Climbing the Ladder in Crafting A Professionalism Framework for Nursing Students in South Africa

Introduction: Globally, higher education institutions face the challenge of training nursing students to meet the healthcare demands of an ever-changing society. In nursing education, innovative ways are essential to instil professionalism among nursing students to prepare them for handling complex practise issues without compromising the professional standards of nursing. This paper focusses on developing a conceptual framework to facilitate professionalism among undergraduate nursing students at a higher education institution in South Africa. Methods: This study was a constructive paradigm research with a qualitative descriptive approach. Data was collected through focus group interviews with participants (three cases). Different phases were followed in the development of the framework using the case method. In Case 1, focus groups (n=8) were held with student nurses at each of the levels of a four-year degree program (n=42). In Case 2, focus groups (n=3) and unstructured interviews (n=1) were conducted with purposively selected nurse educators (n=20), representing academics and clinical facilitators. Case 3 comprised of semi-structured individual interviews (n=5) and focus groups (n=5), a total of 29 preceptors in professional practice. An analysis of a within-case followed by cross-case data analysis resulted in merged themes of three cases that emerged as an overall case study. Results: Actual accounts of the participants` experiences on nursing professionalism during theory and practice education were captured in the six concepts of the Practice Orientated Theory that structured the framework developed. Conclusion: A logical methodological description of creating a framework on nursing professionalism was outlined and the conceptual framework can be evaluated for transferability to other similar nursing education training environments.


INTRODUCTION
Professionalism is a concept that stands out in the education of the health professions of every student, including nursing students, pursuing careers such as nursing as a profession [1] [2] [3] [4] [5]. However, the complexity and attempts to define and describe the concept have been vague and educational strategies over the years have been less effective in inculcating the expected professional behavior in students [6] [7] [8] [9] [10] [11]. Sow et al (2021) [5] point out the uniqueness of professionalism and the need to differentiate and conceptualise it in the different healthcare professions. This implies a necessity to develop a specific framework on professionalism that could be valuable to nursing department at a higher education institution (HEI)to direct the integration of theory and practice of nursing students [7] [12]. Cao et al. (2023) [8] recognise the role nurse educators play, in the preparation of undergraduate students to contribute to a high level of professionalism in the profession. Preparing students for entering their professional work life is essential and part of delivering clinical nursing care [13].
Yet, a distinct conceptual perception of nursing professionalism is lacking [14]. Shen et al (2021) [15] explored a set of general theoretical models to be adapted for the nursing education environment to have a positive impact on the professionalism of undergraduate students. Furthermore, the literature reports that the models and frameworks of professionalism are mostly those of the medical profession [16] [12] [5].
This, despite nurses being the largest group of healthcare providers in the healthcare system with multiple and complex roles that require enormous professional responsibility, attention, and vigilance [17]. Nurse educators (hereafter referred to as educators), in South Africa (SA), are challenged to establish an alternative model of nursing education that impacts the quality of care delivered by competent students [18].
One of the first frameworks for the interpretation of professionalism is the Care, Cure and Core Model (1966), developed by Hall (1968 ) [19] that is applicable to different healthcare settings [20]. However, due to the unique nature of nursing, the standards suggested by Hall were found to be inadequate for the current teaching and assessment of nursing professionalism [20].
One of the most important criteria for nursing is the accumulation of scientific knowledge in professional practice [8] [21] [22]. The conveyance of this knowledge may be in the form of a nursing framework, model, or theory [23]. Brown  The development of the conceptual framework on nursing professionalism entailed different phases ( Figure 1). shifted to the differences and similarities between three cases [26]. The initial question to all participants was: "How is the facilitation of professionalism for students in the undergraduate nursing program for you?".

Phase 1: Situation analysis
The researcher rephrased the question to the participants when they needed clarity [27].
The purpose of the question was conversational, to gain an in-depth understanding of how participants made meaning of their own experiences in nursing professionalism [28]. Participants were allowed to freely express themselves and digitally recorded after informed consent. with the experiences they shared.

Phase 2: Spiral of analysis
The multi-case study included triangulation of Inductive spiral analysis of the multi-case study method entailed ( Figure 2).
Assembling the collected data about individual cases to condense it into a holistic contextualised picture, for understanding the overall case [32]. Data for each case were analysed separately, engaging in a process of moving in analytic circles, touching on several aspects of the analysis between the data text and the account of the findings in the end [33].
Organizing the data of the three cases into separate classified computer files for data and transcripts to be easily located. Repeated listening to recordings was essential before and after verbatim transcribing [33]. Re-reading individual transcripts several times to get a sense of the whole database [33], including initial exploratory notes in the margins of the transcripts.
Describing, classifying, and interpreting data into codes and themes with an independent coder followed.
Following the loop of the spiral of analysis [33], as the researcher built a detailed description of the multiple data sources (the three cases) and data collection methods within the context of the setting,  (Table 2).

Phase 3: Cross-case synthesis and model case
Inductive analysis began with the raw data of sources of all three cases, being broadened to several specific themes, and then to general themes. The data of the major role players, as portrayed in the individual cases (within-case analysis), was grouped into thirteen themes and collapsed into six common themes in the cross-case analysis.  (Tables 2 and 3) and identified its characteristics and role with regard to the survey list of the Practice Oriented Theory [31] (Table 4).
-Integrated the concepts of the findings of the three cases in one framework using the questions of the Practice Oriented Theory [31].
Synthesis, re-synthesis, and clarification of the concepts involved the description of the framework with the purpose of providing a comprehensive understanding of nursing professionalism. Data reconstruction was achieved by using theory generation as proposed by Dickoff et al. (1968) [31].
As part of the conceptual framework validation process, the researcher presented the framework to two separate groups of experts in the field of professional practice, each session lasting around 90 minutes.

Experts completed a validation instrument
with criteria about clarity, simplicity, generality, accessibility, and importance of the framework (adapted from [34]).  Table 1 Phase 1-Objectives, population, and data gathering methods.

Phase 1: Situation analysis
The themes and categories of the in-case analysis of the three cases emerged, of which Theme 1 is demonstrated in Table 2.
In analysing the categories of a theme, concluding statements were drawn that related to the reasoning map of Dickoff et al.
(1968) [31], which later informed the development of the conceptual framework.

Phase 2: Spiral of analysis
In the summary of the findings of the three cases, some examples of quotations are also included.

Findings of Case 1: Students
The first objective of the study was to explore the experiences of nursing students on professionalism during their program (Phase 1). Despite being exposed and trained to

Findings of Case 2: Educators
The second objective of the study was to   Table 4 which indicated the in-depth of the interviews that produced rich data.

The model case
The  practice.

Phase 4: The reasoning map
Through deductive reasoning the Practice Orientated Theory [31]provided the reasoning map (Table 5) (Table 5).
In the context of this study, the students,  Reasons unprofessional behavior and the impact Specifics of professionalism unclear, practical guidelines needed; Professional values taught, but not internalized; Newcomers must show commitment; Demotivation in nursing; Reconsider selection of students and preceptors; Unresolved grievances due to lack of discussion platforms; Traumatic life experiences influence professional behavior; Students need more academic assistance and mentoring in practice ** Concluding statements presented in Table 3  Table 3 Categories and concluding statements of Theme 1 in Case 1

Theme 1: Role modelling of unprofessional behavior of preceptors in practice Categories
Examples of concluding statements (Dickoff et al., 1968) Humiliating and demoralizing style of communication and nontolerant behavior with students •Preceptors as nurse leaders (secondary agent) should encourage students to take the lead and remind seniors of teaching moments in the clinical facilities •Preceptors should create a welcoming atmosphere in the healthcare settings and make students (recipient) feel part of the health team •In nursing, the context of an atmosphere of trust (reliability) is needed between the student (recipient) and the patient where the nurse (learner) has confidence in what she is doing •Preceptors should encourage positive ways of communication (process) that contribute to the emotional and psychological wellbeing of students and refrain from gossiping which is degrading Lack of respect for time •Preceptors have the responsibility (personal reliability) of respecting their working time, as they could demonstrate to students that they are reliable and can be trusted.
•Preceptors remain accountable for tasks delegated to students (recipients) in practice •Preceptors should create a friendly external environment by welcoming students with a positive approach during orientation (process), so that students familiarize themselves with the expectations in patient units Incidences of misconduct and non-commitment to patient care • Patient care should be the first consideration of a preceptor and personal matters should not interfere with patient care duties •Adequate and appropriate clinical teaching and learning material are needed for simulation to prepare students for "real things" (process) in the clinical practice environment Inconsistent expectations of and ignoring of procedural guidelines •Guidance from educators could ensure that students perform tasks within the scope of safe practices Table 4 Themes within case analysis and between case (cross-case analysis) Recognition of learning and teaching needs in training, for professional development of a new generation, and historical heritage of the profession. Table 5 Reasoning map

Questions
Meaning Agents Who is the agent of the activity?
Nurse educators (academics, clinical facilitators) and preceptors who perform the activity of facilitating professionalism in students during training Who is the recipient of the activity? Students registered for a Bachelors in nursing program at a HEI In what context is the activity performed (framework)?
The context in which the activity occurred was in a HEI and nursing practice in health facilities in the WC. What is the energy source for the activity (dynamics)?
Motivational factors required to support students to facilitate professionalism for nursing practise What is the guiding procedure?
Guiding processes and strategies for facilitating professionalism in students for practice What is the endpoint of the activity (terminus)?
The terminus was the conceptual framework for educators and preceptors to facilitate professionalism among students for nursing practice    Service Courage/ Assertive that changes and diversity in terms of culture, generations, language, and socio-economic background created challenges for developing professionalism in nursing. This conceptual framework is methodologically unique as it incorporates the experiences of participants in three cases representing the main stakeholders in the education of students.

LIMITATIONS
The limitation of the study was that the findings could not be generalised to other settings of higher education nursing program, a small sample was used. in-depth interviews, the independent coder and the reviewers who validated the framework at the end.

COMPETING INTERESTS
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

AU HOR ' ON RIBU ION
P.B initiated the study and was responsible for design, data collection and analysis, as well as for the interpretation of data and drafting the manuscript as an outcome of her PhD.
K.J. was the study supervisor and assisted in the conceptualisation of the study design, data analysis, and preparation of the manuscript.

FUNDING INFORMATION
This study received no funding.

DATA AVAILABILITY
Data sharing is not applicable to this article as no new data was analysed.