A concept analysis of professional commitment in nursing

Abstract

Background:

The concept of professional commitment is being widely studied at present. However, although it is considered an indicator for the most human part of nursing care, there is no clear definition for it, and different descriptors are being used indiscriminately to reference it.

Objective:

The aim of this study is to clarify the concept of professional commitment in nursing through the Rodgers’ evolutionary concept analysis process.

Design:

Systematic search using English and Spanish descriptors and concept analysis. Studies published between 2009 and June 2015, front-to-back analysis of the Nursing Ethics journal and manual check of articles cited in studies related to the Nijmegen Professionalism Scale.

Research design:

The procedure of concept analysis developed by Rodgers was used.

Ethical considerations:

Although the topic was not labeled as sensitive and subject to ethical approval, its realization was approved by the Ethical Committee of Clinical Research of Aragon (CEICA) approved the study on 18 March 2015 and also careful procedures have been followed according to ethics expressed in the Declaration of Helsinki.

Findings and discussion:

A total of 17 published studies. A clear definition of the concept was made, and surrogate terms, concept dimension, differential factors related to the concept, sociocultural variations and consequences for nursing practice were identified.

Conclusion:

There is a need for continuous advancement in the development of the concept, specific actions to encourage this and the improvement of evaluation methods for its study.

Keywords

Commitment compromise concept analysis engagement nurse nursing professional practice professionalism professionalization responsibility systematic review

Introduction

Healthcare is in constant change and transformation, due to factors such as increasing the demand for high-quality standards, advances in training, improvement in the practice of health professions, increasing ageing, demand for care, autonomy, expectations and recognition of patients’ rights. All this influences the nature of the health organization that should, in theory, translate into a greater professional commitment. However, it must be borne in mind that hospitals and other places where health services are provided are complex environments, combining different professional groups that, due to the current economic changes, have limited templates, of work and diminished resources, which causes that the health professions are suffering constant symptoms of exhaustion and discontent: it increases the number of conflicts, the stress, the professional wear and dissatisfaction.^1
–3 In particular, the nursing group is considered one of the great risk groups to suffer the so-called burnout syndrome, due to its high degree of relationship with the patient. These situations, generated by a series of factors that are difficult to modify that are sufficiently conditioned by the lack of resources, provoke the search for motivational resources of low cost, that promote of individual way, the professional commitment that has been identified as a factor relevant in the studies that address these problems.⁴ This broad and difficult concept is the key to understanding the difference between care as a professional nurse activity and spontaneous care activity.⁵

In summary, due to the world shortage of nurses, turnover, the decision to leave the profession and consequences such as stress, anxiety, lack of autonomy and excess workload, the nursing be growing concern with the definition and evaluation of professional commitment; however, the apparent ease with which it is recognized, changes in healthcare policy, cultural differences, the evolution of the characteristics of work and the profession, educational methods and other personal factors hinder its definition.⁶

Many attempts have been made to define the ‘professional commitment in nursing construct’. These studies aim to increase the performance of professionals, the quality and safety of healthcare provision, and financial returns, and to study the ethical and moral realm of professional responsibility.

Given the ambiguity that exists and the numerous surrogate terms used to encompass the same construct, detailed study of its definition and characteristics is needed. Evidence that supports its relevance and work on its evolution and quantification are required.

Background

Due to this recent professionalization, nursing has been considered a semi-profession. Nonetheless, through the present implementation of study programmes, research and theory,⁷ nursing possesses a scientific corpus of knowledge and skills that confer professional autonomy. In recent years, research in the field of nursing has generally focused more on technical and clinical advances than on the less tangible aspects of the profession, which appear to be being more studied and valued at this time.

Reflection on professional commitment emerged to improve on the idea that job satisfaction affected behaviours such as absenteeism and staff turnover.⁸

Eagerness to improve the service provided to users of healthcare systems had led research of professional commitment in nursing to become focused on negative factors or consequences for those who practise it, such as burnout syndrome, stress and job dissatisfaction that are directly related to the occupational characteristics of the places where it is practised, and which hinder suitable action to be taken. However, different authors have concluded that professional behaviour depends on other factors.⁹

The studies that deal with the concept are few and ambiguous. Despite the existence of different constructs for the concept and lines of research, no consensus has been reached as to its definition. There are diverse instruments that aim to quantify it; however, these focus on behaviours of daily practice, driven by concerns regarding increased healthcare costs, the shortage of nurses and quality of care, among others, and not on concerns for encouraging the human side of healthcare.

The analysis of concept is necessary to eliminate the ambiguities about it, clarify the dimensions of the construct and above all, study the ethical and moral sphere of professional responsibility that differentiates the spontaneous activity of care from the professional activity of caring. All this will allow the development of initiatives that increase the professional commitment and thus the human quality of the care provided by the nursing professionals.

Design and search methods

It was decided that the method proposed by Rodgers¹⁰ (Figure 1) would be used. This methodology has been used in similar works.^6,11,12

Figure 1.

Rodgers’¹⁰ evolutionary concept analysis process.

In addition to the study of the essence of concepts, the proposed method provides the vision of a changing and dynamic reality, leaving aside the literal or semantic meaning. Due to the objective of the present investigation, this method proves to be very adequate because the concept under study is a changing concept in context, culture and time. This methodology, unlike others, is a cyclical process which facilitates analysis in complex concepts such as the one studied, allows to clarify the current use of concepts and clearly defines their attributes as a basis for the later development of the concept.^11,12 In general, this type of methodology is used when the concept is poorly defined, its characteristics or attributes are not clear or the evolution of this is constant.

The starting point in order to include all uses of the concept was the documents extracted from the work Systematic Review of Professional Commitment summarized in Figure 2 and Table 1.

Figure 2.

Summary of systematic review strategy nursing professional commitment.

Table 1.

Literature review.

	MEDLINE	PubMed	IBECS	Cuiden	SciELO	Enfispo	Cochrane Plus	IME	Web of Science	MEDES	TESEO
Last 5 years
Descriptors and nursing	280	192	9	91	48	6	2	0	326	0	1
Descriptors and nurse	77	57	4	22	3	3	1	0	110	1	1
Descriptors and nurses	194	150	4	16	20	2	1	0	263	1	0
Update
Descriptors and nursing	53	43	0	15	1	0	0	0	79	0	1
Descriptors and nurse	9	9	0	3	0	0	0	0	27	0	1
Descriptors and nurses	33	28	0	2	0	0	0	0	55	0	0

This included 106 works (primary articles) cited in three articles dealing with the construction of the Nijmegen Professionalism Scale.^13
–15

A search was made of the Medline, PubMed, IME, IBECS, Cuiden, SciELO, Enfispo, Cochrane Plus, Web of Science, MEDES and TESEO databases. The literature review was in both English and Spanish languages. It was decided to include the Spanish language since Spain is the country where the study has been carried out and it was also wanted to corroborate that in this language, little has gone into the meaning and relevance of the professional commitment in the nursing profession. The following search concepts were included: ‘Commitment’, ‘Compromise’, ‘Concept analysis’, ‘Engagement’, ‘Professionalism’, ‘Professionalization’, ‘Professional Practice’, ‘Nijmegen’, ‘Responsibility’, ‘Compromiso’, ‘Análisis concepto’, ‘Profesionalismo’, ‘Profesionalización’, ‘Práctica Profesional’ and ‘Responsabilidad’, combining the descriptors/key words with the words ‘Nursing/Enfermería’, ‘Nurse/Enfermera’ and ‘Nurses/Enfermeras’ (operator ‘and’), that were included in the title. Were taken into account the publication date of the originals had to be within the previous 5 years (November 2009–November 2015), since in the preliminary investigation, it was clear that the study of the concept was recent and it was intended to know its current meaning. However, documents were retrieved from the main references, completing the understanding of the evolution of the concept over the last two decades (1994–2007).

To complete the search, due to the ambiguity of the terms used and the definition of the concept, a manual review was carried out and a front-to-back analysis was made of Nursing Ethics (November 2009-November 2014), although this magazine was included in the PubMed repertoire, to analyse one by one the originals published in the last 5 years. Due to which the duration of the process was updated again, according to the same methodology, until June 2015.

Search outcome

After analysing the content of 99 original works, it was decided that the analysis should only include works of a qualitative nature, understanding those documents that did not intend to quantify the professional commitment, that is to say, they did not use instruments of measurement or evaluation, that is to say works whose objective was to describe characteristics, associated factors, implications for the profession or explanation of possible sociocultural variations of the concept. The works of a quantitative nature focused on measuring specific behaviours and did not provide abstract definitions or broad attributes. An exception was made with the inclusion of the original by Jenaro et al.⁹ Despite the use of quantitative methodology, its aim was to analyse the association between the individual characteristics of nurses’ work and the professional commitment. The other selection criteria can be found in Table 2.

Table 2.

Selection criteria.

Inclusion criteria	Exclusion criteria
Articles referring to the nursing profession.	Evaluation/measurement of professional commitment. Use of measurement instruments for professional commitment (by means of a specific instrument, scale or subscale).
Description of the concept, definition of the concept.	Articles referring exclusively to other healthcare professions.
Works related to definition, characteristics, associated factors, implications for the profession and explanation of the possible sociocultural variation of the concept.	Reports on methods for teaching the concept.

A total of 17 works were analysed (Figure 3 and Table 3). The most relevant themes were identified by means if thematic content analysis through provisional categories were created based on the questions: How can professional commitment in nursing be defined?; What are the characteristics or attributes that define it?; What factors are associated with professional commitment in nursing?; What are the implications of achieving optimum levels of professional commitment in nursing?; and Are there sociocultural or temporal variations in the clarification of the concept? (Table 3).

Figure 3.

Strategy selection studies concept analysis nursing professional commitment.

Table 3.

Characteristics analysed studies.

Author(s) (year)	Country	Aim	Results	Conclusion	Surrogate terms
Akhtar-Danesh et al. (2013)¹⁶	Canada	Identify common viewpoints about professionalism held by nursing faculty and students.	Four viewpoints emerged as humanists, portrayers, facilitators and regulators.	The differences indicate that there may be numerous contextual variables that affect individuals’ perceptions of professionalism.	Professionalism
Beattie and Crossan (2015)¹⁷	UK	This article identifies the most important issues that need to be addressed for nurses (the largest group of NHS employees).	The case study for this article on Scottish nurses in a new hospital focused on the interaction between feeling valued, involved and having a voice; and line management support.	Themes and challenges for future empirical research are identified. The two selected elements (feeling valued, involved and having a voice, and line management support) of employee engagement and their significance for nursing staff is explored in this article based on a multi-method case study (‘Central Infirmary’).	Employee engagement
Dehghani et al. (2015)¹⁸	Iran	This study was conducted with the aim of clarifying and reducing the semantic ambiguities around the concept of professionalism.	The analysis demonstrated that professionalism in nursing consists of three main pillars: principles of care, communication and ethics.	Given that the process of professionalism in nursing may have positive outcomes for the nurse, the nursing profession and the health system of the community, these items have been attended to. The present concept analysis can open the way to conducting more extensive research and devising tools to identify the barriers, facilitators and administrative arrangements by clarifying the concept.	Professionalism
Ghadirian et al. (2014)⁶	Iran	The aim of this article is to identify the core attributes of the nursing professionalism.	The analysis showed that nursing professionalism is determined by three attributes of cognitive, attitudinal and psychomotor. In addition, the most important antecedent’s concepts were demographic, experiential, educational, environmental and attitudinal factors.	Nursing professionalism is an inevitable, complex, varied and dynamic process. In this study, the importance, scope and concept of professionalism in nursing, the concept of a beginning for further research and development, and expanding the nursing knowledge are explained and clarified.	Professionalism
Gokenbach and Drenkard (2011)¹⁹	USA	A case study of an organization that on all levels from economic, manpower, quality and safety has benefited from the Magnet journey.	As a result of their study, there were a group of 41 hospitals that were described as ‘magnet’ hospitals because of the characteristics they all shared, and through these elements, they were able to attract and retain professional nurses. These characteristics became known as ‘Forces of Magnetism’.	The Magnet journey has allowed the nursing staff to feel proud of the work they do, feel empowered and in control of their work environment, and ultimately valued by the organization. The commitment has been made by this transformed nursing organization to continually strive to maintain the ‘magnetized’ culture supporting a pursuit of excellence.	Engagement
Hutchings et al. (2012)²⁰	UK	Report on the development of a ranked thematic list encompassing the positive and challenging exemplars of patient-centred professionalism in community nursing.	Each of the five workshops resulted in the production of approximately ten positive and ten challenging exemplars of patient-centred professionalism. The thematization of these exemplars allowed the development of eight broad themes. The Forum event then provided a mechanism for ranking the importance of these themes. The patient, community nurse as a person and nursing ethos were ranked as the most important themes by study participants.	The adapted Nominal Group Work approach was a useful method to allow the development of a ranked thematic list that illustrated the important positive and challenging exemplars of patient-centred professionalism in community nursing.	Patient-centred professionalism
Jafaragaee et al. (2012)²¹	Iran	Analysing the concept of professional commitment in Iranian nurses.	Loyalty and tendency to remain in the profession and responsibility to the professional issues were extracted in theoretical phase. Commitment to promote caring abilities, satisfaction of being a nurse and belonging to the nursing profession were obtained in fieldwork phase. Finally, two main themes including ‘commitment to offering the best nursing care’ and ‘commitment to promotion of the nursing profession’ were extracted.	Nursing is a humanistic profession; it has some particular characteristics due to the profession’s nature. In this article, a definition composed of two main dimensions of professional commitment in nursing has been introduced.	Professional commitment
Jafaraghaee et al. (2014)²²	Iran	This study aimed to explore factors influencing the professional commitment in Iranian nurses.	Two main categories emerged: ‘Challenging with different feelings’ and ‘Managers’ role’. Challenging with different feelings had two subcategories: ‘Burnout’ and ‘sense of valuing’. The other theme was composed of three subcategories: ‘Gratitude or punishment climate’, ‘manager’s view of caring’ and ‘knowledge-based vs routine-based nursing’.	Findings revealed the burnout as a common sense in nurses. They also sensed being valued because of having a chance to help others. Impediments in the healthcare system such as work overload and having more concern in the benefits of organization rather than patient’s care and well-being lead to a sense of humiliation and frustration. Congruence between the managers and nurses perceived values of the profession would be a main driver to the professional commitment. Making a sense of support and gratitude, valuing the care and promoting the knowledge-based practice were among the other important factors for making the professional commitment.	Professional commitment
Jenaro et al. (2011)⁹	Spain	This article analyses the association between nurses individual characteristics, job features and work engagement.	Concerning psychiatric morbidity, 49% nurses met criteria for somatic symptoms, 65.5% met criteria for anxiety and insomnia, 4.6% met criteria for social dysfunction and 10% met criteria for severe depression. There were no effects for length of service or professional category. Nurse managers scored significantly higher in several job stressors compared with other groups. Concerning engagement, 33% of the nurses experienced high dedication, 20.4% experienced high vigour and 36.7% experienced high absorption. Predictors of vigour and dedication were satisfaction with job position, higher quality of working life, lower social dysfunction and lower stress associated with patient care.	Strategies to promote work engagement should be implemented. More attention should be paid to job environments to guarantee job satisfaction. Organizational strategies to reduce the stress associated with patients’ care, and initiatives to improve social and communication skills are also required for nurses to experience vigour and dedication.	Work engagement
Johnson (2015)²³	USA	Explain the concept of professionalism for the nurse profession and some suggestions to be included in the curriculum, orientation and behaviour modelled by more senior nurses.	There is no consistent definition of professionalism and no common understanding. It is apparently easy to recognize but very difficult to define. Here are some suggestions: specialized body of knowledge and lifelong learning; ethics; competence and judgment; communication/interpersonal skills/collaboration; altruism; compassion and caring; reflective engagement over the life of one’s career and evaluation of one’s own practice; professional relationships.	No one is born professional. It is learned through school expectations (discussions of professional attitudes and behaviours), work experience and the modelling of more senior staff. Moreover, if professionalism is a set of behaviours, then it can be measured. It seems to be more caught than taught, although there needs to be a base of information from which to build. This base of information begins in school, but needs to be reinforced on employment through the orientation process. Managers should expect their staff to model professional behaviours for the newly hired staff so as to carry on the traditions of nursing professionalism.	Professionalism
Keeling and Templeman (2013)⁷	UK	To explore final-year nursing students’ perceptions of professionalism using a reflective approach.	The findings revealed that student nurse’s perceived vulnerability, symbolic representation, role modelling, discontent and professional development as elements that informed their own professionalism. Additionally, being able to observe the behaviours of registered nurses appeared to be significant to the student in the development of their own sense of professional identity, using positive and negative role models constructively.	It appears that final-year student nurses are cognizant of the impact of practice scenarios and observational influences, affecting their own perceptions of professionalism. They are able to clearly identify and make sense of experiences in practice, and constructively use this knowledge to positively inform their practice.	Professionalism
Keyko (2014)²⁴	Canada	In this article, I argue that work engagement is essential for ethical nursing practice.	Within a relational ethics perspective, it is evident that work engagement enables nurses to have meaningful relationships in their work and subsequently deliver ethical care. If engagement is essential for ethical nursing practice, the environmental and organizational factors that influence work engagement must be closely examined to pursue the creation of moral communities within healthcare environments.	The existing nursing research offers valuable insights into the predictors and influencing factors that can assist in fostering work engagement and developing moral communities within healthcare environments. Importantly, research points to areas within the current healthcare context that must be further explored if genuine dialogue about how nurses can be more ethical is desired.	Engagement
Lee (2015)²⁵	USA	To report an analysis of the concept of ‘meaning in work’.	Four critical attributes are identified: experienced positive emotion at work; meaning from work itself; meaningful purpose and goals of work; and work as a part of life that contributes towards meaningful existence. The identified antecedent of ‘meaning in work’ was a cognitive shift and the identified consequences were positive personal experience and positive impact on peers and organizations.	This article provides a clear definition of ‘meaning in work’. The resulting coherent definition will facilitate the use of ‘meaning in work’ in nursing research.	Meaning in work
Lees (2009)²⁶	UK	Describe the importance to concept of commitment to care.	The authors show there is a huge difference between the motivation and mentality of turning up to work to do a job, and doing that job really well and contributing to effective through a personal commitment to update practice, rotate work settings or even take secondments as part of lifelong learning, which is likely to be reinvested into patient care and outcomes. This must teamwork. Motivated staff will strive to promote the latter and take pride in what they do, which if eroded will directly impact the quality of care delivered.	The reputation of ‘what nurses do well’ must be looked after to secure the commitment of people with a desire to care, long into the future.	Commitment
Letelier-Valdivia M and Velandia-Mora (2010)²⁷	Chile	Giving nurses reasoning in order to build a path that allows professional excellence to be reached, reflection on professionalism and how to achieve it.	It is possible to reach excellence, but if it remains a discourse and if there is no personal and collective commitment to transmit this culture from one generation to another through a continuous process of inculturation, education and socializing in every stage of professional development, it continues to be insufficient so as to achieve excellence as a professional goal because its practical application requires professionals who have reached moral maturity at both a personal and a professional level, in order to guarantee that decision-making in practice is also the result of responsibility, in accordance with the expectations that society assigns to your professional role.	Achieving excellence through professionalism requires a change in attitude towards work that allows an emotional participation that guarantees not only quality of care but also personal satisfaction for the work performed. In this way, the goal of excellence is turned into the achievement of quality care, understood as a moral commitment that is the concern of the profession in view of its professionalization and where the transit from theory to practice involves the achievement of professionalism, value-added for professional actions.	Professionalism
Walker et al. (2015)²⁸	Australia	Wanted to find out how much they knew about professionalism (its requirements and how it affects patient care) and what they considered to be the personal attitudes, attributes and values which made up professionalism.	The data were distilled into 23 attributes of professionalism, covering the whole spectrum of views and discussion.	This small study validates the education provided on the Nursing Council’s Code of Conduct, nurses’ knowledge of professionalism, New Zealand Nurses Organization’s commitment to drive improvements in skill mix and staffing levels, and good access to continuing education all of which foster the conditions essential for professional practice.	Professionalism
Zibrik et al. (2010)²⁹	Canada/UK	This study examines rural nurses’ experiences of professionalism and articulates the nature of professionalism in rural acute-care settings.	The findings indicate that professionalism among rural nurses is a dynamic, enduring phenomenon that exists in workplace and community contexts. To experience professionalism in rural nursing means being visible in the community while embracing reality in the workplace.	Understanding professionalism in a rural context has significant implications in terms of affirming and identifying sources of job satisfaction among rural nurses and creating professional practice environments in rural areas.	Professionalism

Results

Surrogate terms and relevant uses of the concept

As explained by Ghadirian et al.,⁶ ‘The term “surrogate” is used for the concepts that express the same meaning of the desired concepts. In other words, the term explains the meaning of a concept’. Akhtar-Danesh et al.¹⁶ affirm there is no consensus on the definition of professional commitment in nursing. This may be due to the different terms of substitution that appear in the literature.

The substitutive terms used by the works analysed, which do not necessarily have similar characteristics, (Table 3) are set out below. It also explains the meaning of the term commitment to value differences.

Commitment

This is the commitment of offering service to society, belief in respect and the values of every individual; the commitment to education and autonomy, and the intention to continue to work as a nurse. It is the way people think about the profession and show their loyalty to it.²¹

Professionalism

The concept of professionalism has been studied since the 1960s by healthcare professions. A number of authors provide a general and abstract definition for this concept, while others are more specific through their description of behaviours.

Letelier-Valdivia and Velandia-Mora²⁷ consider it to be ‘a moral ideal of nursing care whose aim is the protection, enhancement and preservation of human dignity’. Akhtar-Danesh et al.¹⁶ include specialization, intellectual and individual responsibility, and group consciousness in their view.

There are authors who consider the concept to mean its practical expression. Zibrik et al.²⁹ define it as the conduct, goals and qualities that designate someone as a professional. Arnold³⁰ considers it to be a set of behaviours put into service of the good of others through vocation, with a body of knowledge and skills. Keeling and Templeman⁷ consider that such behaviours are shaped by autonomy and self-regulation, to which they add the belief in public service that prevails in the United Kingdom. Ghadirian et al.⁶ also highlights the importance of acquiring a professional ideology, measured by the best standards, as does Dehghani et al.,¹⁸ who consider it relevant to take into account personal and professional characteristics. In relation to the latter, Hutchings et al.²⁰ have been focusing on patient-centred professional work. They consider professionalism to be attention and work centred on interest for patients’ characteristics, preferences and desires.

Engagement

There is apparently more consensus in relation to this term, essentially considered an attitude towards work. According to Gokenbach and Drenkard,¹⁹ it refers to an attitude that allows one to be physically, mentally and emotionally connected to work. In keeping with the line previously established by Jenaro et al.⁹ and Keyko,²⁴ they define it as fulfilment and a positive state of mind characterized by drive, dedication and absorption in work. In the research carried out by Beattie and Crossan,¹⁷ which aimed to determine the characteristics of the concept, it is defined as a positive attitude held by an employee towards the organization and its values.

Meaning in work

According to Lees,²⁶ this is the discovery of meaning in the experience of work, the actual job and its purpose.

Attributes of the concept

Attributes are the characteristics of the concept that you set apart from the rest. This step tries to discover the essence of the concept, leaving aside other non-defining characteristics of the concept of professional commitment in nursing. Through the analysed bibliography, this study proposes the following attributes.

Learning the knowledge and skills inherent to the profession

Constant and specialized learning forms a part of the commitment that is acquired through the practice of any profession. However, this aspect takes on great relevance in nursing due to the constant changes that take place. Jafaragaee et al.²¹ firmly believe that the development of knowledge and experience is a defining characteristic of the commitment to offer the best care.

Nevertheless, there is obvious concern regarding the connection between theory and clinical practice. An example of this is the results obtained by Keeling and Templeman⁷ who discovered this concern about the concept of professionalism in nursing students. Knowledge of theory should therefore be understood as an ideal which should be incorporated in daily practice. Thus, this attribute not only includes formal and permanent knowledge in clinical competences, described by authors such as Letelier-Valdivia and Velandia-Mora²⁷ and Walker et al.,²⁸ but also encompasses other aspects, such as the obligation of being informed, learning interpersonal skills, collaboration and communication, and even the ability to adapt.^16,18,20

Acquisition of values

Values are philosophical constructs. While they are general, they are not found in the same way in all people, and hence the importance of their acquisition in professional life. By way of example, Alfred et al.³¹ found significant differences between the values held by nurses in Taiwan and the United States. Professional ethics, however, are rules that should govern the conduct of a group and are ‘imposed’ by the profession as a whole and not by individual commitment.

All the analysed works refer to the importance of personal values in professional practice. An example of this is the work by Akhtar-Danesh et al.,¹⁶ which although differentiating between four profiles when defining professionalism, stressed the importance of values being placed at the service of professional tasks, including the respect for human dignity, personal integrity, protection of privacy and protection of patients from any harm. Other authors point to accessibility and flexibility; empathy and altruism; vocation, personal commitment integrity, compassion and the defence of moral, legal and social values; trust, honesty, positive attitude, kindness, patience and respect for confidentiality, among others.^20,22,27,28

The importance of the acquisition of values is also reflected in the opinion held by Lees,²⁶ who described engagement as a set of five core values. The same importance is seen in the work by Dehghani et al.,¹⁸ which proposed that emphasis should be given to human values and in the work by Jafaragaee et al.,²¹ who insist on the development of these values and the fostering of high-level human virtues.

The development of this aspect, according to the literature analysed, should be brought about by means of a hidden curriculum that tacitly conveys appropriate values.

Acknowledgement of professional responsibility

The acquisition of knowledge, skills and values necessarily involves the acknowledgement of the responsibility that arises in the decision-making process. These also include, as explained by Hutchings et al.,²⁰ the duty of care and attention to high quality.

This does not only entail the ability to reflect over such aspects but also encompasses personal responsibility to the nursing profession; in other words, the constant evaluation of daily practice, and even judgements on the practice of others; adherence to codes of professional ethics; participation in the advancement of the profession, whether through research, teaching or participation in organizations and actions; and the feeling of belonging that hinders abandonment.

This aspect appears explicitly in the consulted literature. Akhtar-Danesh et al.¹⁶ point out that all of their sources included accountability, responsibility and adherence to professional codes of conduct as essential elements that define professionalism. The nursing students interviewed by Keeling and Templeman⁷ revealed their concern for the imminence of responsibility, showing their understanding of nursing as a ‘way of life’, including the importance of the ability to judge others. Jafaragaee et al.²¹ considered promotion of the profession as indicative of commitment; in other words, pride in being a nurse, being responsible and negative about abandonment. Walker et al.²⁸ referred to adherence to a code of conduct, the ability to recognize mistakes, work ethic, awareness, time management, commitment to profound reflection on practice, and evaluating colleagues and accepting evaluation from them. With regard to participation in the advancement of the profession, the opinion given by Natan et al.³² includes as an element of professional commitment the functions of nursing preceptors, whose workload is increased and who take responsibility of the errors of their students.

Professional behaviours

This concept encompasses all types of behaviours that take place in work or in relation to the profession. These include the integral care that aims to prioritize the interests and well-being of patients;¹⁸ the importance of personal appearance, inter-disciplinary collaboration, leadership and attitude;¹⁶ accessibility, flexibility, adaptability, autonomy and working relationships;²⁰ support for other nurses and respect for cultures among others.²⁸ They can also be classified into subdimensions: behaviour towards the patient, behaviour towards other professionals, behaviour towards society and behaviour towards oneself, which would largely depend on the other described attributes.

Individual motivation is therefore an essential condition that characterizes the components of professional commitment. Concurring with Jenaro et al.,⁹ other external factors that are difficult for the professional to change or control are considered predictors and not definitory attributes of professional commitment.

Implications, consequences and hypotheses of the concept

The analysed literature shows the growing interest in the study of the concept. It is considered that the study of professional commitment will increase the quality of care and patient safety, personal satisfaction and that of users, professional authority and the ability to make decisions; will lead to the development of proficiency programmes to improve the effectiveness of education, reduce accidents and errors; will promote risk management, the creation of employment regulations, socialization, professional development, promotion of the profession and development of the concept itself.^{9,18,21,25,27,29}

All of these aspects are crucial for the development of nursing as a profession and for patients seeking quality care. In the same way, it is considered that staff with high levels of professional commitment strive to promote integral care, prioritizing patients without neglecting their responsibility towards themselves and their professions, which is a priority in current healthcare.^9,18,27 Moreover, in the long term, these professionals will increase their participation and satisfaction, fostering creativity and innovation.^22,25,27

Nonetheless, it is interesting to reflect on the opinion given by Ghadirian et al.,⁶ who despite pointing out the positive aspects derived from fostering professional commitment, sustain that in situations of uncertainty, blind spots may be created in the organization and the flow of vital information may be stopped as the result of professional groups forming their own subculture, particularly in their habits of language and communication. Therefore, they tend to be separated, even if they are working with other groups within an organization. If we include this possibility, there should be insistence on the importance of supporting other professionals and teamwork.

Concepts that are related, factors and elements

The analysed literature contains a number of factors of a general, multidimensional and dynamic nature which, while not being definitory items, be the concepts that are related to professional commitment and vice versa.

Examples of this are the studies by Beattie and Crossan,¹⁷ who describe elements of employee engagement such as feeling valued and having a voice, satisfaction in the workplace, significant work, support culture and support for management, among others; by Hutchings et al.,²⁰ who point out aspects related to the workplace: limited access to information, equipment and sufficient resources; suitability of facilities and so on; those related to users: lack of compliance with treatment, erroneous perceptions of the role of nurses, lack of involvement by carers and so on; and by Akhtar-Danesh et al.,¹⁶ who highlight the communication of beliefs and appropriate regulations by institutions. Other significant elements found in the consulted literature are given in Table 4.

Table 4.

Concepts that are related.

Factors related to the work environment	Motivation and support from managers and supervisors, structure, characteristics, context and organizational/institutional culture.	Work profile and climate (teamwork, communication, collaboration, adequate time management, bureaucratic obligations, adequacy of workloads, freedom related to independence of criterion and routine-based practice).	Adequacy of resources (sufficient and adequate resources, staffing, ease of access to continuous education and training, etc.).	Financial security, in the form of work stability (the large number of temporary workers hinder links with the institution and profession).
Factors related to the personal environment	Professional satisfaction and quality of working life.	Level of self-transcendence (ability to find meaning in life directed towards something or somebody other than oneself).	Burnout (research has shown that low levels of intrinsic motivation are associated with low levels of engagement at work and high levels of burnout (Adriaenssens et al., 2015)) and stress.³³
Factors related to experience	Intention to remain and not leave the profession.
Demographic factors	Marital status, sex, etc. (these can influence as predictive socio-demographic characteristics).
Social factors	Satisfaction in society, perception of uses about nursing work, visibility and value in the community context.

Sociocultural and temporal variations

Due to the previously described factors, Dehghani et al.¹⁸ consider that the concept can vary between countries depending on the culture and context.

For instance, the work by Jafaraghaee et al.²² concludes that Iranian nurses assume professional commitment as the result of their religious beliefs, a circumstance that does not occur in other environments. Another study conducted by Zibrik et al.²⁹ showed that a rural environment inevitably affected the ways in which nurses experienced and fulfilled their professional functions. Moreover, as described by De Araujo-Sartorio and Pavone-Zoboli,³⁴ the image of the nurse also depends on the specific context and culture of each work setting.

With regard to temporality, the development of new technologies, new care roles, changing expectations in patients and young nurses mean that the factors of the concept are in constant evolution.^28,35

A number of authors even suggest that the concept varies on an individual and personal basis. Lees²⁶ believes that employees perceive the importance of work in relation to other areas of their lives, and define it according to the context of personal life. Hutchings et al.²⁰ also include the specific relationship between nurse and user.

An exemplar or model case of the concept

As discussed in the article by Ghadirian et al.,⁶ of a similar nature to this work, it is difficult to describe a specific case that explains the true meaning of professional commitment due to the very nature of the concept.

Nevertheless, a number of works can be found that may explain the essence of the concept by means of the actual words of participants (semi-structured interviews).^{7,16,22,28,29} A recent work can also be consulted in which Dehghani et al.¹⁸ propose a specific case in the Iranian context.

Discussion

From the results extracted by this research, the professional commitment in nursing could be defined as the acquisition of knowledge and skills that allow a moral idea to be formed, through values, about the provision of good service of care, acknowledging the autonomy, self-regulation and responsibility inherent to the nursing profession, which creates a feeling of belonging to the profession. It is an attitude that provides a physical, mental and emotional connection to work and professional behaviours, measured by quality standards and placed at the service of others, and in which the offering of the best services should prevail, taking into account the professional and personal characteristics of patients according to the situation.

The proposed definition, together with the attributes identified could reflect a theory that is highly valid for nursing as it describes the essential components that should govern the profession. The concepts that are related, which cannot be considered definitory because they are beyond the control of the professionals themselves, should be studied in relation to the concept. Therefore, echoing Jenaro et al.,⁹ research into this concept should be encouraged in different contexts and circumstances in order to confirm the universal elements of the concept and their sociocultural and temporal variations, including the different roles in the profession (nurse practitioner, educator, researcher, administrative or management functions).

It is important to highlight the positive consequences of research into and work on fostering professional commitment for the profession from a positive perspective. The high rates of psychiatric morbidity among nurse administrators lead to the conclusion that models of commitment must be fostered that advocate increasing the personal motivation professionals from a positive perspective, instead of focusing efforts on rewards, which are not good methods for resolving the nursing shortage, for example.^9,36

Therefore, it is necessary to study alternatives that do not depend so much on material resources, but on the actual professional. More studies to date have focused on burnout and stress,³⁷ particularly with regard to prevention²⁴ and not on more positive alternatives for job promotion. Consequently, there are difficulties to identify situations where professionals with low professional commitment offer low-quality care, without suffering from identifiable conditions such as stress or burnout syndrome.

Limitations

Data sources searched were limited to those published during November 2009–June 2015, with the exception of landmark articles; however, it was intended to know the meaning of the concept at present.

The limitation caused by the subjectivity of the surrogate terms used in the initial search should be recognized. In order to reduce this subjectivity, the terms were extracted from the existing literature and a sufficient number of descriptors were used in order to leave no gaps in the search.

The heterogeneity of the selected documents, understood as the differences in type, origin and so on, can be considered as another limitation. For example, the work of Jenaro et al.⁹ analyses the association between nurses’ individual characteristics, job features and work engagement, not professional commitment. However, this characteristic has helped to more clearly define the concept by means of the different points of view and different terms used found in the existing literature.

As has been explained, Rodger’s evolutionary method is considered the most adequate to perform the analysis of concept, therefore, it is necessary to consider as a limitation the possibility of finding variations if alternative methods are used.

Finally, the use of the concept has only been analysed from qualitative works. This restricted the number of works in the literature and may have left a number of uses unstudied. However, it was considered that the qualitative approach would more appropriately cover both the abstract and the practical realms of the concept and can therefore be considered as strength of this study.

Conclusion

The identified terms are used indistinctly to encompass one concept. It is necessary to unify all of them in a concept that includes all the described elements.

The concept of professional commitment has been clearly defined, encompassing both the abstract and practical realms, and its attributes identified as encompassed by four dimensions. This analysis proposes a definition that can be considered universally valid, and does away with certain ambiguities.

It is necessary to continue research into the variations that the concept may have depending on the sociocultural and temporal context.³⁵ Only in this way can specific actions be adequately focused on fostering it and effective methods found to evaluate it in every context. Nursing is a universal profession, regardless of the fact that its practice is regulated in every country, and therefore, the proposed definition can be considered a starting point for the in-depth study of each context.³⁸

Major technological developments, amendments by health organizations to the controls limiting the autonomy and development of the profession, and the current economic situation and lack of resources compel the nursing profession to improve the attention given to its human side. This can only be achieved through the fostering of individual and collective professional commitment, which seems to be the only reason for remaining in the profession and improvements to levels of quality and services provided.^4,24,39

It is necessary to advance the development of the concept, perhaps specific actions to promote it and, consequently, to improve the methods for evaluating it in order to study it, without losing sight of the difficulty involved in achieving accurate tools.^40
–42 In fact, a number of authors warn against the idea of taking this concept to be an ideal, which would give rise to exhaustion,⁴³ and it is believed that it should be monitored rather than measured.⁴¹

Footnotes

Acknowledgement

The authors thank Visitación Ortega Riba for her professionalism and assistance provided in obtaining the documents for analysis.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a grant awarded through the competition held by Víctor Grífols i Lucas Foundation, Spain.

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