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Professional presence: an internal compass to guide you in nursing practice.

In October 2012, the revised Standards of Practice for Registered Nurses was approved by the Nurses Association of New Brunswick's (NANB) Board of Directors. Standard 4, Public Trust, addresses professional presence. Section 4.1 reads: "The registered nurse demonstrates a professional presence and models professional behavior," (NANB, 2012). Public trust in a healthcare profession is created when what a client expects is in sync with the health care they receive. Hence, a gap between what a client expects from the healthcare team and actual care received, could result in decreased trust and decreased satisfaction in healthcare providers (Scottish Government, 2012).

In early fall 2012, the Practice Department at NANB sent out an informal survey to members and to student nurses regarding professional presence in nursing. In total, 1,001 surveys (980 RNs and 21 student nurses) were completed and the results from this survey will be discussed with supporting information found in current literature.

Professional Presence

Professional presence is more than a to-do list, but it does include how you look and the impression you give upon entering a room. It reaches beyond the uniform to include self-confidence and a way of being, knowing and doing. Lachman (as cited in Muzio, 2007) lists the following characteristics of an RN with a professional presence: competent; collaborative; able to cope with uncertainty; reflective in practice; open to change; optimistic; passionate; empathetic; full of integrity; adheres to professional standards, guidelines and codes; able to articulate one's role; maintains a professional image; and implements proper use of name and title.

McMahon and Christopher (2011) describe nursing presence as physically "being there" and psychologically "being with" the client (presence = being there + being with). For example, an RN using a personal communication device at the bedside is an RN who is physically there, but potentially not with the client psychologically. An RN committed to holistic care is more likely to relationally engage with the client while performing clinical hands-on care, including care involving technological devices. To be professional and to be present means professional presence needs to be embedded into who you are as a person.

When asked on the NANB survey if technology and skill related tasks were interfering with the humanistic aspects of nursing, 63% of the respondents agreed, but many wrote that it was the perceived lack of adequate numbers of RNs and not the technology that was the interference. One RN wrote: "Skill related tasks and technology are an important part of the world around us and nursing must adapt to integrate this with the humanistic aspects of our profession." Healthcare should not be process-driven and bureaucratic but rather, client-centered. The client is not an interruption to an RN's work--but the purpose of it. Standard 3 is entitled Client-Centered Practice and section 3.1 states that the RN "practices using a client-centered approach," (NANB, 2012). RNs should focus on working with clients; a "doing with" approach to care versus a "doing to" approach.

Professional Image

Professional image is an integral component of professional presence and it is created when there are positive interpersonal skills, polite behavior, professional attire, and confidence in one's knowledge and abilities. It is influenced by active listening and effective communication (both written and verbal), personal attitudes and appearances (Davidhizar, 2005).

Appearance is ongoing in most nurse-client relationships; therefore it is not only the first impression that counts, but every encounter with the RN. A consistent exposure to professional presence will most likely foster a therapeutic relationship between the RN and the client. A first impression communicates how the RN feels and respects the self. If the client thinks the RN takes care of and respects his or her self, then they will be inclined to trust the RN to take care of them as well (LaSala & Nelson, 2005). RNs have the ability to increase public and collegial respect for the profession of Nursing through professional presence.

Professional Presence and Trust

Changes in society's expectations and advancements in both science and technology have increased health care consumers' knowledge and expectations. There is a demand for transparency and accountability. Society is quick to congratulate and quick to condemn, therefore the first impression through to the last impression are pertinent. Professional presence needs to be a constant in the workplace and one's social life (including social media).

Professional presence, communicated through words, actions and physical appearance can either cause a lack of trust, or be the commencement of a trusting nurse-client relationship (Davidhizar, 2005; Mahon, 2011; Spitzer, 2012). When asked in the NANB survey, 58% of the RNs responded that it appeared clients were satisfied with nursing care in their workplace and 39% replied that clients were somewhat satisfied with the nursing care. This was personal perception of clients' reactions, but it was an overwhelming positive response.

Standard 2 is entitled Knowledge-Based Practice and section 2.5 states: "An RN initiates, maintains and concludes the therapeutic nurse-client relationship," (NANB, 2012). Professional presence is foundational in the therapeutic nurse-client relationship and has the ability to transcend all interactions between the RN and the client. Tone of voice, appropriate touch, body language conveying genuine concern and self-confidence in one's professional abilities, are all characteristics of an RN being present with clients. An RN being truly present with the client should foster a meaningful and trusting exchange (Zyblock, 2010).

A visible nametag and an introduction, including name and the designation RN, should also foster a sense of trust that someone is in charge of client care and capable of providing safe, competent and ethical care (Davidhizar, 2005). Speaking with confidence and compassion is often a reassurance of the RN's capability and ability to meet the demands of the job and the needs of the clients.

Work Environment and Leadership

A supportive environment which fosters learning and models professionalism, will encourage RNs with varying years of experience to strive to grow in knowledge, confidence, and the ability to provide quality health service to clients. Role-modeling is important in developing awareness of professional behaviour or a lack of it. When asked if professional presence and behaviour should be recognized and reinforced in day-to-day practice, 99% of respondents to the NANB survey replied YES, but only 61% felt strong and effective leadership, including positive rolemodeling was actually present in their workplace. One respondent shared: "I think we all have our own professional role models in the workplace. I have a few who have been like that for me since the beginning. I think some of the RNs that tend to have an overall bad attitude towards their work are less likely to have role models than those who have support."

Leadership is about finding your strengths and helping others to do so, too. It is about RNs working together to provide quality care despite the circumstances, while being open to new ways of "doing" nursing but also not "chucking" the strengths of the profession out the proverbial window. It is about "knowing what we know" and not being afraid to stand firm on that knowledge base. When asked: "Do you consider yourself a leader," 80% of the respondents to the NANB survey replied YES. One RN wrote: "I believe we are all leaders. Every RN has something to share, to offer and we can learn a lot from one another. Being a leader is believing in what you do and wanting to improve our profession, and the care we offer." Another RN expressed the impact of an aging workforce on leadership in nursing: "As many of the nurses near retirement, they often seek positions in areas where there is less shift work. This means that many of the experienced nurses have left the unit, leaving it staffed with inexperienced nurses. The mentors are gone, making it more difficult for new nurses to make that transition from graduates to RNs."

During confidential interviews, RNs from three hospitals in Ontario revealed why they thought nursing morale and patient satisfaction were so low in their workplaces. Client care was diminished by the low morale of the staff who perceived that they were not valued as professionals (Ferguson-Pare, 2012). RNs revealed the desire to be respected as professionals, with opportunities to learn. They wanted the tools to do their work in a supportive environment which allowed them to work to their best potential. They expressed the need to be heard and included in the interprofessional team.

The findings from the NANB survey were not much different from Ontario. One New Brunswick RN wrote: "I think part of the reason for the good morale is the autonomy that RNs have, as this is a department outside of the hospital where RNs have a lot of autonomy and do not have the hierarchical structure..." Another wrote: "Our efforts are rarely appreciated and we receive a great deal of negative feedback. When I speak to my co-workers, they all see/hear/feel the decline in morale." Most respondents working in areas in which their role has less hierarchy and more autonomy stated that their workplace has good morale.

From an organizational perspective or an employer perspective, boundaries and principles need to be clearly laid out, the values of the employer need to be shared with and modeled by staff, and expectations need to be clearly defined. This includes communicating professional values and professional expectations (Scottish Government, 2012). Many RNs from the NANB survey shared that the teamwork amongst RNs at the unit level is good, but there is a perceived disconnect from management and upper management, including nurse leaders. When asked if they thought there was good collaboration amongst healthcare professionals in their workplace, 56% of respondents to the NANB survey replied YES and 36% replied SOMETIMES.

Retention of staff and quality of care go hand-in-hand. Retention of staff is probable if RNs feel they are valued for their knowledge and contribution to the health care team. Reciprocal respect from nurse to nurse and nurse to other healthcare provider is a characteristic which impacts clients and staff alike. Regarding staff morale in their workplace, 32% of respondents in the NANB survey replied that staff morale was not good and 46% replied that it was only satisfactory.

Professional presence is also impacted by context. Context includes support from the employer and the expectations from others, including clients. Nursing is not for the faint at heart--RNs are required to react professionally in varying circumstances or to have "situational judgment". The term "situational judgment" refers to the ability to judge circumstances and then react in the most appropriate way (Scottish Government, 2012). In other words, one may have knowledge and skill but not react appropriately in a situation and come across as unprofessional. Self reflection as a practitioner is considered professional behaviour, including how one's practice adheres to employer policy, regulatory standards, the code of ethics, and legislation. This may be described as professional self-awareness. Professionals who self-reflect are more apt to respond positively to feedback and are more willing to adapt to change behaviour and practices as required (Scottish Government, 2012).

Conclusion

The concept of presence is widely accepted as a core relational skill within the profession of nursing. Scope of nursing practice continues to expand and RNs are challenged to prioritize the humanistic aspects of nursing care as they integrate increasing numbers of technical and scientific expectations (McMahon & Christopher, 2011). Standard 1 entitled Responsibility and Accountability states that the RN is "responsible for practicing safely, competently and ethically and is accountable to the client, employer, profession and the public," (NANB, 2012). Registered nurses need to value the profession of nursing and what RNs contribute to the healthcare team and to the public.

Valuing the nursing profession is projected in our appearance, body language, and both verbal and nonverbal communications including characteristics of professional presence. Professionalism must speak to multigenerational RNs that reflect today's realities in the healthcare workplace, to become a spark that motivates staff to work with passion. Professional presence can become the driving force for safe, competent and ethical care--an internal compass that guides RNs in their nursing practice (Scottish Government, 2012).

NANB invites you to take part in a virtual forum, happening from December 12, 2012, until January 11, 2013, on professional presence in nursing. The facilitator of the forum will be Dr. Catherine Aquino-Russell from the UNB Moncton Faculty of Nursing.

REFERENCES

Davidhizar, R. (Summer, 2005). Creating a professional image. The Journal of Practical Nursing, 22-24.

Ferguson-Pare, M. (2012). Perspectives on leadership: Moving out of the corner of our room. Nursing Science Quarterly, 24(4), 393-396.

LaSala, K. & Nelson, J. (2005). What contributes to professionalism? MEDSURG Nursing, 14(1), 63-67.

Mahon, K. (2011). The impressions we leave... Dynamics, 22(3), 5-6.

McMahon, M. & Christopher, K. (2011). Toward a mid-range theory of nursing presence. Nursing Forum, 46(2), 71-82.

Muzio, L. (2007). Standards and foundation competencies for the practice of registered nurses. SRNA Newsbulletin, 9(1), 7.

Nurses Association of New Brunswick. (2012). Standards of practice for registered nurses. Fredericton, NB: Author.

Scottish Government. (July, 2012). Professionalism in nursing, midwifery and the allied health professions in Scotland: A report to the Coordinating Council for the

NMAHP Contribution to the Healthcare Quality Strategy for NHS Scotland. Edinburgh, UK: Author.

Spitzer, R. (April, 2012). Professionals First! Nurse Leader, 8-11.

Zyblock, M. (2010). Nursing presence in contemporary nursing practice. Nursing Forum, 45(2), 120-124.
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Author:Priest, Susanne
Publication:Info Nursing
Date:Dec 22, 2012
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