From the Inside Out: A New Approach to Teaching Professional Identity

Formation and Professional Ethics

Nancy Crigger PhD, MA, FNP-BC, Nelda Godfrey PhD, ACNS-BC,

FAAN

PII: S8755-7223(14)00062-3
DOI: doi: 10.1016/[Link].2014.03.004
Reference: YJPNU 822

To appear in: Journal of Professional Nursing

Received date: 3 May 2013

Please cite this article as: Crigger, N. & Godfrey, N., From the Inside Out: A New
Approach to Teaching Professional Identity Formation and Professional Ethics, Journal
of Professional Nursing (2014), doi: 10.1016/[Link].2014.03.004

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT

From the Inside Out: A New Approach to Teaching Professional Identity Formation and

P T
Professional Ethics

RI
SC
Nancy Crigger, PhD, MA, FNP-BC

Graceland University

NU
1401 West Truman Road
MA
Independence, MO 64050

816-423-7477
ED
PT

Nelda Godfrey, PhD, ACNS-BC, FAAN

CE

University of Kansas
AC

3901 Rainbow Blvd

Kansas City, KS 66160

913-588-1654

ngodfrey@[Link]

(corresponding author)

1
 ACCEPTED MANUSCRIPT

From the Inside Out: A New Approach to Teaching Professional Identity Formation and

Professional Ethics

T
Abstract

P
RI
Professional identity formation is a dynamic process that begins in undergraduate

nursing education and continues to develop throughout one’s professional career. In

SC
recent decades, nursing educators emphasized the social dimension of professional

NU
identity formation in which professionalization is achieved through following rules,
MA
codes, and standards set by the profession. Character or psychological development and

the proper use of virtues like integrity, compassion or courage, are often part of the
ED

hidden curriculum. The purpose of this paper is to introduce a recently developed

conception of professionalism that is grounded in virtue ethics and integrates both

PT

social and character development into a professional identity that is dynamic, situated,
CE

and lifelong. The conception is operationalized through the Framework for Nurse

Professionals (FrNP) and the Stair-Step Model of Professional Transformation. The FrNP
AC

and the Stair-Step Model promote a robust and morally resilient professional nursing

identity that will foster professional growth throughout one’s career.

2
 ACCEPTED MANUSCRIPT

In the next decade and beyond, educating nurse professionals to maintain a high

level of moral excellence in practice will be challenging. The most evident threat to

professional integrity relate to economically driven changes. Productivity and outcomes

P T
of care (Sellman, 2011) and changes from government healthcare reform will

RI
dramatically impact healthcare professionals’ practice in the future (Cantor, Monheit,

SC
DeLia & Lloyd, 2012; Perkins, 2013; Johnson, Cowin, Wilson & Young, 2012).

Additionally, many professions have experienced a decline in public trust and

NU
educators have linked this decline to a failure in professional education (Godfrey &
MA
Crigger, 2011). Some educators and scholars claim that professional education in many

disciplines should be strengthened and that education on character development should

ED

be re-instituted into the educational process (Crigger & Godfrey, 2011; Dall ‘Alba,

2009). Whatever the reasons, many professions have revisited professional education in
PT

their respective disciplines and have implemented changes in professional development

CE

education, what is now commonly called professional identity formation (Johnson, et

AC

al., 2012; O’Brien & Irby, 2013).

Professional identity formation and its relationship to moral excellence and

moral resiliency in practice have not been well conceptualized or researched in nursing

literature (Crigger & Godfrey, 2011). Therefore, a more robust and comprehensive

conception of professional identity that includes both social and psychological elements

and addresses the application of professional ethics throughout one’s practicing career

is a valuable addition to nursing education.

3
 ACCEPTED MANUSCRIPT

The current interest in professional identity formation has led us, the authors, to

develop a comprehensive conceptual framework for professional identity formation and

professional growth applicable for all levels of education. This paper is a presentation of

P T
a two part conceptualization of professional identity formation and growth that is

RI
operationalized through The Framework for Nurse Professionals (FrNP), a structural

SC
model, and the Stair-Step Model of Professional Transformation (Stair-Step Model), a

process model for communication to others. The FrNP and the Stair-step Model

NU
described herein are condensed from a more complete published description (Crigger &
MA
Godfrey, 2011).
ED

Background in Professional Identity Formation

PT

Landmark Research
CE

Contemporary research in nursing education offers direction for future

AC

professional education. A landmark study by Benner, Stuphen, Leonard and Day (2010)

recommended four essential shifts in nursing education based on their extensive

multisite research on professional undergraduate nursing education. Three of these

recommended changes--increasing salient and situated learning, integrating classroom

and clinical approaches, and improving clinical judgment--address cognitive elements of

education. The fourth recommendation addressed the moral element of nursing.

Benner, et al. (2010) advocate a shift from a focus on socialization and a role view of

professionalism to one that embraces identity formation (Benner, et al, 2010).

4
 ACCEPTED MANUSCRIPT

Benner, et al. (2010) concluded that while evidence of professional identity and

moral development was seen in undergraduate clinical settings, formation of

professional identity was notably absent in laboratory and didactic environments.

P T
Further, other scholars claim that professional identity formation may progress little

RI
beyond basic education in many professions (McCammon & Brody, 2012; Dall’ Alba,

SC
2009). Professionals, as graduates, may be superficially rather than deeply committed to

professional ideals (McCammon & Brody, 2012). A superficial commitment to

NU
professionalism can set a professional up for future failure. Just as with any skill or
MA
knowledge, one’s professional identity and moral resiliency, if not nurtured, can erode

and lead to a diminution of quality in practice, compromised thinking and even

ED

wrongdoing (Martin, 1999).

PT

Early and Profound

CE

Professional identity formation originates in basic nursing education. Educators

AC

begin the process of converting a lay person into an individual whose values are

consistent with those of the profession and who will act consistently on these values in

professional practice (Benner, et al., 2010; Clouder, 2003; Johnson, et al, 2012; Kaiser,

2002). Kaiser (2002), has termed the process of becoming a professional as a breaking

down of individuality or a “denying of uniqueness” that replaces the student’s non-

conformed, non-professional identity with a professional ideology ( p. 95). Successful

professionalization results in radical change in self-identity.

5
 ACCEPTED MANUSCRIPT

From a practical perspective, seasoned educators bear witness to the profound

change that beginning nursing students undergo during their educational journeys. If

successful, fledgling students, who enter nursing school with a naive outsider view of

P T
the professional nurse, will be transformed into professional insiders who are of good

RI
character, have internalized the discipline’s values, and will continue to maintain a level

SC
of moral excellence throughout their careers.

NU
The Two Paradigms of Professional Identity
MA
Professional identity is comprised of two distinct professional paradigms: social

and psychological. The socialization process is characterized by doing. Nurses are good
ED

professionals if they value and follow the rules, standards and codes of the discipline

and of society. The psychological professional is characterized by being. Nurses are good
PT

professionals through developing their character. Virtues like courage, humility,

CE

forgiveness, integrity and compassion are developed and internalized. One without the
AC

other presents an incomplete conception of professional identity (McCammon & Brody,

2012; Crigger & Godfrey, 2011).

Professional identity, used herein, refers to an individual’s perception of himself

or herself, who, as a member of a profession, has responsibilities to society, recipients

of care, other professionals, and to himself or herself. With this conceptualization of

professional identity, the ethical aspect of a professional becomes paramount; it is the

fundamental basis on which professional identity rests (Crigger & Godfrey, 2011). Ethics

broadens from the idea of solving the occasional and sometimes profound ethical

6
 ACCEPTED MANUSCRIPT

practice dilemma to a compass that guides the many decisions made in everyday

practice.

P T
A Lifelong Process

RI
Professionalization begins with the educational process but does not end there.

SC
Just as practicing professional nurses keep up with new knowledge in their field through

continuing education, nurses are also growing as professionals through practicing their

NU
profession, reflecting on practice and improving their professional sense of self
MA
throughout the process. The term life-long learning is commonly used in professional

organizations, institutions and schools of nursing. Life-long learning, in its truest sense,
ED

addresses cognitive aspects of knowing what to do in practice, but also the ethical

knowledge of what should be done.

PT
CE

Why Revisit Professional Identity Formation in Nursing Education?

AC

If the educational method of teaching professional identity and development of

ethical behavior in clinical undergraduate nursing education is generally considered a

strength, as Benner, et al. (2010) suggest, then why should educators invest more

resources or instructional time in professional identity formation ? Why fix something

that is not broken?

Three reasons suggest that nursing education and the profession should

continue to strengthen students’ and graduates’ professional identity and moral

resiliency: strengthening success, promoting societal trust, and improving outcomes in

7
 ACCEPTED MANUSCRIPT

professional education. According to positive psychology proponents (Handelsman,

Knapp & Gottlieb, 2009) one should use strengths rather than weaknesses as outcomes

for work and education productivity. The result, the positive strategy assumes, will not

P T
only improve one’s areas of strength but also improve weaker performance areas. The

RI
belief is that things you do best will rejuvenate, challenge and restore. This positive

SC
approach will improve the individual’s performance overall, thus improving weaker

performance. The idiom, “a rising tide raises all ships’, is a fitting metaphor for the

NU
strategy of using strengths to improve weaknesses.
MA
Second, a good view of nurses by the public at present does not assure that

public trust in nurse professionals will continue. Practice and professional expectations
ED

change over time and may result in a diminution of public confidence. As nurses expand

their scope of professional practice and adapt to meet societal needs (IOM, 2010), new
PT

ethically challenging issues arise. New responsibilities may bring new challenges. For
CE

example, Sellman (2011) expressed concern that professionalism is in danger of being

AC

usurped by business, managerialism and measured outcomes. Care focused on

outcomes can devalue the moral relationships and human elements of practice. As

numbers of recipients of care swell and resources dwindle, the pressure to reduce

quality in favor of quantity poses a threat for future healthcare.

Finally, nursing professional education literature, overall, has just begun to re-

examine professional identity formation and professional ethics (Harris, 2008; Coulehan,

Williams, McCreary & Belling, 2003; Sullivan, 2005; Weaver, Peter, Koch & Wilson,

2011). Overall, there is a call to a new conception of professionalism, that socialization

8
 ACCEPTED MANUSCRIPT

without internalization is not enough to produce and equip professionals (McCammon

& Brody, 2012; Clouder, 2003; Dall’Alba, 2009; Johnson, et al., 2012). The

reconceptualization of professionalism begins with establishing the place of social and

P T
psychological paradigms in professional education, of recognition of the fundamental

RI
nature of professionalism as an ethical, situated process, and to develop ways to

SC
educate nursing students to become practitioners who are morally resilient and do good

work.

NU
Unfortunately, little is known about professional identity formation in nursing
MA
and less is known about professional identity as one’s career unfolds. Dierckx de

Casterle, Izumi, Godfrey and Denhaerynck (2008) conducting a meta-analysis of 1592

ED

registered nurses in four countries, evaluated their response to ethical dilemmas. The

nurses participating in the research responded to ethical issues by conforming and

PT

following the rules, rather than using higher order critical and situated thinking. The
CE

findings of Dierckx de Casterle et al. (2008) suggest that nurses remain at the
AC

conventional level, or middle level of Kohlberg’s hierarchy of moral development rather

than progressing to post-conventional levels of moral resolution (Crigger & Godfrey,

2011). In other words, they are good rule followers, and are conforming to the social

identity paradigm, but may lack development in character and application of situational

thinking to practice.

The Transformational, Ethical Framework for Nurse Professionals (FrNP)

9
 ACCEPTED MANUSCRIPT

Using a comprehensive view of professionalism that included both social and

psychological paradigms and virtue ethics, two educational heuristics were developed.

The first, Framework for Nurse Professionals (FrNP), is a highly simplified structure that

P T
explicates factors considered in making practice decisions (Figure 1).

RI
The FrNP consists of three main components that situate the nurse professional

SC
in practice: the moral agent, practical wisdom or action, and outcome or telos. The

moral agent is the student or practicing nurse professional who is faced daily with a

NU
multitude of decisions. To make morally sound decisions in practice and to act in fitting
MA
ways within the context of the situation, nurses draws from multiple social, ethical and

psychological sources that are depicted in the visual model of the FrNP. The FrNP
ED

combines the three main ethical traditions: principled ethics (rules), utilitarian ethics

(outcomes) and less well known, virtue ethics (situated).

PT

Concepts from Aristotelian virtue ethics are used within the framework. Virtues
CE

are good character qualities like courage, humility or integrity. Phronesis is the process
AC

of deliberation, determining fitting or properly contextualized choices and the follow

through with the appropriate actions. The telos or outcome of phronesis can be broadly

classified into social outcomes and individual outcomes. The outcome or telos, from a

virtue ethics perspective, impacts both the moral agent and practice. The telos or

outcome of the practitioner is to be a good person and professional who does good

work (Crigger & Godfrey, 2011).

The FrNP addresses how nurses make the many decisions as they perform their

daily work. Practice is the result of a multitude of decisions. Hare (1989) conceptualized

10
 ACCEPTED MANUSCRIPT

ethical decisions occurring not only in situations of moral conflict, but as common

everyday decision-making that occurs so frequently that the decision-makers will

habituate and be unaware that a decision to act in the right way was even made

P T
(Crigger, 1997). For example, Nurse H takes report, and listens. Nurse H could easily let

RI
her thoughts stray to what was going on at home, or text a message during report, but

SC
decides to fully attend to the report information rather than be distracted. Nurse H’s

choice to listen is meeting her professional expectation of herself. She does it because

NU
she perceives this behavior to be what a good professional should do. As can be seen in
MA
this example, Nurse H is likely oblivious to her choice to act ethically.

Any practice decision is a complex interplay of factors. The moral

ED

appropriateness of the practice decision should be considered from the perspective of

all ethical traditions: principled (deontological) ethics, utilitarian (consequentialism)

PT

ethics, and virtue ethics are all in play. What is the outcome (utilitarian ethics)? What
CE

guidelines, rules and standards are met or not met (principled ethics)? Can the provider
AC

use his virtues of courage, integrity and compassion, for example, to do the right thing

at the right time for the right reason in this situation (virtue ethics)?

Decisions made in practice are made contextually. Phronesis occurs to determine

the fittingness of a practice choice. For example, Nurse Practitioner T sees a child with a

viral infection. The mother requests an antibiotic because her daughter always develops

an ear infection following a cold. Nurse Practitioner T has seen this child four times

previously for a viral infection and each time the mother returned with the child one to

two days later with a frank otitis media. Though Nurse Practitioner T knows that there is

11
 ACCEPTED MANUSCRIPT

overwhelming evidence not to treat prophylactically, she knows of the cost and

potential harm in prescribing an antibiotic.

Nurse Practitioner T, given the situation and after deliberation, might choose

P T
watchful waiting by giving a prescription and allowing the mother to decide if and when

RI
to initiate treatment with the antibiotic. In this case, Nurse Practitioner T is using

SC
compassion and courage to shape her decision, as the decision is clearly not following

standards and guidelines (principled ethics) nor using outcomes from the literature to

NU
make the treatment decision (utilitarian ethics).
MA
The Stair-Step Model of Professional Transformation
ED

The Stair-Step Model of Professional Transformation (Crigger & Godfrey, 2011)

illustrates how FrNP practice decisions are nested within a process that begins with
PT

professional identity formation and continues with professional career growth (Figure
CE

2). As evident in the visual model, the first step on the staircase is where newly
AC

graduated nurses begin their career climb.

A new graduate has an ideal of who a professional nurse is and what a

professional nurse does. The first step represents the ethical traditions of principled

ethics and utilitarian ethics. The novice professional nurse’s practice should meet at

least the social expectations of the profession and have good outcomes in patient care.

The new nurse adheres to the social expectation of the codes, the policies and

institutions of the workplace and practices within state nurse practice act.

12
 ACCEPTED MANUSCRIPT

During the professional nurse’s career, she or he should desire to be a better

professional than one that just meeting standards, rules, and codes. Through practice

and personal commitment to an ideal, the nurse ascends the staircase, and these steps

P T
represent going above and beyond what is required by social expectations from the

RI
rules, codes and membership expectations of the discipline. Virtue ethics, unlike the two

SC
other ethical traditions, provides transition from the bottom step to the ideal

perception of who the professional nurse would like to become at the top of the

NU
staircase. The staircase conceptualizes the process by which the nurse professional can
MA
flourish and grow over the course of his or her career. Although the nurse may take

occasional step down, by making an error or by misconduct, hopefully she is morally

ED

resilient and corrects any wrongdoing as her career advances.

The importance of addressing error and wrongdoing as part of the model cannot
PT

be emphasized enough. Erde (2008) claimed that professional education in many

CE

disciplines has ignored errors and dangers in professionalism, what he termed the “dark
AC

side” (p. 9) of professionalism. Ignoring errors and professional wrongdoing in

professional education is based on a false assumption that professionals will not err.

This unrealistic gap in education omits management of failure when it occurs to a

professional. Errors and failures are included in the Stair-Step Model and are part of the

process. Identification of a slip is the beginning of reconciliation rather than

condemnation. Mistakes are part of being human, and although it is preferred that they

not occur, they do and subsequently should be used as a means for professional growth.

13
 ACCEPTED MANUSCRIPT

The Stair-Step Model is also important because it addresses the ideal. A

transformational view is futuristic in which the ideal is a goal, a telos, perhaps a self-

determined perfection that cannot be achieved. There is always something in practice

P T
or in one’s professional identity that can be improved upon. In essence, the goal or telos

RI
is always there—but never entirely reached. This striving to improve, to become a

SC
better nurse professional, and to do better work is reflective of the human condition.

We see the ideal, but often fail; we are caught in the weakness of being human, but

NU
nonetheless see the telos or goal of perfection and continue to strive toward it.
MA
Application of the FrNP and the Stair-Step Model
ED

The FrNP and the Stair-Step Model of Professional Transformation are linked.

The FrNP provides a conceptualization of professional practice and how ethics is the
PT

foundation of everyday practice. The Stair-Step Model provides the longitudinal

CE

perception of professional identity formation and professional growth over one’s

AC

career. Each one, however, is self-explanatory and can be used to organize and explain

professional development, moral resiliency, and growth.

Professional Identity Formation and Growth Education

Professional identity formation begins the first day of a student’s education and

should extend until graduation from the program. The primary responsibility of the

faculty is to educate students in both the social professional identity of social

expectations (rules, codes, standards, the doing of nursing) but also the individual’s

development of attributes and values that are internalized, what some call the being of

14
 ACCEPTED MANUSCRIPT

nursing ( Kaiser, 2002; Clouder, 2003; Dall’Alba, 2009; Johnson, et al., 2012).

Professional education should begin early in nursing education curriculum and be

reinforced in clinical and classroom education.

P T
Professional identity continues to develop as nurses engage in their professional

RI
work environments or further their education. Once graduated, the nurse continues to

SC
nurture professional identity through practice. For example, watching behaviors of

other more senior nurses in practice, participating as a member of an institutional

NU
review board or hospital ethics committee, learning from one’s successes and mistakes,
MA
or learning from the culture on a unit continue the growth of one’s professional identity.

An organizational culture is also influential in fostering continued professional

ED

identity development. An emphasis on the structural empowerment and

transformational leadership components of the Magnet model (ANCC, 2013) can foster
PT

and encourage more focused growth of nursing’s professional identity within a care
CE

environment.
AC

A New Professionalism for Educators

The reconceptualization of professionalism is a comprehensive effort.

Educators know intuitively that helping to form a professional identity is more than

operationalizing the sociological view of professionalism. Raising awareness to

intentionally address the psychological view, the internalization of professionalism

through character development and the situated use of virtues are important first steps.

15
 ACCEPTED MANUSCRIPT

Specific teaching approaches for both social and psychological identity formation are

presented in Table 2.

Faculty ownership of a comprehensive and richer view of professionalism will set

P T
the stage for changes in curriculum development and instructional methods. In one

RI
Midwestern state university undergraduate program, the faculty began with the AACN

SC
Baccalaureate Essentials for Professional Nursing Practice (2008) and determined that

three courses on professional identity were needed to meet the Essentials outcomes

NU
(Kumm & Fletcher, 2012): Introduction to the Profession (2 credits), Ethics, Values and
MA
Roles (3 credits), and Navigating the Profession (2 credits). The FrNP and Stairstep

Model of Professional Transformation were introduced in the first course and continued
ED

to frame content for the next two courses.

Essential strategies of instruction were more interactional and included

PT

reflection in which students used experiences in practice to self-critique, and historical

CE

figures to illustrate character and virtues. For example, Nightingale was used a person
AC

of courage and wisdom. Classroom activities also included discussion about critical

incidences in which the dark side of practice issues emerge, how to make ethically-

situated decisions, and how to manage wrongdoing in the profession, recovery, and

ethical responses to mistakes.

The courses were designed to emphasize decisions of practice as a balance

among ethical traditions and include both social and psychological paradigms of

professionalism. A social paradigm focus in a beginning undergraduate professional

identity course might include the following essay questions: Explain how forming and

16
 ACCEPTED MANUSCRIPT

acting upon one’s identity as a professional leads to professional behaviors and attitudes

that differ from those of a lay person, or Explain how a multidisciplinary worldview or

standards of professional conduct adds to a professional’s understanding of personal

P T
and professional accountability.

RI
Professional psychological development is addressed through education in the

SC
virtues or characteristics that are valued in nurse professionals and how to use these

virtues well in practice. Example essay questions that address the psychological

NU
paradigm of professional identity might include: Evaluate yourself on your ability to be a
MA
person of integrity, compassion and courage. Discuss what thoughts and actions

support your decisions or Using the Stair Step Model, describe your current ideal of a
ED

professional nurse. How might you see this ideal change over time?
PT

Summary
CE

Nurses’ professional identity is a dynamic process that forms in undergraduate

AC

nursing education and continues throughout one’s professional career. This paper

presents a more comprehensive view of professionalism that is operationalized through

The Framework for Nurse Professionals (FrNP), a structural model, and the Stair-Step

Model of Professional Transformation. Reconceptualization of professional identity

formation education and application will require a commitment by educators to develop

curricula and methods of instruction that promote professional identity formation as a

fundamentally ethical, situated and transformational process.

17
 ACCEPTED MANUSCRIPT

References

P T
AACN (2008). The Baccalaureate Essentials of Professional Nursing Practice.

RI
Washington DC: American Association of Colleges of Nursing.

SC
ANCC (2013). Magnet Recognition Program Model.

[Link]

NU
Model. Retrieved December 31, 2013.
MA
Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for

radical transformation. San Francisco: Jossey-Bass.

ED

Cantor, J.C., Monheit, A.C., DeLia, D. & Lloyd, K. (2012). Early impact of the Affordable

Care Act on health insurance coverage of young adults. Health Services Research,
PT

47(5):1773-90. doi: 10.1111/j.1475-6773.2012.01458.x.

CE

Clouder, l. (2003). Becoming professional: Exploring the complexities of professional

AC

socialization in health and social care. Learning in Health and Social Care, 2(4);

213-222.

Coulehan, J., Williams, P.C., McCreary, V. & Belling, C. (2003). The best lack all

conviction: biomedical ethics, professionalism, and social responsibility.

Cambridge Quarterly of Healthcare Ethics, 12; 21-38.

Crigger, N.J. (1997). Universal prescriptivism: Traditional moral theory revisited. Journal

of Advanced Nursing, 20, 538 – 543.

18
 ACCEPTED MANUSCRIPT

Crigger, N. & Godfrey, N. (2011). The making of nurse professionals: A

transformational, ethical approach. Sudbury, MA: JB Learning.

Dall’Alba, G. (2009). Learning professional ways of being: Ambiguities of becoming,

T
Educational Philosophy and Theory, 41(1); 34-45.

P
RI
Dierckx de Casterle, B., Izumi, S., Godfrey, N.S., & Denhaerynck, K. (2008). Nurses

SC
responses to ethical dilemmas in nursing practice: Meta-analysis, Journal of

Advanced Nursing, 63(6); 540-549.

NU
Erde, E. (2008). Professionalism’s facets: Ambiguity, ambivalence, and nostalgia, Journal
MA
of Medicine and Philosophy, 33; 6-26.

Godfrey, N. and Crigger, N. (2012). Ethics and professional conduct: Striving for a
ED

professional ideal. Journal of Nursing Regulation, 3(1); 32-39.

Handelsman, M.M., Knapp, S. & Gottlieb, M. (2009). Positive ethics: themes and
PT

variations, Chap. 11, in Oxford Handbook of Positive Psychology, ED C.R. Snyder

CE

& S.J. Lopez, Oxford: Oxford University Press.

Hare, R.M. (1989). Moral thinking. Oxford, UK: Clarendon Press.

AC

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health.

Retrieved from [Link]

[Link].

Johnson M, Cowin LS, Wilson I, Young H. (2012). Professional identity and nursing:

contemporary theoretical developments and future research challenges.

International Nursing Review. 59(4):562-9. doi: 10.1111/j.1466-

7657.2012.01013.x. Epub 2012 Jul 6.

19
 ACCEPTED MANUSCRIPT

Kaiser, R. (2002). Fixing identity by denying uniqueness: An analysis of professional

identity in medicine, Journal of Medical Humanities, 23(2); 95-105.

Kumm, S. & Fletcher, K. (2012). From daunting task to new beginnings: bachelor of

P T
science of nursing curriculum revision using the new Essentials. Journal of

RI
Professional Nursing, 28(2):82-9

SC
Martin, M. (1999). Explaining wrongdoing in professions, Journal of Social Philosophy,

30(2); 236-250.

NU
McCammon, S.D. & Brody, H. (2012). How virtue ethics informs medical professionalism,
MA
HEC Forum, 24; 257-272.

O’Brien, B.C. & Irby, D.M. (2013). Enacting the Carnegie Foundation call for reform of
ED

medical school and residency, Teaching Learning Medicine;25; Suppl.1; s1-8.

Perkins, J. (2013). Implication of the Supreme Court’s ACA Medicaid decision. Journal of
PT

Law, Medicine and Ethics, 41 (suppl:77-79). Dci10.1111/jme.12045.

CE

Sellman, D. (2011). Professional values and nursing, Medical Health Care and
AC

Philosophy, 14; 203-208.

Sullivan, W.M. (2005). Work and integrity. (2nd ed.) San Francisco: Jossey-Bass.

Weaver, R., Peter, K., Koch, J. & Wilson, I. (2011). “Part of the team:” Professional

identity and social exclusivity in medical students. Medical Education, 45(12):1220-9.

DOI:10.1111/j.1365-2923.2011.04046.x

20
 ACCEPTED MANUSCRIPT

Table 1. A Comparison of Teaching Methods and Content for Social and Psychological Identity
Formation

Content Social Psychological

PT
RI
Nursing standards, Meet social expectations Develop qualities/values
institutional rules, codes and toward integrity, honesty, and

SC
policy loyalty

Practice effective, positive Develop social skills, Develop qualities of

NU
social behaviors communication, political and compassion, gratitude,
social awareness humility, forgiveness and
sense of justice that lead to
MA
positive social behaviors

Competency in skill and Demonstrates levels of Growth in attitudes that

knowledge knowledge and skills in promote continuing
ED

academic setting education, development of

wisdom (phronesis),
PT

intellectual curiosity and

reflection on practice.
CE

Knowledge of ethical theory Demonstrates knowledge of Owns ethics; frames ethics as

and practice decision-making ethical decision-making; basis for personal everyday
raised awareness of ethical practice. Sees self as an
AC

issues, develops an ethical being, and explores

understanding of justice; uses how to apply ethics to
cases to illustrate ethical situations in current practice.
dilemmas.
Uses ethical principles and
Applies ethical principles and outcomes as well as situated
outcomes for decision-making critical thinking for decision-
making

Knowledge mastery, Narrative with attention to

observation of ideal or role internal response, reflection
Teaching Methods models, based on social on attitudes, values; use of
expectations, reflection on role model but focus on
rules, and what is right or psychological aspects rather
than doing ; use of exemplars

21
 ACCEPTED MANUSCRIPT

wrong from history or everyday

practice; development of
virtues or qualities of the
individual with no assumption
that one already has integrity

T
or compassion.

P
RI
SC
NU
MA
ED
PT
CE
AC

22
 ACCEPTED MANUSCRIPT

T
Social

IP
 Deliberation Social

CR
Codes Results of actions
Standards

S
Traditions Responses from
 Making fitting

NU
Rules others
Norms choices

MA
Social ideals

ED
Psychological  Acting upon
Past experiences
Psychological
Personal ideals PTthose choices Flourishing—moving
CE
Concurrent toward the ideal
experiences
AC

Virtues
Affective factors
 Practice Slips—or mistakes,
moving away from
Preferences
Perceptions the ideal
Knowledge

Figure 1. Framework for Nurse Professionals (FrNP): the Transformational Process. (Adapted from Crigger, N. &
Godfrey, N. (2011). The making of nurse professionals: A transformational, ethical approach. Sudbury, MA: J&B
Learning. p. 60. (permission requested)
23
 ACCEPTED MANUSCRIPT

Figure 2. The Stair Step Model of Professional Transformation

P T
RI
SC
NU
MA
ED
PT
CE
AC

From Crigger, N. & Godfrey, N. (2011). The making of nurse professionals: A transformational, ethical
approach. Sudbury, MA: J&B Learning. p. 64. (permission requested)