Change is inevitable, especially in today’s healthcare organizations. Commitment to professional growth and development is essential in order to remain a viable member of the healthcare team (Dimauro, 2000).

The nursing profession has long recognized the value of the expert nurse (Benner, 1984). Herzberg, in his organizational theory, the Motivation-Hygiene Theory, considered growth and development to be a professional success factor. In the Maturity Motivation Theory, Argyris portrayed growth as having deep interests, consciousness, and self-control (Argyris, 1957). Professional growth is vital to individuals, organizations, and the professions, including the nursing profession (Morgan, 2007). Although skillful and knowledgeable nurses contribute to organizational goals and work efficiency, developing professionally can be a significant challenge for clinical nurses (Clark & Holmes, 2007; Meagher, 2004; National Council for the Professional Development of Nursing and Midwifery, 2004).

In order to better understand professional growth and development the Ovid, Proquest, Medline, and Scopus data bases between 2000 and 2010 were searched, using the keywords “professional development,” “professional growth,” and “competency.” Professional growth was explained as referring to the development of knowledge, skills, and expertise that enable one to perform at a higher level of efficiency (California Polytechnic State University San Luis Obispo, California, 1985). The United States (US) National Staff Development Council (2010) described professional development as referring to a comprehensive, sustained, and intensive approach to improving personnel. Tanskey (1991) noted that professional development involves learning that is broad, complex, and related to the totality of the learner, rather than learning that is related to a specific skill. It is a proactive process that enables people to make progress in their career. Although the need for both professional growth and professional development is frequently mentioned in the nursing literature, discussion regarding the experience and associated outcomes of this growth and development is limited.

Even though Iran has seen a renewed emphasis on human resource management since the early 1980s, there is still no position within Iranian health care organizations that is assigned the responsibility for the management of human resources. In Iran nurses make up a significant portion of the employees in the healthcare system. However, they do not enjoy the same status in healthcare organizations as do physicians (Adib Hajbaghery, Salsali, & Ahmadi, 2005; Dehghan Nayeri, Nazari, Salsali, Ahmadi, & Adib Hajbaghery, 2006). Research in Iran has identified consequences of this status differential to include dissatisfaction, lack of motivation, and low quality of the service among nurses, all of which lead to patient dissatisfaction (Dehghan Nayeri, et al, 2006; Emamzadeh Ghasemi, Vanaki, Dehghan Nayeri, & Faghihzadeh, 2002; Ghaljeh, Ghaljaei, & Mazlom, 2008). Even though Iran has seen a renewed emphasis on human resource management since the early 1980s, there is still no position within Iranian health care organizations that is assigned the responsibility for the management of human resources. To date, very limited attention is given to staff and organizational performance in Iran. This study aimed to investigate nurses’ understanding of their professional growth and development by eliciting the stories of the 21 participating nurses.

In this article we will present a qualitative study in which 21 Iranian nurses, whose years of nursing experience ranged from 3 to 28 years, shared their perceptions of their professional growth and development. We will discuss how these nurses described their skill and psychosocial development within the themes of developing judgment, improving communication, instilling confidence, seeing the whole patient, and strengthening their commitment to nursing.

The Study

Method

In this study the first author conducted in-depth, semi-structured interviews. The intent of the interviews was to capture narratives describing how participants had grown and developed professionally. Participants shared their understanding of situations in which they had grown and developed during their years of experience as professional nurses.

Sample/Participants

The participants were drawn from among the professional nurses working in different wards of two public hospitals in Iran. Fifteen participants were recruited from one hospital and six participants were recruited from the other hospital. Purposeful sampling was conducted with participants selected on the basis of willingness to share firsthand information regarding their experiences of growing and developing professionally. These nurses were selected in consultation with nurse managers. The nurses ranged in work experience from 3 to 28 years. Four nurses had 0-10 years of experience, 9 had 11-20 years of experience, and 8 had 21-30 years of experience.

Data Collection

The data were collected by semi-structured, open-ended interviews conducted by the first author. All participants were informed of the purpose and design of the study and the voluntary nature of their participation. First 17 clinical nurses were interviewed; later, interviews with 4 nursing managers were conducted. Interviews continued until saturation of the data was reached and the researcher was no longer obtaining any new data (Streubert, Speziale, & Carpenter, 2007).

After the participants gave permission to participate, they were asked to describe their experiences and perceptions of their growth and development in their professional life. The following questions were asked:

1. What does professional growth and development mean to you?
2. What criteria made you feel well developed?
3. What experiences have you had that enabled you to feel well developed?

All interviews were all held in private locations within the workplace setting. Interviews were tape recorded with permission.

Data Analysis

First, one of the researchers (first author, a PhD student) listened to each recorded interview and transcribed the content. Another author checked this process by listening to a random selection of interviews, comparing what she heard to the transcribed document, thus checking for accuracy. Following this process, the data were analyzed using the method of content analysis to identify relevant themes highlighted by these nurses in describing their professional growth. An inductive coding process was used to derive the categories and the themes from the data. Categories and themes were identified from the early interviews and then tested and revised through analyses of succeeding interviews. Finally the coding proceeded to the more specific concepts found in the various themes and the analysis looked for relationships between themes and categories.

In this analysis the researcher first reviewed the line-to-line data to identify details that had been presented. Next the responses were separated according to the question that was answered. Then the researcher divided the text into meaning units for example: feel relaxed while I’m at work; work without calling the doctor; previously the patient’s satisfaction was not important to me. The meaning units were then condensed, coded, labeled, and organized in similar areas in order to search for themes. From these areas, two key themes and five sub-themes emerged. The authors worked as a team throughout this process, with the first author doing the initial analysis and the second and third authors (faculty members) reviewing the analysis during the various stages of the analysis process. The three authors discussed the analysis together to resolve any contradictions.

Rigor

This study gained rigor as from the first author’s extensive contact and involvement with the participants. Early in the study the first author worked to show her interest in the participants and made her considerable availability clear to them. This gave the participants confidence that she was interested in them and that she would be available to them. Also some of the nurses participated in two interviews. This extended involvement helped to build trust between the research interviewer and the participants and to enhance the researcher’s understanding of the research context. Accuracy and rigor were further enhanced as two faculty members analyzed the interview scripts and the extracted codes. Additionally, the themes extracted were subsequently discussed with selected participants who had previously indicated a willingness to be involved in further inquiry. These discussions enabled the researchers to refine the themes in light of this participant feedback.

Ethical Considerations

All participants consented in writing to participating in and audiotaping of the interviews. The hospital directors and head nurses also agreed to the participation of their staff nurses. This research study was approved by the Tehran University of Medical Science’s Committee of Ethics.

Study Findings and Discussion

In this study the Iranian nurses focused on describing how they had grown and developed professionally. In contrast to the general descriptions of professional growth and development provided by the California Polytechnic State University and the U.S. National Staff Development Council (mentioned above), these participants focused more on describing their own situations of professional growth and development. The Iranian nurses described their own development as occurring in two broad areas, namely skill development, and psychosocial development, areas having some correspondence to the above definitions of professional growth and professional development respectively. Within these broad areas they identified five themes. Themes related to skill development included developing judgment, improving communication, and instilling confidence. Themes within the psychosocial development area included seeing the whole patient and increasing commitment. Each of these two areas, with their associated themes will be discussed below.

As we discuss each area we will first present our findings and then discuss the correspondence between our findings and the general body of literature addressing professional growth and development. Brief descriptions of the Iranian culture as it relates to these themes will also be presented.

Skill Development

Developing Judgment

Iranians strive to demonstrate competency, work capacity, and independence. Nurses in this study identified these characteristics as demonstrating their professional growth. Participants described nurses who had developed professional judgment as having professional knowledge, taking the right actions, learning to anticipate the care needed, and planning and exercising discipline at work. One participant explained, “at this level [of development], anymore when some ill patients are entered simultaneously in the ward, I distinguish very fast who has priority. I do not push, and I don’t get confused.” Another nurse described her experience thus:

Now you know I can see growth in myself. Lots of things have changed, especially my ability to managing care giving to the patients. Now, I’m much more skillful. Now I can make some adverse things stop, which previously I had to wait to see if they would stop by themselves.

They considered themselves as developing judgment even when they were able to demonstrate small increases in their judgment. As reported by one nurse, “I can now easily say I’m able to work my shift a whole day without calling the doctor for help. This means growth.” This autonomy was defined as self-dependence and non-dependence on the doctor.

Iranians strive to demonstrate competency, work capacity, and independence. Nurses in this study identified these characteristics as demonstrating their professional growth.

Improving Communication

Participants considered their ability to increase both their understanding of patients and their communication skills as indicative of their professional growth. They took pride developing these skills. The participants described themselves as having more conflicts and being less compatible with others early in their careers when they hadn’t yet learned how to treat their colleagues professionally or seek their cooperation in difficult situations. One nurse said, “I was pretty intolerant and quarrelsome, but now, I’m well-experienced. I feel relaxed with others on my job and keep calm, and this is my development.” Another nurse said, “My temperaments have improved. Now, I feel that I should behave in a way that satisfies the patients.” Developing the ability to respond patiently to others’ adverse behaviors was also considered to be indicative of one’s development. Over time their communication management improved and they reported that they are now pleased with their relations with their colleagues.

Generally Iranians are known as the affable, good communicators and hospitable. These participants considered their ability to be affable and hospitable in the work setting as a sign of positive change and development.

Instilling Confidence

In Iran respecting elders and requesting help from an experienced man is the norm. When the [female] nurses...found that they, themselves, were offering help to elders, they recognized that a change had taken place within them. Nurses found that, as nurses, they became a source of information for their colleagues and were trusted by the colleagues and patients. One nurse said, “Now I help my colleagues and the inexperienced people and provide them with my experiences.” Participants took pride in being able to help their less experienced colleagues and serve as a source of information for them. They found this ability to be a source of pride and a measure of their development. They also knew they were growing professionally when patients depended on them and considered them dependable. One nurse reported, “Now, I hear the patient saying I feel relaxed to see you; I [have] concluded that they feel relaxed while I’m at work, so I’ve reached where I was going to reach.” Another nurse said, “To me, the fact that people around me ask me their questions and count on me means I’m no longer a novice.”

In Iran respecting elders and requesting help from an experienced man is the norm. When the nurses, who were predominantly female, found that they, themselves, were offering help to elders, they recognized that a change had taken place within them.

Correspondence between Findings and the Literature

Several other researchers have sought to describe what professional growth and development in nursing entail. Walker (2007), while using interviews to elicit the qualities of competent nurses, identified basic knowledge and specific skills as qualities of a competent nurse. In our study nurses also identified that the possession of specific skills was a sign of growth. Hurme (2007) applied the Delphi Method to address competency and acceptable caregiving in rural nurses, noting technical/clinical skills, creative thinking skills, communicative skills, and administrative skills as being important. These findings, like ours, noted the importance of nursing skills and communication abilities. Nikbakht Nasrabadi and colleagues' phenomenological study (2005) considered ‘professionalism in the first year on the job.’ They found the concept of professionalism to be synonymous with sufficient knowledge, experience, and skills in care, as did the participants in our study. Vanaki and Memarian (2009) studied Iranian nurses using grounded theory. Their nurses defined, competency as full clinical skillfulness, communicativeness, creative thinking, problem solving, and practicing in a professionally ethical manner, stressing judgment and communication skills. These researchers, too, found many of the same indicators as we did regarding skill development. These descriptions are similar to what the California Polytechnic State University described as professional growth.

Psychosocial Development

Seeing the Patient Holistically

Participants considered themselves as ‘well developed’ when they could understand patients beyond their disease and value them as human beings. They used phrases such as: including a broader viewpoint, being patient centered, being dedicated to patients, and respecting patients’ wishes and rights, as examples of their professional development. One of the participants said:

...they needed a certain level of professional development before they could relate to patients...and avoid discriminating against patients who were different from them. Previously, the only thing I preferred was getting the things done for the patient. Patient’s satisfaction was not important to me, and I never thought about it, but now, it’s a matter of great importance to me. I care for them. For instance, I try to find a job for those who have lost their jobs due to their disease.

In order to provide this level of care nurses needed to appreciate and respect patients coming from different areas, and having different cultures and levels of economical welfare. They noted they needed a certain level of professional development before they could relate to patients in this manner and avoid discriminating against patients who were different from them. Another nurse said, “Well, whoever they are and in any situation they are, the patients make no difference to me, and I respect them and try to meet their needs as far as I can.”

Iranians, as a people, have always tried to respect others. The nurses in this study recognized the importance of showing this respect to all people, no matter how different they might be from the nurses themselves.

Increasing Commitment

Participants described two types of commitment as they spoke about their professional development. These two types included commitment to work and inner commitment as discussed further below.

Inner commitment. Inner commitment to these participants meant a sensing of one’s conscience and a responsibility to work for God’s sake. Nurses explained that feeling an obligation to practice in an ethical and responsible manner was a sign that they were moving along in their professional development. One nurse said, “I feel great responsibility, and I can’t neglect a small thing about the patient. Previously, I used to pass by, but now I take it serious.” Nurses also considered having a good temperament as indicative of development. Another nurse explained:

I felt awful when my colleague asked me why the would-die patient is not taken home to relax. One must put oneself in his/her shoes. I respect the patient, and even continue to do so after his/her death.

When stress from fear of punishment due to mistakes, turned into fear for the sake of the patients, nurses felt that their “development had come true.” One of the nurses described her experience saying, “Well, I don’t have any stress for my own sake, but for my patient, and I’ll do my best, even if he doesn’t understand it.” This type of commitment is related to interest. Interest in patients provided the motivation for achieving professional growth. One participant noted, “I really love my work, and I still love to work in the busy wards. After so many years; I think I’m even more interested now.”

Inner commitment was also related to remembering God at work. As nurses gained experience they reported that their religious considerations and precision of care increased; they considered this as part of their development. Inner commitment was also related to remembering God at work. As nurses gained experience they reported that their religious considerations and precision of care increased; they considered this as part of their development. More interestingly, as they experienced an increased sense of commitment and a deeper perception of the organization, they increasingly recognized that the organization was not a strong support for them, nor did it provide sufficient opportunities for them and prepare them to work in the organization. The organization did not motivate them to work well. Rather they became interested in their work internally; they considered the positive effect of sensing God in their lives as indicative of their development. One participant said, "The organization doesn’t do anything. It’s the mercy of God that works. Now, we enjoy the heartiest wishes of the patients, and it’s God that observes us. We have Him, even if nobody else feels thankful to us." Another nurse said, “Frequently in my life I’ve felt it from the events happening to me that He has seen my service. My biggest sign of my development is that God is directing me; I feel the presence of God.”

This value is common among Iranians because of their religion. They see God's supervision in all stages of their life, including their career. Although the term ‘commitment’ has been repeatedly mentioned in nursing texts, the terms related to work commitments and ultimately professional ethics are mentioned more in the literature than are terms related to God. In this study Iranian nurses’ experiences and views went beyond work commitment (as discussed below). Commitment for them meant an inner commitment that relates to God. In spite of the lack of organizational support and external motivation, this kind of commitment generated strong incentives and propelled them towards accomplishing better work.

This finding may relate to the fact that Iranian nursing has been influenced by traditional and socio-cultural factors that affect the nurses' views of their profession (Nasrabadi, Seif, Latifi, & Rasoolzadeh, 2009). Culturally, Iranians are Muslims (98%). According to the World Health Organization, Iran's literacy rate is 82% (Dehghan Nayeri, & Negarandeh, 2009).

They felt responsible not only for their colleagues but also for the patients who needed their care. This belief is internally oriented; it is not a role formally assigned to them by the organization. Commitment to work. Commitment to work was a rather noticeable aspect of the development of these nurses. The following comment illustrates one nurse’s experience of the continuing effect of being committed to do the work assigned: “When one makes progress and develops, her success makes her a commitment that one cannot forget about that easily. I feel like I’ve got a commitment that one should do it anyway.” Nurses such as this one saw the fact that they were able to continue working in a stressful, challenging, and non-supportive organizations, and not leave these positions, indicated that they had achieved a degree of professional development. Another nurse shared:

Now, I feel I’ve got commitment to my work. For example, I could use my medical leave, and I really needed it, but I didn’t use that vacation because the section didn’t have enough staff, and my presence was helpful. I try to accompany my colleagues.

They felt responsible not only for their colleagues but also for the patients who needed their care. This belief is internally oriented; it is not a role formally assigned to them by the organization. One nurse said, “I didn’t use to do these things previously; I just came and did my routine work and left; however, I [now] guide my novice colleagues, no matter if the organization doesn’t know this.”

Correspondence between Findings and the Literature

Other researchers have observed many of these same psychosocial indicators of professional development. Jantzen (2007) described professional development as a form of learning and of changing attitude and performance through experience. The Iranian nurses also noted that their attitudes toward patient care changed over time. Fagerberg (2004) defined professional development as the ability to focus holistically rather than to look at the details, emphasizing patient satisfaction and transfer of knowledge to practice. These traits were also identified by the Iranian nurses. Zhang, et al. (2001) found that interpersonal understanding, commitment, informational gathering, and comforting were indicators of well-developed nurses. These indicators are similar to some of the indicators we found. However, our Iranian nurses did not identify information gathering as part of the growth process. Although Zhang, et al. spoke about commitment, they did not see commitment as being an internal trait as did the nurses we interviewed. Meretoja et al. (2004) identified patient guidance, ethical care, identifying changes in patients’ conditions, holistic attention, autonomy, and valuing the patient as a human as signs of professional growth and development. Although many of these traits were also mentioned in our study, Meretoja et al. never referred to religion and religious perspectives. Hughes (2005) reported nurses as believing a professional development program improved their performance by expanding their knowledge, promoting safer care, and increasing their commitment to other nurses, but did not mention commitment to the work and the organization.

In summary, many of our indicators of professional development related to psychosocial development have also been identified by other researchers. Most descriptions discussed by these Iranian nurses were similar in nature to those reported by Tanskey (1991) in that they were broad, complex, and related to the totality of the learner. However, other authors have not reported nurses' sensing of God in their personal lives. The Iranian Study by Vanaki and Memarian (2009), however, did report this sense of being observed by God.

Conclusion

I (first author) believe that this inner commitment to God was a new insight, one that is less valued by the Iranian managers and nursing policy makers. The intent of this study was to identify how Iranian nurses describe professional growth and development. The descriptors they gave were many and varied. The participants believed that well-developed nurses should be not only skillful but also interested in their job. They noted that nurses should develop their technical and communication skills so that patients and peers can trust the nurse’s judgment and that nurses can look at patients holistically, as human beings. These nurses also reported an inner commitment to the work of nursing care and to God who observed their performance. They experience of sensing his effect on their lives was also reported as characteristic of well-developed professionals. I (first author) believe that this inner commitment to God was a new insight, one that is less valued by the Iranian managers and nursing policy makers.

This study found that although other researchers have suggested many of the same professional development competencies as did this study, there remains a need for research that delves deeper into nurses’ perceptions of professional development, going beyond technical and communicative expertise, and addressing the more personal and spiritual aspects of the clinical nurse’s professional role. In this study the participants began to describe the behaviors they believed characterized the professionally mature nurse. The findings of this study suggest that human resources departments develop programs that would enable nurses to become the kind of nurses they believe they should be, thus maximizing their influence on the entire health system, and ultimately all of society.

Acknowledgement: This research was supported by Tehran University of Medical Science, Nursing & Midwifery Faculty.

Authors

Flora Rahimaghaee, MSc, RN
E-mail: frahimaghaee@gmail.com

Ms. Rahimaghaee is a PhD student in Nursing and Midwifery Faculty at the Tehran University of Medical Science (TUMS). She received her MSc in Nursing Education, and her BSc in Nursing from the Guilan University of Medical Science in Iran. She currently holds the position of faculty of nursing at Islamic Azad University- Tonekabon Branch. Her areas of scholarship include clinical education, internship programs in Iran, and nursing student experiences in clinical settings.

Dehghan Nayeri, PhD, RN
E-mail: nahid.nayeri@gmail.com

Dr. Dehghan Nayeri (corresponding author) is an Associate Professor and Dean of Education in Nursing and Midwifery Faculty at the Tehran University of Medical Science (TUMS). She received her PhD in Nursing, her MSc in Nursing Management, and her BSc in Nursing from the TUMS in Tehran, Iran. She is affiliated with the Faculty of Nursing and Midwifery, Nursing and Midwifery Care Research Center in Iran. Dr. Dehghan Nayeri serves on the Editorial Boards of the Journal of Nursing and Midwifery (HAYAT) and the Iranian Journal of Critical Care Nursing (IJCCN). She is a reviewer for the journal Medical Ethics (TUMS). Her areas of scholarship include nursing productivity, role conflict, and competency.

Eesa Mohammadi, PhD, RN
E-mail: mohamade@modares.ac.ir

Dr. Eesa Mohammadi is an Associate Professor in Nursing Faculty at the Tarbiat Modares University. He received his PhD in nursing from the Tarbiat Modares University, his MSc in Nursing from the Shahid Beheshti University of Medical Science, and his BSc in Nursing from the Tarbiat Modares University in Iran. Dr. Eesa Mohammadi is a Member of the Board of Directors of the Iranian Nursing Scientific Association and Editor of the journal, Scientific Association Nursing. His areas of scholarship include nurses’ competency, clinical settings, nursing care, and clinical interventions.

Adib Hajbaghery, M., Salsali, M., & Ahmadi, F. (2005). A model for empowerment of nursing in Iran. BMC Health Service Research, 5, 1-24.

© 2010 OJIN: The Online Journal of Issues in Nursing
 Article published November 9, 2010