Introduction
Professionalism is a transcultural construct and a fundamental concept in nursing for providing quality care [1-3]. Due to the complexity and multiple sides of this concept, it lacks a clear and precise definition [4, 5]. Experts in nursing consider professionalism to be traits, characteristics, or expected behaviors created due to the interaction between the person, the workplace, and other people, being advantageous for society [6, 7]. Some consider professionalism in nursing to be nurses’ attitudes toward their jobs and clinical practice in providing high-quality and safe patient care [8]. The characteristics of a professional nurse generally include adherence to ethical principles and professional standards, expertise, scientific preparation, commitment and responsibility [9], questioning spirit, independence, support, creative thinking, research attitude, and cooperation [10].
Today, due to the increasing progress of healthcare technologies, the demand for the presence of professional nurses and professionalization has increased [11]. Professionalism encompasses the legalization of the nurses’ role, promotion of competence, job satisfaction and retention, and better interaction with the environment and others. It also improves the quality of care and patient satisfaction, resulting in positive outcomes for the organization and society. Professional nurses are legally responsible and accountable for their services [2, 5, 12]. In addition, the professionalism of nurses is one of the concerns of health system trustees [13]. It stands as one of the most critical issues for nursing leaders. Despite significant developments, nurses lack enough scientific knowledge and independence. People still cast doubt upon nurses’ professional identity and roles [8]. The results of recent studies have reported low scores of nurses in professionalism. In some countries, nurses have been criticized due to insufficient growth in the quality of care [10]. Some studies attributed the low quality of nursing care to their lack of knowledge, skills, and work experience and their feeling of powerlessness and non-involvement in the decision-making process. However, most nurses believe that the main problems are the small number of professional nurses in the health system, the lack of formulation of professionalism indicators, and the absence of teaching content on the definition and development of these indicators in nursing [11, 14]. Therefore, promoting professionalism in nursing requires a better understanding of the attributes of professionalism and the development of a suitable conceptual model for its accurate measurement [15].
In nursing, Miller was the first one to design a wheel-like professionalism model, including 9 features: Educational background; adherence to the code of ethics; participation in the professional organization; continuing education and competency; communication and publication; autonomy and self-regulation; community service; theory use, development, and evaluation; and research involvement [16]. Other researchers added new features such as participation in increasing scientific load, cooperation, personal growth, committee activity [17], support, responsibility, innovation, insight, the inquisitive spirit [10], belonging to the profession, and commitment [18]. Other scholars suggested 20-21 features in three aspects: Cognitive, behavioral, and emotional for professional nurses [15, 19]. Furthermore, 5 characteristics were introduced for nurses working in special care units [7]. The latest definition of “professionalism in nursing” included 17 main concepts and 4 themes: Individual prerequisites, professional prerequisites, suitable educational and organizational structure, and individual/social factors [20].
The literature review revealed no comprehensive and valuable definition of professionalism in nursing. In fact, the diversity of the concept’s attributes in the introduced models is obvious [5, 7, 15, 19-21]. However, review studies are needed because of the dynamic nature of this concept, influenced by the social, cultural, scientific, technological, and contextual changes. On the other hand, improving professionalism requires a better understanding of the concept and the development of a suitable conceptual model for its accurate measurement. Therefore, the current study aims to review the latest studies regarding the definition and attributes of “professionalism in nursing.”

Materials and Methods
The present study used the integrated review method of Whittemore and Knafl, a modified version of Cooper’s 5-stage method. The 5 stages of this review method include specifying the problem, searching the literature, evaluating and extracting data, analyzing data, and presenting the results [22-24]. 
Based on the first stage, the following question was designed: What are the definitions, dimensions, and attributes of professionalism in nursing? 
In the second stage, a systematic literature review was conducted to determine the attributes and dimensions of professionalism in nursing. The studies published from 1985 (beginning of modeling in nursing) to 2021 in English or Persian were searched in international databases, such as CINAHL, EBSCO, PubMed, ProQuest, The Cochrane Library, EMBASE, SAGE, Science Direct, and Google Scholar search engine as well as national databases, including SID, MagIran, IranDoc and the medical sciences theses search engine. We employed the keywords “professionalism,” “professional,” “professionalization,” and “professional behavior” and their combination with the keyword’s “nurse” and “nursing.” The manual search of the references of articles was also accomplished. Screening and selection of eligible articles were done by two authors independently and considering the inclusion and exclusion criteria in three steps: Reading titles, reading abstracts, and reading the full text of articles, documents, or theses. The inclusion criteria included the studies conducted on nursing staff, written in Persian or English, and the availability of the full texts. The studies conducted solely on nursing students or other fields, abstracts of conference papers, and letters to the editor were excluded.
In the third stage, critical evaluation and data extraction was done. At this stage, to ensure the quality and accuracy of the extracted articles, two authors screened the articles using the qualitative and quantitative checklists of Graneheim and Lundman [25, 26]. The accepted studies at this stage (n=90) were classified based on quality into three groups: Good (n=14), moderate/with some limitations (n=40), and low/with many limitations (n=36). Studies with numerous and unacceptable limitations were excluded. The third author resolved any disagreement about the quality of the articles. 
In the fourth and fifth stages, based on Graneheim and Lundman’s qualitative content analysis method [25], the first and second authors read each article or document several times, and semantic units were identified and annotated in the “results,” “discussion,” and “conclusions” sections of the articles based on the research question. Then, the contents related to the frank and hidden definitions, attributes, dimensions, antecedents, and consequences of “professionalism in nursing” were manually entered into the coding table as semantic units. The codes were evaluated in similarity and contrast and placed in specific classes. Classes similar to each other were merged, and the categories and subcategories of professionalism in nursing were obtained [22].

Results
The initial search yielded 4186 studies published in the last 38 years. After removing duplicate and unrelated articles (n=4131), 54 studies and documents with different methodologies entered the analysis stage (Figure 1). Of these, 47 were articles, 5 were theses, and 2 were guidelines. Regarding study design, 17 used qualitative, 27 employed quantitative, 4 used mixed-method, and 4 were review studies. Most (94%) studies were in English, and the others (6%) were in Persian; 68% were published between 2011 and 2021. The increasing trend of published studies in recent years (35% between 2016 and 2021) indicates the necessity to address the professionalism category from the point of view of nursing scholars.
In these studies, the number of defined attributes for professionalism ranged from 4 [27] to 23 [28]. The studies were conducted in different environments (nursing colleges, public hospitals, private hospitals, and different health departments) and on different levels of nursing (teachers, managers, nursing staff). The samples in one study were nurses and doctors, and in another study, nurses and midwives. The smallest sample size was 8, which was related to qualitative studies [29, 30], and the largest was 5920, which was related to a quantitative study [31]. After analyzing the studies, we managed to extract the definitions, attributes, antecedents, and consequences of “professionalism in nursing.” Table 1 details the reviewed studies, including the name of the author(s), year of publication, type of study, definitions, attributes, antecedents, and consequences of the concept of “professionalism in nursing.”








Table 2 presents the results of the data analysis obtained by the content analysis method.


The findings revealed three themes: Attributes, antecedents, and consequences. The theme of attributes included 23 subcategories and 8 categories: Academic specialized knowledge, continuous pursuit of competence, autonomy, professional commitment, professional interaction, accountability, adherence to ethical principles and values, and advocacy. The theme of antecedents had 8 subcategories and 3 categories: Personal, organizational, and social factors. The theme of consequences revealed 5 subcategories and 2 categories: Individual and social outcomes. Figure 2 displays the conceptual model of “professionalism in nursing.”
Discussion
The findings of this study showed that 8 characteristics of specialized academic knowledge, continuous pursuit of competence, autonomy, professional commitment, professional interaction, accountability, adherence to ethical principles and values, and advocacy are necessary for a professional nurse. These characteristics provide a clear and precise definition of “professionalism in nursing” (Table 2).
Most studies have offered complex and multidimensional definitions of professionalism in nursing [1, 4, 12]. Many studies employed the attributes to define professionalism in nursing [15, 19, 32]. In the latest definition of “professionalism in nursing,” 4 categories of individual prerequisites, professional prerequisites, appropriate structures, socio-individual factors, and 17 subcategories have been introduced [20]. The results of the present study also showed that “professionalism in nursing” is a multidimensional concept. A professional nurse has specialized academic knowledge, constantly strives to maintain and improve his/her competence, and adheres to professional ethics codes, cultural and spiritual values, laws, and standards. In addition, through commitment to professional organizations and providing high-quality patient care, nurses represent a positive identity of the nursing profession to society, as well as their obligation to the profession and patients. On the other hand, nurses are responsible and accountable for the results of their actions and independently implement the necessary care plan for the patients.
In more than half of the studies, one of the main characteristics of nursing professionalism was academic specialized knowledge acquired through formal education at the university and scientific research. It creates the basis of the nurse’s professional performance, leading to the proper problem-solving process, independent and collaborative decision-making, and providing safe, competent, ethical, and compassionate care using available evidence [33]. This characteristic agrees with the findings of Miller [16] and the nursing standards in Iran [34]. In some studies, nurses with a higher university education obtain a higher professionalism score [4, 8, 10, 35]. According to some studies, most nurses without a university education gain lower scores in professionalism [35-37].
Another characteristic of nursing professionalism is the continuous pursuit of competence with subcategories of competence/continuous learning, professional care, and clinical reasoning/creative thinking. In most studies, providing, maintaining, and improving the quality of care are presented as the duties of a professional nurse and a sign of clinical competence and effective nursing management. On the other hand, a qualified nurse should possess clinical reasoning and creative thinking. In most studies, such as Miller’s study, some professional tools and guidelines of the 2015 ethical codes of nurses [16, 30, 38], competence, and continuous learning are introduced ::as char::acteristics of professionalism. Studies have shown continuous learning increases professionalism [8, 39, 40].
Adherence to ethical codes and values has also been proposed in most studies as a characteristic of professionalism in nursing. In our study, this characteristic showed the following subcategories: Adherence to codes of professional ethics, adherence to spiritual and cultural values, and adherence to legal values and standards. Adherence to codes of professional ethics has been cited in some studies as adherence to the ethical nursing codes [16, 29, 41], compliance with the ethical principles [5, 11], and providing ethical work [42]. Professional ethics is one of Iran’s seven professional nursing standards [34]. Soheili et al. considered spiritual care an integral part of holistic care and one of the aspects of nursing care [43] mentioned in ethical codes and nursing guidelines.
Professional commitment was another attribute with the following subcategories: Membership in professional organizations, positive professional identity, belonging, and professional commitment. Membership in professional organizations provides nurses independence and professional power. It signifies the commitment to the profession. Being interested, having a positive attitude towards the profession, being committed to full-time work, and helping to develop professional standards exhibit the nurse’s sense of belonging and commitment to the profession, organization, and society, assisting in the development of the profession. In other studies, membership in professional organizations is introduced as a characteristic of a professional nurse [16, 41, 44, 45]. Adams considered the commitment to serve society as a sign of pledge to the profession and mentioned it as an essential characteristic of a professional nurse [46].
Another attribute from the reviewed studies was accountability, with two subcategories of responsibility and accountability. Accountability means an individual’s internal commitment to perform the duties entrusted to him/her and is a key element of professional standards. Nurses are expected to accept responsibility for care measures and use their knowledge and skills to benefit the patient [47]. Different studies have introduced that professional nurses are responsible for providing high-quality and safe care services and for the consequences of the services offered to patients [18, 33, 48].
Another extracted attribute was autonomy, with two subcategories of independence and self-regulation. A professional nurse is self-controlled and self-directed to manage time, prioritize tasks, make appropriate decisions and correct judgments, and evaluate colleagues, students, and academic members. This attribute has been mentioned in some studies as self-control, self-regulation, and independence [15], or just independence [10, 30] or clinical independence [49]. Today, nurses seek to have independent performance. Non-participation in establishing administrative rules, compliance with the doctor, and other health issues are among the reasons for the low independence of nurses [10, 36].
Another attribute was advocacy with three subcategories: Patient support, self-support, and colleague support. Only patient support was cited in half of the studies, leaving self-support and colleague support. A supportive nurse prioritizes the patient’s interests and uses a patient-oriented approach. The nurses should try to motivate themselves. Supporting measures for nurses include the exercise of a backing system, having professional and organizational support, assessment by colleagues to improve the level of competence, receiving respect from patients and colleagues, a suitable reward system, maintaining the nurse’s job security, and improving his/her job satisfaction. Recent studies have stated that following the increase in nurses’ knowledge and skills, their responsibilities, consequences, and professional vulnerability have increased. Hence, nurses should receive support from themselves, colleagues, and the organization [13, 18, 19, 42]. The subcategory of colleague support was extracted from the code of ethics for Iranian nurses, the Handbook of Nursing Professional Standards in Iran, and the fifth provision of the American Nurses Association code of ethics [28, 32, 34, 50]. A professional nurse should help develop other nurses’ professional knowledge and ability and instill a sense of empathy, compassion, and dedication to their colleagues. 
The final extracted attribute was professional interaction with three subcategories: Communication with the patient, communication with colleagues, and interdisciplinary communication. In most studies, only the nurse-patient interaction has been mentioned under the term “professional interaction with the patient” [1, 51, 52]. In a professional interaction, while observing social values and using appropriate words, the nurse establishes an open, honest, therapeutic, caring relationship with the patient, adapts to various conditions, and resolves communication challenges. In a few studies, interdisciplinary communication was mentioned under the terms of collaborative practice [53], doctor-nurse communication [54], participation, cooperation, and interprofessional communication of nurses [15, 21, 31, 48]. Having a sense of cooperation and partnership and establishing proper professional communication with colleagues, doctors, and other specialists with a patient-centered approach, appropriate social interaction, and the spirit of teamwork are the characteristics of a professional nurse. Therapeutic and professional communication with patients, colleagues, and medical team members can improve the professional identity of nursing and is essential for professionalism.
Another finding of the current study was the extraction of the antecedents of “professionalism in nursing” with 3 categories and 8 subcategories. Personal/occupational, organizational, and social factors were found as the antecedents of professionalism in nursing (Table 2). Individual factors included age, gender, work experience, marital status, self-image, and having a neat and clean appearance. The department of service, high workload, lack of staff and equipment, low salaries, employment type, and having professional power and position in the organization are presented as occupational factors affecting professionalism in nursing. On the other hand, motivational factors, such as earning sufficient income, a suitable organizational atmosphere, and receiving organizational support, are also effective in creating job security and professional performance in nurses. The level of professionalism in nurses differs concerning various cultures and work fields. These findings are in accordance with the results of studies that stated that individual factors affect the professionalism of nurses [8, 55]. Nikbakht Nasrabadi argued that organizational and social factors, such as job status and lack of respect from nursing managers and doctors, as well as the attitudes of patients, families, and people toward the nursing profession, impact the professional performance of nurses [56]. Other studies have also shown that the attitudes of patients and their families towards the nursing profession and receiving respect from patients lead to better performance of nurses [5, 57]. Therefore, providing appropriate structure and equipment, sufficient human resources, a suitable organizational atmosphere, delegation of authority, constructive supervision, and using social media to create a positive view of nursing in people should impact the “professionalism of nursing.”
We also classified the consequences of “professionalism in nursing” into 2 categories of individual and social outcomes with 5 subcategories (Table 2). The outcomes of the nurse’s professional performance for the patient include improving the quality of care, providing safe care, reducing errors and harm to the patient, improving positive health outcomes, establishing effective therapeutic communication, and increasing patient satisfaction. These results were extracted from Ghaderian ’s study, which reported positive results for the patient and nurses as the consequences of professionalism [19].
Another important finding of the present study was the development of a comprehensive and accurate conceptual model for “professionalism in nursing.” In addition to determining the new attributes of the concept, this conceptual model uniquely specifies the antecedents and consequences of the concept clearly and accurately. This conceptual model has a circular design plotting the linear relationships and mutual interactions between the factors. In Miller’s professionalism model [16] and Kim et al.’s professionalism evaluation model [3], only the characteristics of the concept were mentioned. A complete conceptual model is constructive for simulation and a better understanding concepts and topics. Therefore, besides creating a better understanding of professionalism, the current conceptual model can be used to develop tools to measure “professionalism in nursing.” 
One of the limitations of the present study was the review of studies and documents published in Persian or English languages. It is recommended to review related studies in other languages.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: I R.USWR.REC.1397.118). 

Funding
This research received no grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conducting the search, examining the articles, and writing the article: Sakineh Parastesh, Mohammadali Hosseini, and Farahnaz Mohammadi-Shahbolaghi; Study design, data analysis, editing, and final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors are grateful for all supports of research team during this study.


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