their understandings. Changes in their understanding of professionalism after work experience could be attributed to issues in the cognition of professional role in practice.

It has been demonstrated that nurses with a negative role model have a negative impact on the development of self-confidence and professional recognition of nursing students, while those with a positive role model help nursing students to develop knowledge, skills, values and beliefs [17]. A study on the cognition of senior high school students of nurses revealed that nurse internships may have a positive impact on the nursing concept, as well as on the recruitment and retention of nurses [18]. Studies on career development demonstrated that positive role models should be established to facilitate the professional development of nursing students, while the clinical nurses, teachers and supervisors that they contact during an internship play an important role [19]. This suggests that nursing management should facilitate shaping models for nurses and nursing students to improve their professional recognition. Kelly et al. [20] reported that a visit to the Nightingale History Museum in UK is an effective way to enhance the professional cognition of nursing students. Therefore, it is highly significant to investigate the cognition and recognition of Nightingale and its nursing spirit by nurses and nursing students.

What exactly is Nightingale’s nursing professionalism? Based on the survey items mentioned above and the results of factor analysis, these items can be classified into professional emotion (e.g., dedication and sympathy), professional capability (e.g., keen insight, professional judgment, professional care, leadership, and innovation) and professional ethics (e.g., teamwork, exquisite skills, comfort, help, respect for life, love and dedication, prudence and responsibility). Florence Nightingale wrote in her diary that “God calls me to serve her. God’s call is for me to work hard among the poor with strong faith”. The strong belief of Florence Nightingale in nursing led her to implement nursing education and nursing reform without fear of difficulties, thus, becoming a pioneer of modern nursing [21]. Although it is not necessary for every nurse to have the same religious beliefs as Nightingale, nurses must have a persistent love for nursing and exhibit love, sympathy, and dedication to patients. This is defined as professional emotion.

Florence Nightingale also believed that love cannot replace professional training or surpass professional knowledge. Instead, deep dedication to professionalism and belief is required. She believed that nurses who do not develop professional skills via systematic learning are essentially ‘Potter and cobble’ on patients [21]. Although Humanistic care is the essence of nursing, nursing without professional knowledge as support is no more than charity. Nursing must rely on scientific knowledge and technology to enhance the value of nursing, so that they can effectively serve the public. Therefore, professional capability is an essential part of Nightingale’s nursing professionalism. In addition to advanced professional knowledge and skilled professional skills, a qualified nurse should have noble professional ethics and norms. Florence Nightingale always adhered to the character of nurses. She believed that an excellent nurse should be punctual, quiet, trustworthy, tidy and regular. Indeed, Florence Nightingale considered a good personality to be the criterion for nursing workers [21]. Studies have claimed that professional ethics are the basis of professional recognition [22]. Nursing requires nursing staff to love their careers, be prudent and responsible, and work as a team with doctors and other relevant personnel. This was Nightingale’s requirement and expectation for nursing, as well as one of the core connotations of Nightingale’s nursing professionalism in the new era. Nurses must have professional ethics, which are the necessary guarantee for the physical and mental rights of patients, and it is the third constituent element of Nightingale’s nursing professionalism. This is defined as professional ethics.

The major limitation of this study is the representativeness and universality of the sample. This study solely reflects the situation of China and does not involve nurses in other countries. Moreover, the survey was conducted by snowball sampling with no targeted and rigorous control design. Thus, it is impossible to compare the survey results of nurses in hospitals in different regions. Additionally, the customized questionnaire used in this study may be biased in terms of items. Therefore, it is suggested that future studies involve more samples and a qualitative interview to comprehensively and deeply understand the cognition and recognition of Nightingale’s nursing professionalism by nurses.

Although the data need to be interpreted with caution owing to the limitations described above, the factor analysis suggests that the structure of Nightingale’s nursing professionalism includes professional emotion, professional ability and professional ethics, which are all essential and constitute an interactive triangular model. These three factors can only result in a high level of professionalism by interactive promotion and improvement. Moreover, the survey results indicate that nurses and nursing students have the same level of understanding of Nightingale’s nursing professionalism. They highly recognize Nightingale’s nursing professionalism, indicating that this model is still applicable and plays a guiding role for nurses in contemporary times. This suggests that nursing education and nursing managers should fully utilize this model to improve the professionalism of nurses.