Professional Identity in Nursing: Adopting a Systems Approach Regarding Diversity, Equity, and Inclusion

Professional identity is increasingly considered an educational objective and aspirational goal for most of the health professions (Cruess et al., 2019). Familiarity with professional identity in nursing (PIN) education circles has lagged, but little by little, more faculty and students are becoming aware of the term and its definition. PIN is “a sense of oneself, in relationship with others, that is influenced by characteristics, norms and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse” (University of Kansas Medical Center, 2022). In a Nursing Education Perspectives Headlines column published in 2020, we described how the National League for Nursing (NLN) engaged with other nursing organizations to form the International Society for Professional Identity in Nursing in advance of the International Year of the Nurse and Midwife in 2020 (Brewington & Godfrey, 2020). Through an iterative process, nursing leaders from the United States and Canada who represented education, regulation, and practice (Goodolf & Godfrey, 2021) explored the concept of PIN and created four domains to form a contemporary view of nursing as a discipline: values and ethics, knowledge, nurse as leader, and professional comportment. The group then developed definitions, key elements, competencies, and exemplars for each domain. This work led to the development of a PIN conceptual model that researchers have tested with United States- and internationally educated nurses. Findings from studies of practicing nurses (Priddy & Phillips, 2021), beginning student nurses (Cornwell et al., 2021), and instrument development (Landis et al., 2022) confirm the relevance of the definition and domains. The concept, definition, and domains of PIN fit synergistically with the systems-level lens of diversity, equity, and inclusion (DEI). However, this systems perspective cannot be understood until there is a discussion of structural racism, defined by Bailey et al. (2017) “as intentional laws and policies, practices, sanctioned and implemented by various levels of the government and embedded in the economic system.” IMPACT OF STRUCTURAL RACISM Society has perpetuated structural racism for over 400 years. It is our responsibility as nurses to understand its impact on DEI. Further definition of these terms is important. Diversity is one of the NLN core values, which we define as a “culture of inclusive excellence encompassing many identities, influenced by the intersections of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical disabilities, religious and political beliefs, or ideologies” (www.nln.org/about/core-values). In a broader sense, equity refers to “fairness in the treatment of people in terms of both opportunity and outcome” (Zeynep et al., 2022, p. 920). Healthy People 2030 (n.d.) defines health equity as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” Finally, Healthy People 2030 defines inclusion as “creating a culture that fosters belonging and incorporation of diverse groups.” When explaining the nexus between PIN and DEI, we need to reflect on the definition of PIN and consider all four domains, specifically, “values and ethics — a sense of core values and principles that guide conduct; knowledge — analysis and application of information delivered from nursing and other disciplines, experiences, critical reflection and scientific discovery; nurse as leader — inspiring self and others to transform a shared vision into reality; and professional comportment — a nurse’s professional behavior demonstrated through words, actions, and presence” (University of Kansas Medical Center, 2022). There is a nexus between DEI and PIN. To ensure excellent outcomes and health equity in communities, nurse leaders must use their knowledge to integrate DEI (Lyman et al., 2022). Nurse leaders also must assess their own values, ethics, biases, beliefs, and privileges and encourage their organizations to do the same. They must determine their perceptions and interactions with people who are different and do not look like them. Finally, as nurse leaders work with interprofessional teams, they must exemplify professional behavior. In a 2013 National Academy of Medicine discussion paper, Kaplan and colleagues encouraged the US health care system to take a systems approach to improve health and consider the many parts to an organization or structure when decisions are made and actions are taken (Kaplan et al., 2013). Taking a systems approach can improve health and quality and ultimately increase performance. This is true for health care and specifically nursing and nursing education. What happens in the hospital setting affects the community setting. If what is taught in nursing school is incongruent with the practice setting, there will be conflict, and nurses’ professional identity will be disrupted. The integration of PIN must span the breadth and depth of nursing. This begins when people enter a nursing program at all levels and potentially ends with retirement from the profession. It also includes every setting where nurses work. Hospitals, health care clinics, schools, communities, and regulatory boards are just some of those settings. When professional identity is integrated at the systems level, administrators, chief executive officers, and other health care personnel will understand the importance and value it brings not only to the nursing profession but also to all disciplines with which nurses interact. CONCLUSION Understanding professional identity formation with a DEI lens from a systems approach can improve health care, the nursing profession, and society at large. It will take all of us to see it happen. If organizational systems expect to have an impact on PIN and the nexus between DEI, they must improve their organizations’ culture. Furthermore, organizations must build a culture of empowerment where nurses are authorized to integrate into patient care the four domains of PIN — values and ethics, knowledge, nurse as leader, and professional comportment. Nurses must also apply the principles of DEI to provide care for individuals, families, communities, and populations in any health care setting. Sanchez (2021) purports that “that there is an intersection with diversity, equity, and inclusion and quality improvement.” This means that innovations in how patient care is delivered need to be done in a supportive environment. Finally, creating a positive organizational culture where nurses integrate PIN and DEI for the sake of positive patient outcomes is everyone’s business. The NLN continues to support the International Society for Professional Identity in Nursing and a systems approach to health equity that recognizes the impact of systemic racism on the NLN core value of diversity and inclusion.

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