Original Article Facilitators and Barriers to the Professionalization of in

Hosein Habibzadeh, PhD Candidate; Fazlollah Ahmadi, PhD; Zohreh Vanaki, PhD

Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran

Corresponding author: Fazlollah Ahmadi, PhD; Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, P.O. Box: 14115-331, Tehran, Iran. Tel: +98 21 82883590; Fax: +98-21 82883558; Email: [email protected]

Received: 24 October 2012 Revised: 29 November 2012 Accepted: 3 December 2012

Abstract Background In recent years, healthcare organizations have supported the professionalization of nursing in order to improve the quality of care delivered to . The purpose of this study was to explore facilitators and barriers to professionalization of nursing in Iran. Methods A qualitative study was conducted using the conventional content analysis. Semi-structured interviews were held with 18 nurses working in various nursing positions and in different healthcare settings. Themes related to the professionalization of nursing was developed. Results During the data analysis, five themes were developed: “communication”, “motivation and attitude”, “organizational culture and structure”, “academic education”, and “supportive resources”. Each theme as a factor impacted the professionalization of nursing in a positive or negative manner. Conclusion Recognizing factors influencing professionalization of nursing contributes to improvement of quality of nursing care delivered to patients. Healthcare system authorities can facilitate the development of the nursing profession and facilitate the professionalization of nursing through increasing the number of postgraduate nurses and also improving the nurses’ work conditions.

Keywords: Content analysis; Nursing; Professionalization; Qualitative research

Please cite this article as: Habibzadeh H, Ahmadi F, Vanaki Z. Facilitators and Barriers to the Professionalization of Nursing in Iran. IJCBNM. 2013;1(1): 16-25.

Introduction

Although professionalization is a familiar concept used in nursing, there is an ongoing controversy on whether nursing is a profession.1 Nowadays, becoming professional is a challenge in nursing.2

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American Association of Clinical Nursing skills must begin from clinical settings and (AACN) and other nursing education centres continue to other situations.13 as well as healthcare organizations emphasize With regard to the background of the importance of the professionalization of professionalization of nursing in Iran, nursing.3,4 Such organizations encourage Iranian nursing has been strongly initiating changes in the structure influenced by the British nursing tradition of the healthcare system to facilitate characterized by the apprenticeship style professionalization, which can lead to the of . About a quarter of a improvement of the quality of care.5,6 century ago, nurses began to be educated There are many factors influencing the in higher education institutions and development of the nursing profession. the bachelor’s degree in nursing was Therefore, recognising and determining determined as the minimum requirement to such factors can be the first step to move enter nursing practice. Despite the changes, towards the professionalization of nursing.7,8 nursing is still striving to be accepted and For instance, a descriptive study in the recognized as a profession by the public. U.S. by Bruhn (2001) on the culture of This change was heralded as an opportunity professionalization in healthcare professions to enhance the professional status of nurses showed that the indices of professionalization in Iran. At present, university-based consisted of ‘moral consideration to the programs for nursing consist of Bachelor public’, ‘sympathy and empathy’, ‘quality of Science (BSc), Master of Science (MSc), of healthcare’, ‘professional consideration’, and (PhD) degrees.14 ‘communication’, ‘accountability’, Development of modern nursing education ‘collaborative work’, ‘humanity’, ‘knowledge in Iran has faced a lot of difficulties since improvement’, and ‘being a model’.9 its beginning early in the twentieth century. Additionally, Jamison et al. (1999) in the In other words, the main direction of nurse U.S. using the constant comparative method education has been positive in the early years revealed that healthcare organizations should of this century, but it has faced undeniable design a new model of professional due to challenges,15 and professionalization of its connection to the professionalization of nursing has been one of these challenges. nursing, which could predict a high quality For instance, Tabari-Khomeiran et al. nursing care.10 Rischel et al. (2008) in (2007) and Adib Hajbaghery (2003) in their Denmark declared the necessity of designing studies in Iran revealed that nurses were a new pattern for professionalization of the core elements of the professionalization nursing based on different cultures and of nursing, and healthcare organizations contexts.11 Also, Christine and Wynd (2003) would positively influence it. In addition, in a descriptive study in the U.S. on a random improving the nurses’ professional identity, sample of clinical nurses introduced factors self-confidence would empower the nurses’ contributing to the professionalization of professional capabilities. It was advised nursing. They believed that nursing was that involving the nurses in the process moving toward professionalization, but of decision-making would empower them different social and professional changes and replace the routine-oriented style of should be considered in order to facilitate delivering nursing care with evidence- it. In this respect, a lack of coordination of based nursing practice.8,15 Moreover, it nursing with such changes has hindered the was believed that a new structure must be professionalization of nursing.12 According designed to help with the professionalization to Julie et al. (2006), the professionalization of nursing.16,17 of nursing using specific communicative According to the literature, a few behaviours associated with different nursing qualitative studies in Iran have been

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conducted on the professionalization of subthemes were identified, data saturation nursing,14 professional competence,18 and was achieved. The participants were professional empowerment,19 but no study interviewed in a private room at their was available on facilitators and obstacles workplaces. The interview guide consisted to the professionalization of Iranian of open-ended questions to allow the nursing. Therefore, this study aimed to respondents to explain their own opinions, explore facilitators and obstacles to nursing perceptions, and experiences freely without professionalization from Iranian nurses’ any limitation. Each participant was asked perspectives. to describe his/her own experiences on the professionalization of nursing. The main questions asked during the interviews were: Subjects and Methods o What are your experiences on nursing professionalization? Study Design o According to your work experiences, A qualitative study using a conventional which factors may influence the professional- content analysis approach was used. Content ization of nursing? analysis is a descriptive qualitative approach The duration of each interview session whereby the researcher identifies themes ranged from 20 minutes to 2 hours with an or patterns in data in order to reflect the average of 75 minutes. The first researcher participants’ experiences.20 It is an approach for contacted each potential participant to sorting through large amounts of data, making explain the aim of the study and its research inferences from data about their context, questions. If the participant agreed to take providing new insights, and conceptualizing part in the research, an interview session realities presented in the text.20,21 was scheduled. Probing questions were used during the interviews in order to clarify the Participants and Settings participants’ comments and increase the The study participants consisted of depth of interviews. 18 people (6 nurses, 3 head nurses, 2 supervisors, 2 , 3 nurse educators, Data Analysis and 2 members of the Iranian Nursing The data collection and analysis were Organization (INO) chosen through conducted consecutively. Initially all of the purposive sampling method.21 Their age interviews were transcribed verbatim and range was between 27 and 52 years. Of read several times in order to get the sense the participants, 9 nurses had a bachelor’s of whole. A total of 486 primary codes degree, and 7 and 2 master and PhD were identified from the transcriptions. The degrees, respectively. Seven nurses were codes were considered to be provisional and female. As an inclusion criterion, having revised several times in order to find the the experience of working as a clinical latent meanings behind the participants’ nurse for more than 5 years in a clinical statements and sentences. In this respect, setting was considered for the selection of the level of abstraction of the codes was the participants in order to gather in-depth improved through conducting comparisons and high quality data. between codes during the different stages of data gathering and analysis. Similar codes Data Collection relating to the same content were grouped Data were collected and analyzed over a together and the themes were developed.20 six month period in 2009. The participants were interviewed using semi-structured Rigour interviews and once the main themes and Member checking, peer checking, and

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external audit established the credibility Table 1: Themes developed during data analysis of the data collection and analysis. Themes During member checking, a summary of Communication the participants’ transcriptions and their Motivation and attitude primary analysis were provided to ensure Organizational culture and structure Academic education that the researchers were presenting their Supportive resources real world. During peer checking and external auditing, the findings were given to a couple of qualitative researchers to Communication confirm the accuracy of data analysis. The participants mentioned that commu- Maximum variation of sampling in terms nication increased the possibility of gaining of the type of hospital, level of education, a better professional identity for nurses. They and participants’ age provided data on a exemplified communication as an essential wide range of perspectives and perceptions, tool for the professionalization of nursing to which enhanced the credibility and be the provision of an active and developed conformability of collected data. It was relationship with patients, healthcare team also tried to thoroughly record the process members, and the public. of data collection and analysis, and the The participants pointed out that creating detailed contextual subtleties of the study a new culture of interpersonal relationship, phenomenon in order to facilitate audit especially the nurse- and nurse- trailing, and transferability of findings, physician relationship was required. In respectively. addition, nurses should be empowered to have the capability to introduce themselves accurately and be socialised in the public. Ethical Consideration Some participants stated: The research proposal was approved by “The professionalization of nursing will the Research Ethics Committee affiliated occur when an effective communication is with Tarbiat Modares University. The first made with patients. It is the heart of nursing author informed the participants about the that leads to the improvement of the quality purpose of the study. It was explained that of nursing care.” (A male clinical nurse and the participation was voluntary. They were two female nurse educators). assured regarding the confidentiality and Another participant noted: anonymity of their identities throughout the “I work in the emergency ward; two study process. Finally, informed consent physicians are working with me having an was obtained from those who willingly inaccurate image of nursing. Thus, we have agreed to be interviewed. no good time during working with each other. On the other hand, there is a physician who has an accurate image of nursing. We Results discuss about scientific subjects and do our duties using professional methods.” (A Five main themes emerged during the data female clinical nurse) analysis: “communication”, “motivation Others pointed out that “It is my right and attitude”, “organizational culture and that the society becomes familiar with my structure”, “academic education”, and profession [nursing], but I feel that the “supportive resources”. The themes showed the public has not an appropriate image of main factors influencing the professionalization the nursing profession; so we must try to of nursing in a positive as well as negative establish a strong communication with manner (table 1). the society.” (A male clinical nurse and a

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female clinical nurse) One another participant said: “If nurses feel professional authority, Motivation and Attitude they can hope to become professional. According to the participants, During the past 18 years, I have experienced “motivation and attitude” of nurses was that these two factors must be developed an important requisite for starting and among nurses, if Iranian nursing system is supporting the professionalization of going to become professional” (A Female nursing. Nurses must believe that they are clinical nurse) independent and responsible, scientifically efficient, important figures in the healthcare Organizational Culture and Structure system, and also competent enough to The culture and structure of the healthcare become a professional. From the nurse’s system was another important factor, which perspectives, some of the substantial acted either as facilitator or inhibitor to variables include ‘autonomy’, ‘self-esteem’, the professionalization of nursing. As the ‘responsibility’, ‘scientific efficacy’, and participants indicated, physician-centred ‘professional authority’. culture, and insufficiencies in human Three participants commented: resources management could hinder the “To me the most important factor in the nurses’ capabilities in clinical settings. The professionalization of nursing is the attitude participations’ quotations exemplified the of nurses themselves”. We can become meanings related to this theme. professional, if we are motivated and believe A nurse mentioned: that we can establish the professional indexes “Nurses capabilities are not utilized in Iran. Then, we can develop our capacity appropriately, because of some for professionalization” (A member of INO organizational factors. All managers and two male educator nurses) believe that male nurses are in a better A female clinical nurse said: position than female nurses for nursing “Nurses’ capabilities are not used management positions and I think this is appropriately. In one of my work shifts, I not fair” (A female clinical nurse) decided to give bed bath to my patient who One participant declared: was relatively bedridden and had no any “The culture of the healthcare system physician order about his mobility. The doesn’t consider the role of nurses patient’s doctor said to me: ‘you shouldn’t correctly. There is an old and unscientific do this’. I felt that nurses had not any sort climate that induces misunderstanding of of autonomy and in this situation, we could nurses’ positions and roles, and physicians not reach professionalization indexes. This are considered to be more important than made me unhappy and hopeless.” nurses.” (A female clinical nurse) Another nurse reported: Another participant noted: “In our ward, there was a nurse with “I think we are far away from the real master degree. If she would give a report meaning of nursing; sometimes, I haven’t any about the patient’s condition to the doctor, opportunity to care for my patient, because the doctor believed in her and involved his we should do some duties such as heavy paper idea and diagnosis in the therapeutic plan. works, writing patient records, consultation In one case, I saw that the doctor changed forms and so on. I think that this is some the patient’s orders according to the sort of deviation from nursing and results nurse’s report. In this situation, all nurses in a remarkable reduction in the quality of felt having power and self-esteem and they nursing care.” (A male clinical nurse) believed that Iranian nursing could become Two participants added: professional.” (A male clinical nurse) “The culture and structure in the

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healthcare system is needed to be Supportive Resources reengineered specially in the nursing care Supportive resources were recognized by evaluation approach. Nurses are evaluated Iranian nurses to be necessary to move toward based on paper works, writing patient professionalization. The participants’ views records, but not on the quality of care and experiences on supportive resources delivered to patients.” (A member of INO consisted of defending the nurse’s right’, and a female educator nurse) ‘being supported by nurse managers and Another nurse noted: nursing unions. As participants explained, “Nurses must only practice nursing care supportive resources in nursing systems had and be responsible only for their duties. We a decisive role in nursing professionalization. must have authority and responsibility.” (A However, a lack of support was a barrier of male nursing ) the professionalization of nursing. A participant mentioned: Academic Education “I think this is a right that we [nurses] As our data analysis indicated, the would be supported by our own colleagues educational system was as an integral part and managers.” (A female clinical nurse) of the professionalization of nursing. The Another nurse noted: professionalization of nursing originated “If you want to become a professional, from the theoretical identity of the nursing you must have power in the healthcare curriculum content and the theory-practice system. During past years, we have had gap. The theoretical content of the nursing many problems in our profession, but since curriculum led to a poor level of the nurses’ the establishment of nursing organization clinical competency and education–practice in Iran, I feel that we are authorized and gap, which were barriers to the process of powerful” (A female clinical nurse) the professionalization of nursing. Two other participants declared: One nurse said: According to two participants, “Educators must train nurses as “Establishment of the Iranian Nursing professionals. Our scientific borderlines Organization (INO) was a milestone in must be separated from other medical Iranian nursing and the development sciences disciplines. We must practice of other similar organizations would be based on nursing theories and not based effective and supportive resources, which on pure medical information.” (A female could facilitate the professionalization clinical nurse) of nursing.” (An INO official nurse and a The participants believed that education female nurse matron) in academic settings was an index of the Another nurse mentioned: professionalization of nursing. Providing “During the past 23 years, I found long-life and continuing education even in that without the support of the Ministry of post-graduate nurses was judged to be critical Health, we could not be professional” (A for nurses to maintain competency in clinical male ) settings to move toward professionalization. A participant noted: “Establishing MSc and PhD degrees Discussion in nursing was an important factor to help the development of nursing. However, in This study introduced several main factors such the first step we must remove the theory– as social, communicational, organizational, practice gap as a barrier greatly influencing educational, and emotional impact of nursing professionalization.” (A female professionalization of Iranian nursing. nurse supervisor) It was found that a professional

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atmosphere must be established promoting et al. (2004). They showed that negative the role of nurses in the Iranian healthcare cultural and structural factors affected system. According to WHO (2012), the role the nurses’ professional self-confidence of nurses is important in the healthcare and superimposed this negative belief that team. Considering the importance of nurses were subordinates and handmaids nursing services in any healthcare system, to physicians and could take no authority the 54th World Health Assembly (WHA) and responsibility in practice.19 Daley’s recommended the designation of strategies (2000) research also indicated that nurses to strengthen and promote the role of nurses often felt that organizational structures and in the healthcare system.22 political issues blocked their independence Accordingly, creating an active and in decision-making.25 effective communication known as Other structural factors have impeded the socialization was mentioned to be a role of nurses specifically in the application major factor for professionalization. Hall of their professional knowledge and skills (1967) introduced a professionalization in practice. Nurses in this study frequently model including five professional indexes. complained about misevaluations in nursing He believed that communication with care. Some of them implied that they society and socialization were important had some organizational and individual factors influencing professionalization. barriers such as heavy workloads, staff Professional communication in the shortages, obscure job descriptions, and therapeutic team, especially the nurse- the lack of time to do professional care. physician relationship, was a facilitator to Many studies confirm these findings and professionalization.23 emphasize the importance of high quality It was also found that nurses needed and competent nursing care in the process to communicate with patients to be of the professionalization of nursing.26-28 professionalized. Moreover, Anoosheh et Beck and Young (2005) stated that al. (2009) found that providing effective legitimate professional identities or habits communication with patients was an being engaged in practice.29 essential aspect of nursing care and As the results of this study indicated, the understanding barriers inhibiting nurse- application of human-resource management patient communication could provide led to the improvement of quality of an opportunity to eliminate them.24 healthcare and would enhance the nurses’ Moreover, Adib Hagbaghery et al. (2003) professional identity, self-confidence, discussed that miscommunication with and empower them in developing patients might lead to the development of and demonstrating their professional an unprofessional image of nursing and capabilities. Developing a participative reduce the quality of nursing care.8 Also, management style and involving the Julie et al. (2006) confirmed that inter- nurses in the process of decision-making disciplinary communication was essential can empower them. It can also aid in the for professionalization and effective team replacement of the routine-oriented style communication was a vital aspect of of delivering nursing care being evidence- nursing practice.13 based one in clinical settings. These findings In the present study, the nurses believed confirm those of the study carried out by that there were no accurate organizational MacPhee and Scott (2002). They concluded culture and structure to support moving that involving the nurses in the patient toward nursing professionalization. These care management process enhancedtheir findings are confirmed by those of a motivation and led to the improvement of study carried out by Adib Hagbaghery their professional identity.30

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According to the participants’ Conclusion experiences, academic education, and appropriate nursing education curriculum Healthcare system authorities are expected were required to help the facilitation of to help the professionalization of nursing. In the professionalization of nursing. They this respect, social, cultural, and economic believed that higher academic education in issues impeding the ability of Iranian nursing would be effective in this respect. nurses to become fully professionalized The nursing curriculum in the bachelor should be removed. Nurse managers and degree in nursing seemed to be insufficient administrators can facilitate the development and it was believed that professional nurses of the nursing profession and accelerate would not be graduated, which would reduce the professionalization of nursing through the speed of professionalization. Donna and increasing the number of nurses with higher Barbara (2001) reported that nurses must academic degrees, improving the nurses’ work establish educational standards, if they conditions, and inviting their collaboration in would like to become a professional.31 decision-making. This study was conducted on The participants described the gap a limited sample of nurses. Therefore, future between educational programs and actual studies are suggested to be conducted on other practice. Wilson and Hayes (2000) reported healthcare providers and healthcare system that nurses could learn strategies to cover managers in order to draw a more complete the education–practice gap through gaining picture of this phenomenon. necessary competencies after graduation and incorporating them in daily work routines.32 Nurses noted that they needed Acknowledgement supportive resources to feel empowered and edauthoriz. They believed that supports by This study was one part of the first author matrons and head nurses’ were crucial. It PhD dissertation. Tarbiat Modares University is in the same line with the Evets’ (2006) supervised and supported this study financially. findings indicating that motivating nurses The authors wish to thank all the participants was needed in order to develop a profession. for their sincere cooperation in the study. She emphasized the effect of supportive resources in enhancing staff motivation.33 Conflict of interest: None declared According to the participants, nurses themselves were an important factor in facilitating the professionalization of nursing References and authority and self-esteem had catalyst roles in the process of professionalization. 1 De Cooman R, De Gieter S, Pepermans Since the establishment of Iranian nursing R, et al. Freshmen in nursing: Job motives organization (INO), the nurses have felt and work values of a new generation. J having power and authority. Hughes (2002), Nurs Manag. 2008;16:56-64. Laschinger et al. (2001), and Salvadores et 2 Brooks I. Swailes S. Analysis of the al. (2001) emphasized the importance of relationship between nurse influences having the feeling of authority to become over flexible working and commitment a professional.27,34-36 Moreover, Evelyn et to nursing. J Adv Nurs. 2002;38:117-26. al. (2007) reported that establishing self- 3 Mechanic D. Managed care and the esteem in nursing students and the sense of imperative for a new professional ethic. being included in the team and supported Health Aff. 2000;19:100-11. by authorities are facilitators in becoming 4 American Association of Colleges of a professional.36 Nursing. Hallmarks of the professional

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