ABSTRACT
Objective
This study aims to deeply examine the perceptions of nurses towards nursing philosophy. The study is a qualitative study conducted in phenomenological design.
Methods
The study group consists of 9 nurses. Data were collected face to face using a semi-structured interview form and analyzed with the content analysis technique. Three main themes and fifteen sub-themes emerged as a result of the content analysis.
Results
Content analysis revealed three main themes and fifteen sub-themes. The themes are: Nature of the profession (Belonging, Competence, Professionalism), Echo of time (Development, Motivation, Experience), Ripple effect (Helping, Caring), World of values (Human dignity, Providing benefit, Non-maleficence, Honesty, Justice, Privacy, Conscience).
Conclusion
The findings of this study can help nurses, nurse managers and nursing academics in increasing the quality of the nursing service to be provided. It is recommended that further studies be carried out on the nursing philosophy of current nursing students, who will be the nurses of the future, focusing on the process through which the nursing profession is first experienced.
INTRODUCTION
Nursing is in constant development, not only as a profession or discipline but also as a science (1). Nurses are expected to have the most up-to-date knowledge and clinical skills to ensure that patients receive the best care in every region of the world. Equipping nurses with nursing knowledge is very important but not enough on its own (2). Nurses are responsible for integrating the science and art of nursing into patient care to achieve optimal patient outcomes (3). The most fundamental way to accomplish this is to allow nursing philosophies to be reflected in patient care. Nursing philosophy serves as a foundational guide that shapes nurses’ professional values, ethical principles, and approaches to individuals. This philosophy enables nurses to adopt a holistic care approach by considering not only physical care but also psychological, social, and emotional needs. As a result, the centrality of nursing philosophy in practicing the profession is vital for enhancing the quality of patient care and strengthening the trust between the patient and the healthcare team.
Since nursing involves direct interactions with people, in addition to nursing knowledge, it is valuable to gain and adopt competence in the fields of professional values, legal and ethical responsibilities, and nursing philosophy. Nursing has become a scientific discipline based on understanding the basic principles and philosophy that shape it (4). It represents a whole consisting of abstract structures based on values, goals, and decisions that guide professional behaviors and practices (5). The development of nursing philosophy is an abstract effort and includes the development and assessment of the affective domain (6). The affective domain involves individuals’ emotional responses, values, attitudes, and motivations, and development in this area requires a long process. Professional philosophy is extremely important for a practice-based discipline such as nursing and is a basic tool that shapes the professional identity and practice of nursing (7).
A developed nursing philosophy not only contributes to nurses’ clinical practices but also plays a significant role in areas such as clinical management, education, and research, which, in turn, directly affects the quality of patient care (8). In this context, the critical role that nursing philosophy plays in nurses’ individual and professional development has a profound effect on nursing practice. Although there were various review studies in the literature on the necessity to address nursing philosophy in a broader context, there was only one study on the examination of nursing philosophy in depth (8-12). There was no study on the investigation of nursing philosophy in depth in our country. This deficiency makes it difficult to understand how nursing philosophy is shaped as part of nurses’ professional identities and how the purpose of the existence of nursing is perceived.
Addressing nurses’ perceptions of nursing philosophy allows gaining some insights into how philosophical values that form the basis of nursing practice are effective in clinical decision-making and patient care (5). Nurses’ perceptions of nursing philosophy are also noteworthy in terms of showing how ethical and professional values that shape nursing practices are internalized. In addition, an in-depth examination of nurses’ perceptions of nursing philosophy will provide information that will guide nurses’ professional development and contribute to intervention studies aimed at improving their knowledge and skills in this area. Therefore, addressing the nursing philosophies of nurses will provide a profound understanding of the nursing profession and strengthen professional practices. Accordingly, this study aimed to examine nurses’ perceptions of nursing philosophy in depth and provide the necessary theoretical foundations to improve nursing practice.
MATERIAL AND METHOD
Research Design
This research was conducted using a phenomenological research design to comprehensively understand and interpret nurses’ perceptions of nursing philosophy. Phenomenology, based on the philosophical studies of Edmund Husserl, is a qualitative research approach that aims to discover the essence of the phenomena experienced by individuals and their subjective perceptions of these phenomena (13). This study was designed in accordance with the guidelines of the Consolidated Criteria Guide (COREQ) checklist, which is used to report qualitative research clearly and comprehensively (14).
Study Group
The study was conducted with nurses working in a public hospital in a province in the Central Anatolia Region of Türkiye. The maximum variation sampling method, one of the purposive sampling types, was employed to determine the subjects of the study. This sampling method aims to reflect the diversity of individuals evaluated regarding the problem in question to the maximum extent (15). In this context, the year of the study and the department studied were considered as maximum diversity criteria for inclusion in the sample group.
As reported by Creswell(16), the number of participants in phenomenological studies is recommended to be between 5 and 25 by Polkinghorne and between 3 and 10 by Dukes. It is also stated that in qualitative studies, the number of participants can be determined in a way that meets the objectives of the study, can provide detailed data, is consistent with the research question(s) and analytical framework, and provides data saturation, instead of large groups (16). In this context, as a result of the data obtained from in-depth interviews with nurses, the data saturation was evaluated, and the data collection process was completed with nine participants. None of the nurses quit the study during data collection.
Nurses who had an undergraduate nursing degree, volunteered to participate in the study, and actively worked in the clinic were included in the study. Nurses who graduated from a health vocational high school were not included in case they affected the results of the study.
Research Instruments and Processes
The study was conducted in a public hospital operating in a province in the Central Anatolia Region of Türkiye. Participants were determined using purposive sampling. After the nurses working in the hospital where the study was conducted were evaluated according to the inclusion criteria, they were informed about the study by the third author, and then written and verbal consent was obtained from those who agreed to participate in the study.
Semi-structured Interview Form: The data of the study were collected face to face using the semi-structured interview technique. During the interviews, the researchers used a semi-structured interview form created following a review of the literature to examine nurses’ perceptions of nursing philosophy in depth (1, 7, 17, 18). After the interview form was prepared, five faculty members in the field of nursing were consulted for its evaluation in terms of content, scope, language, and qualitative research method. The interview form was revised in line with the feedback from the experts. In addition, a pilot application that included a nurse was conducted. The data obtained in the pilot application were not included in the analysis. After this application, the semi-structured interview form was finalized. The form comprised 11 questions, including two used for introduction, three main, and seven probing items. The questions on the semi-structured interview form are listed below.
1. Talk about yourself, please? (age, marital status, and education level)
2. Talk about your professional life, please?
2.1. Why did you want to become a nurse?
2.2. What do you think was the most important thing that led you to this profession?
2.3. What personal interest do you think led you to this profession?
2.4. What does being a nurse mean to you?
2.5. How does being a nurse, as a practitioner of this profession, make you feel?
3. How would you define your own nursing philosophy as a practitioner of this profession?
3.1. How do you think you affect individuals, families, and society while practicing your profession?
3.2. How do you think your values shape your professional practices?
4. Is there anything else you would like to say about being a nurse?
The study data were collected between March and April 2024 by the third author of the study. There was no direct relationship between the researcher and the nurses. To ensure the privacy of the nurses and to enable them to express themselves better, the interviews were conducted in a room in the department where the nurses worked. The room was bright enough, there was no noise or complexity, and there was nothing to hinder communication. The interviews were recorded using a voice recorder with the permission of the nurses, and additionally, some notes were taken. The nurses were informed about the purpose and details of the study. Written consent was obtained from the nurses who agreed to participate in the study, and then their verbal consent was recorded. The interviews took about 28-42 minutes.
Statistical Analysis
The audio recordings obtained in the study were transcribed, and a 52-page-long raw data document was obtained on Microsoft Word. The data were analyzed using the content analysis technique, which is one of the most widely used methodologies to examine a phenomenon in qualitative research and is frequently used in nursing research. In the study, first, all the transcriptions were read in depth and line by line, and important expressions or sentences referring to the phenomenon under study were identified. Then the codes were categorized and reported according to their similarities and differences to establish the main idea in the data.
Ethic
The research was conducted following the Declaration of Helsinki. Ethics committee approval was obtained from the Ethics Committee of Nevşehir Hacı Bektaş Veli University Non-Interventional Clinical Research (number: 2023.12.16, date: 14.12.2023). Institutional permission was obtained from the hospital board where the research was conducted (approval number: 16, date: 14.12.2023). Written and verbal consent was obtained from the participants before the research was initiated. Informed consent forms were obtained from the nurses. Participants’ identities were kept confidential, and their information was anonymized. The documents, files, records, and raw data used during the research process were stored in a password-protected computer, accessible only by the researchers.
RESULTS
Almost all of the participants were female (n=8). The average age was 35.66±8.01 years, and the average work experience was 11.77±8.07 years. Participants’ characteristics are presented in Table 1.
Four main themes and sixteen subthemes emerged about the participants’ nursing philosophies. The themes and subthemes obtained in the study are presented in Table 2.
Theme 1: The Nature of the Profession
Three-quarters of the nurses defined their nursing philosophy in terms of their sense of belonging to the nursing profession. Almost half of the nurses stated that they practiced their profession based on professional competence, while a small number stated that they practiced the profession based on professionalism. The theme of the nature of the profession was evaluated with three subthemes: belonging, competence, and professionalism.
Sub-theme 1: Belonging
“As I gained professional experience and progressed in the profession, I felt that I belonged to my profession and understood it better.” (P1-Neurosurgery Department)
“First of all, I feel privileged compared to other professions because I do something that not everyone can do. I do something that is acquired beyond learning by reading books. I use the knowledge, skills, and experience specific to care that I have internalized. That is why I feel privileged.” (P7-Intensive Care Unit)
Sub-theme 2: Competence
“Being a nurse is possible by having competence to perform appropriate interventions on patients and having field-related knowledge and skills.” (P6-Chest Department)
“Actually, I know my limits; I am aware of what I can and cannot do.” (P6-Chest Department)
Sub-theme 3: Professionalism
“I think that the nursing profession should be performed from a professional perspective. The concept of professionalism includes being fair to patients, providing the care they deserve, preventing harm to the patient, having enough knowledge and skills, working with a lifelong learning philosophy, protecting professional identity, and ensuring professional unity. All of these concepts constitute my professional understanding and professional philosophy. I look at it within this framework and consider these approaches while working.” (P7-Intensive Care Unit)
“I think individual values should not affect the profession. It is clear how a nurse should behave and give responses in the face of events. Individual values should be effective in our social life. This is how I think and what being professional is… I think my professional practice is based on professionalism.” (P9-Dialysis Unit)
Theme 2: Echo of Time
A small number of nurses stated that their nursing philosophy included self-development, the feedback they received after providing care to the patient motivated them, and that this constituted their nursing philosophy. Some of the nurses defined the professional experience they had gained over the years as their philosophy. The theme of the echo of time was evaluated with three sub-themes: development, motivation, and experience.
Sub-theme 1: Development
“My nursing philosophy is self-development. How can I become a better nurse? How can I equip myself more? What can I do for the benefit of my patient? Thinking about how I can do things better in my job constitutes the philosophy of my profession.” (P5-Emergency Department)
“The nursing profession places a great responsibility on you. It has many responsibilities, and I try my best to fulfill them. In this regard, I thought I had to improve myself from the moment I started the profession, and I have been trying to do so since.” (P7-Intensive Care Unit)
Sub-theme 2: Motivation
“When you provide a patient with care, you get incredible satisfaction… The people you provide care for are human, and you can get good or bad responses from them. Positive responses increase our motivation. We get very happy when patients pray, say positive things, express that they are happy with us, and leave satisfied.” (P5-Emergency Department)
“In the nursing profession, you can see the outcomes of all the interventions you apply to the patient and get feedback about your work. In other words, you understand this either by observation, verbal expressions, or parameters. This outcome is something noticeable, and it affects me a lot. It motivates me in this regard, that is, it encourages me to do my job.” (P1-Neurosurgery Department)
Sub-theme 3: Experience
“I can easily say that I am competent in my field of work. I think I have improved myself in many areas since the first day. Being in the same service for four years has given me self-confidence. The learning process does not end with undergraduate education; it continues through experience in the service.” (P5-Emergency Department)
“In cases of pregnant women who have experienced violence, pregnant adolescents, and pregnant women who have had a miscarriage, it is necessary to be very careful, make good observations, and have the right approach. In the first years of my career, I had a hard time with these issues, and there were days when I cried a lot and could not sleep at night. Over time, I can see that I have become more experienced, have gained a healthier and more accepting approach, and have come to a point where I can work without hurting myself emotionally.” (P8-Obstetrics and Gynaecology Department)
Theme 3: Ripple Effect
Almost all of the nurses expressed their nursing philosophy as helping and providing care for those in need. The theme of the ripple effect was evaluated with two sub-themes: helping and caring.
Sub-theme 1: Helping
“Nursing is already a profession based on providing care. Helping is the basis of nursing. So I have to be able to help and want to help. I have to make this help meaningful.” (P2-Pediatrics Department)
“Being a nurse means helping patients when they need it; whatever need it is, physical or psychological.” (P8-Gynecology Department)
Sub-theme 2: Caring
“Being a nurse means knowing people in all aspects, being able to evaluate patients holistically and determine their needs, and providing nursing care for them according to their needs.” (P7-Intensive Care Unit)
“I think being a nurse primarily means being aware of people. It means recognizing and meeting the needs of patients who cannot support themselves.” (P5-Emergency Department)
“It is very important for us that a mother’s pregnancy ends healthily, she holds her baby in her arms healthily, and that she raises her baby healthily. If both the baby and the mother are healthy, society will be healthy as well. Just as when you throw a stone into water, ripples form and spread around, the same thing happens with the interventions we make. I can say that the care we provide spreads in ripples and affects the entire society.” (P8- Gynecology Department)
Theme 4: World of Values
While a small number of nurses stated that the meaning they attributed to nursing was respecting human dignity, according to nearly a third of the nurses, providing benefits and giving no harm constituted their philosophy in their profession. Some of the nurses also defined their nursing philosophy as honesty, justice, privacy, and conscience. The theme of the world of values was evaluated with seven sub-themes: human dignity, providing benefit, non-maleficence, honesty, justice, privacy, and conscience.
Sub-theme 1: Human Dignity
“I respect my patients and I want to be respected by them. Respect is important to me. This is important for seeing and giving value.” (P4-Psychiatry Department)
“When approaching a patient, we should not forget that they are human. We need to be professional… One of the things we should be careful about is not to personalize situations. We, nurses, are the ones who monitor the patient 24 hours a day, and we are the ones who intervene and notify when a problem occurs. We should not forget that the target of these practices is a human being. (P5-Emergency Department)
Sub-theme 2: Providing Benefit
“I think that my nursing philosophy is to benefit people I don’t know and to ensure that they become healthy.” (P1-Neurosurgery Department)
“Actually, my perspective is that I definitely want to do whatever is in the best interest of the patient. Sometimes, there may be statements (from our colleagues) that say it is not in our job description. I think that nurses can do anything that will benefit the patient.” (P6-Chest Department)
Sub-theme 3: Non-maleficence
“First of all, my nursing philosophy is non-maleficence… non-maleficence; doing the right thing, and doing it at the right time. This is my clearest philosophy: non-maleficence. Let’s first prevent maleficence. Of course, doing the right thing, as it should be, is also important. If people care about this, they will prevent mistakes and harm when they do their job properly. Of course, we are human and there is always a possibility of making mistakes, but being a nurse also places a different burden on people because nurses are members of a professional group. Our profession does not accept mistakes because we work with human beings.” (P2-Pediatrics Department)
“Maybe our interventions directly affect the individual. Perhaps the most important issue in the operating room is to prevent harm to the patient.” (P3-Operating Room)
Sub-theme 4: Honesty
“I am for honesty, both with myself and the people around me. Honesty is an important value for me because many things are under the control of the nurse in the nursing profession. Sometimes only you know what you have or what you haven’t done… Here, you need to be honest with both yourself and the patient. For example, the tip of the nasal cannula touches the ground, or the syringe touches something. You can’t ignore the contamination and use it. You can’t continue as if nothing happened. You would be neglecting that patient.” (P5-Emergency Department)
“I am always for honesty. No matter what happens, I am in favor of telling the patient the truth… Therefore, as a nurse, I attach great importance to providing accurate information.” (P3-Operating Room)
Sub-theme 5: Justice
“For example, sometimes we need to intervene in very private areas of patients. I never discriminate between genders or in terms of other characteristics. For me, the person in front of me is a human being, and I meet whatever the person needs at that moment. I do not discriminate against my patients in any way.” (P6-Chest Department)
“Since justice is very important to me, I can say that I pay attention to justice in my profession as well. This affects all areas from working hours to materials used in the service, time allocated to patients, and communication. Everyone should be given their rights. Patients should receive the nursing care they deserve in the hospital. I am the one who will provide this care, and if I cannot do it as required, how can I assume the responsibility for this?” (P8-Obstetrics and Gynaecology Department)
Sub-theme 6: Privacy
“Another important issue for me is privacy. I value privacy in my daily life, too. We witness many special moments of patients, and we keep this information confidential. I follow this principle in my daily life, too, but I am more sensitive when I am in the hospital.” (P6-Chest Department)
Sub-theme 7: Conscience
“If I were to come back to this world a second time, I would like to be a nurse again because I do it with great pleasure. I get a lot of satisfaction, and I tell myself this after every shift and every procedure. I question myself in my conscience. I think there is no one better than me if my conscience is clear, if I am satisfied, and if I am happy and peaceful…” (P2-Pediatrics Department)
“My conscience needs to be clear when I leave the hospital. You have to be conscientious if you are a nurse.” (P4-Psychiatry Department)
“Spirituality and conscience are very important here. The nurse is alone with the patient and his/her conscience on many issues.” (P8-Obstetrics and Gynaecology Department)
DISCUSSION
Nursing philosophy refers to the ethical values that shape the choices a nurse makes at work, beliefs, and motivation to be a part of the profession and emphasizes an orientation that determines the nature of the work to be accomplished (18, 19). In this qualitative study, nurses’ perceptions of nursing philosophy were examined in depth.
In our study, nurses stated that their perceptions of belonging, competence, and professionalism shaped their nursing philosophy. Professional belonging is defined as the interest in the profession, identification with the profession, and effort to continue it, while belonging in nursing is expressed as the perception of acceptance in the profession, trust, and respect (20-23). It is stated that belonging is a strong source of motivation (24). Considering the human interaction nature of the nursing profession, feeling belonging is indispensable for the development and sustainability of the nursing profession and the importance of belonging to the profession. It has also been emphasized by international nursing organisations (25). According to the literature, a negative sense of belonging leads to inadequate performance in the profession and failure, while a positive sense of professional belonging increases work motivation and work efficiency, leads to motivation for learning and development, and develops confidence and self-esteem (20, 24, 26, 27). In addition, it has been stated in the literature that competent nurses have an important role in providing safe care for patients, which emphasizes the importance of competence for the nursing profession (28). Competence is the knowledge, skills, abilities, behaviors, or capacity that individuals must have to perform their duties appropriately and skillfully (29). It is known that professional belonging and competence affect the professional approach (30). Accordingly, it is possible to say that the sense of belonging, competence, and professionalism are the characteristics that nurses must have to continue their profession due to the nature of the nursing profession. In this study, it was observed that although the nurses explained their nursing philosophy using the concepts of competence and professionalism, they did not emphasize all the competence areas of nursing. This result shows that the competencies determined for nursing should be developed in pre- and post-graduate nursing education. However, nurses need to be competent to provide effective, reliable, and high-quality care (31). When these competencies have been developed, the autonomy of the nursing profession can be strengthened, and the quality of patient care is positively affected. In addition, it is recommended that nurses’ ability to act professionally be supported so that competence can develop positively.
In this study, nurses stated that development, motivation, and experience structured their nursing philosophy as their working lives progressed over the years. They added that they achieved these gains with the echo effect of time in terms of development, motivation, and experience. This situation showed that they felt trusted, valued, and accepted in the professional sense (27). Accordingly, it is possible to say that the experience that nurses gained over the years provided awareness about their professional development and that the positive feedback they received from patients shaped their perspectives on their profession as a source of motivation. Considering that patient feedback supports the professional development of nurses and shapes their experience and motivation, it is recommended that patient-nurse interactions be supported with feedback.
Nursing is a profession that deals with humans and is based on nursing care (32). Nursing science aims to improve people’s health, relieve suffering, and provide the care and assistance needed for human health and well-being (33). The aim of nursing care is to systematically meet patients’ needs (34). Providing care and assistance are nurses’ independent functions in which they use their professional knowledge, skills, and abilities (35). In our study, nurses expressed their nursing philosophy as helping and providing care. The fact that nurses defined their professional philosophy as providing care and helping showed that the essence of nursing was understood by nurses. In addition, nurses’ statements about nursing philosophy as knowing people in all aspects, being able to evaluate the patient holistically, being able to determine the needs of the patient, and providing nursing care to patients according to their needs emphasized the necessity of providing nursing care through the nursing process. This emphasis also revealed that nursing could not be done haphazardly and was a scientific discipline. Accordingly, when the effect of this understanding of care and helping on all humanity, from the individual to society, is considered, the quality of the care that nurses will provide becomes important once again.
In our study, nurses stated that they provided nursing care in line with the ethical and moral values of nursing, including human dignity, providing benefit, giving no harm, honesty, justice, privacy, and conscience. Nursing care is the essence of the nursing profession, which includes ethics, morality, values, efficacy, competence, respect, and trust (36). While providing nursing care, the nurse should accept that the individual is a whole with his/her values, beliefs, attitudes, actions, and behaviors and should believe that the individual has the right to receive high-level nursing services (12, 37). Nursing services provided with ethical principles and professional values positively affect the quality of the art of nursing care. Therefore, nurses should know professional ethical principles and implement nursing care with a positive ethical understanding (38). Nursing services provided by nurses with a positive ethical understanding will ensure patient and employee satisfaction and patient safety, and increase the quality of nursing care (39). Nursing care provided by nurses, considering professional ethics and moral values, is quite valuable in terms of strengthening their professional autonomy and increasing their professional satisfaction.
Study Limitations
This study has several limitations. First, the results are representative of the individuals in the study group and cannot be generalized. Second, the data were collected through semi-structured interviews; therefore, their reliability is limited by the accuracy of the information provided by the participants.
CONCLUSION
This is one of the rare studies that examine nurses’ perceptions of nursing philosophy in depth. The findings of the current study are significant as they represent the first qualitative research conducted in our country to reveal nurses’ professional philosophy. It is recommended that further studies be carried out on the nursing philosophy of current nursing students, who will be the nurses of the future, focusing on the process through which the nursing profession is first experienced.
