Professionalism in Nursing Behaviors of
Nurse Practitioners
DONNA ADAMS, DNSC, RN,* AND BARBARA K. MILLER, PHD, RN†
Little research on the level of professionalism of
nurse practitioners has been published to date. These
nurses are expected to practice relatively autono-
mously in delivering client care and therefore must
monitor their own levels of professionalism. At a na-
tional conference, 502 nurse practitioners completed
the Professionalism in Nursing Behaviors Inventory.
Participants represented all of the states and the
most common specialties of nurse practitioners.
Nearly 68 per cent had been practitioners less than 5
years and were primarily employed in physicians’ of-
fices. The majority had received their master’s de-
grees from schools with nurse practitioner curricula,
and 8 per cent held doctorates. More than one half of
the practitioners had written a research proposal or
participated in a project within the past 2 years. In
terms of autonomy, nearly 50 per cent of the nurses
had written their own job descriptions. Maintaining
certification motivated them to engage in some pro-
fessionalism behaviors. Results indicated these nurse
practitioners had high levels of professionalism.
(Index words: Nursing; Professionalism; Behaviors;
Nurse Practitioners) J Prof Nurs 17:203-210, 2001.
Copyright © 2001 by W.B. Saunders Company
T HE THRUST OF NURSING in the new century
will continue to emphasize advanced practice
and the appropriate settings in which it occurs. Nurse
practitioners’ extended education, with a basis in the-
ory and research, has enhanced their image. The use of
a scientific foundation for every type of nursing prac-
tice has become essential. Thus, more autonomous
nurses with increased credentials are convincing soci-
ety even further of the value of nursing. As with any
profession, obligations and commitment are inherent.
Defining professionalism in nursing has been as dif-
ficult a feat as that achieved by nurse practitioners (NP)
*Associate Professor, Arizona State University, College of Nurs-
ing, Tempe, AZ.
†Professor Emeritus, Arizona State University, College of Nurs-
ing, Tempe, AZ.
Address correspondence and reprint requests to Dr. Adams: Ar-
izona State University, College of Nursing, Tempe, AZ. E-mail:
donna.adams@asu.edu.
Copyright © 2001 by W.B. Saunders Company
8755-7223/01/1704-0012$35.00/0
doi:10.1053/jpnu.2001.25913
Journal of Professional Nursing, Vol 17, No 4 (July–August), 2001: pp 203-210
to gain their rightful place in delivering quality and
cost-effective care. For many years, scholars in other
fields identified nursing as a semiprofession because of
the lack of a university-based education as the entry
level, the lack of autonomy, and a paucity of theory and
research to serve as a foundation for the field (Etzioni,
1969). The fact that the nursing profession was com-
posed primarily of women hindered its achievement
of a full profession as well because it was considered
women’s work and therefore less valuable. Nursing re-
mains confusing to the public because of the various
ways of gaining entry into the field. As theory and
research in nursing increased, and women’s worth in
society was realized, nurses, in turn, became more au-
tonomous and nursing was generally recognized as a
full profession. More recently, the health care climate
has embraced primary care, and NPs with advanced
education have become recognized as valuable mem-
bers of health care teams. Nurse practitioners provide
comprehensive, effective health care (Garrard et al.,
1990; Nichols, 1992).
Purpose
Little is known about the levels of professionalism of
nurse practitioners. Therefore, the purpose of this
study was to investigate behaviors indicative of profes-
sionalism in nurse practitioners.
Method
SAMPLE
The convenience sample of nurse practitioners was
obtained from attendees at the American Academy of
Nurse Practitioners Annual Conference held in Phoe-
nix, Arizona, in 1998. Nurses, staff, students, and pre-
senters other than nurse practitioners were included in
the 1,624 participants. Only the 502 responses from
certified nurse practitioners were used for this study.
Subjects completing the usable questionnaires repre-
sented all states.
Appropriate human subjects review groups ap-
203
204
proved the study. At the conference, potential subjects
received a research packet and a cover letter stating that
completion and return of the anonymous questionnaire
to an enclosed box signified consent to participate.
INSTRUMENT
The Wheel of Professionalism in Nursing is a model
of professionalism behaviors (see Figure 1). These be-
haviors previously were identified by sociologists (Flex-
ner, 1972; Freidson, 1983; Hall, 1982; Millerson,
1964), nursing leaders (Aydelotte, 1983; Downs,
1978; Styles, 1982), the American Nurses Association
(ANA) policy statement (1980), standards of practice,
Figure 1. Wheel of Professionalism in Nursing. Copyright ©1984 Barbara Kemp Miller.
ADAMS AND MILLER
and the ANA Code for Nurses (1985). An instrument
was designed to test the Wheel model.
The original tool, the Professionalism in Nursing
Behaviors’ Inventory, was constructed, revised, and
used for various studies (Miller, Adams, & Beck,
1993); then adapted for Nurse Practitioners in 1998 by
the authors. Forty-eight items comprise the instru-
ment, 10 of which question demographics and opin-
ions of professionalism in nursing questionnaires. The
nine categories of behaviors representing professional-
ism are determined by 38 items. The categories include
educational preparation, autonomy, theory, and ad-
herence to the ANA Code of Ethics, as well as partici-
PROFESSIONALISM IN NURSING BEHAVIORS 205

pation in publication, research, professional organiza- TABLE 1. Demographic Characteristics of

tions, and community service, as well as maintaining Nurse Practitioners
competency. Total N ⫽ 502 %
In previous studies using the tool, Cronbach’s alpha
Sex
has ranged from .64 to .87 (Adams, Miller, & Beck, Women 441 87.8
1996; Miller et al., 1993) and was .74 for the current Men 29 5.8
research. Nurses employed in educational and practice Not responding 32 6.4
Age
areas established the content validity. A total compos- 20–25 3 0.6
ite score of 27 is possible because behaviors are 26–30 18 3.6
weighted within each of the nine categories to equal 3. 31–40 112 22.3
41–50 256 51
51⫹ 112 22.3
DATA ANALYSIS Not responding 1 0.2
Years as RN
Statistical tests in SPSS were used to analyze the 0–5 31 6.2
data. Means were used to identify the scores in the 6–10 49 9.8
11–15 88 17.5
weighted scale for the nine categories, and a composite 16–20 114 22.7
score was derived from the totals in each. 21–25 114 22.7
26⫹ 105 20.9
Not responding 1 0.2
Findings Years as NP
0–5 340 67.7
DEMOGRAPHIC CHARACTERISTICS 6–10 46 9.2
11–15 41 8.2
The sample was composed of 441 (88 per cent) 16–20 42 8.4
women and 29 (6 per cent) men with 32 (6 per cent) 21–25 27 5.4
participants not identifying their sex. Demographic 26⫹ 5 1.0
Not responding 1 0.1
data are presented in Table 1. The demographics of the Place of employment
sample were fairly comparable to those available na- Physician’s office/clinic 229 45.6
tionally for nurse practitioners (U.S. Department of Hospital 65 12.9
Free-standing facility 51 10.2
Health and Human Services, 1996). Male respondents School of nursing 23 4.6
in the study were slightly higher (5.8 per cent) than is Occupational health/industry 9 1.8
represented in the national NP population (4.3 per Self-employed 8 1.6
Nursing home 7 1.4
cent). Overall, 71 per cent of NPs nationally are 40
More than 1 area 24 5.0
years of age or older, whereas 73 per cent of the NPs in Other 83 16.5
this study were in that age group. A limitation of the Not responding 3 0.4
study is that educational backgrounds may differ from
the participants in this study who chose to attend the
convention and NPs who did not attend. Results of the study are explained in relation to each
With the recent emphasis toward educating increas- of the Wheel’s 9 categories. The categories are then
ing numbers of nurse practitioners, it was not surpris- compared with existing standards, roles, and educa-
ing to find that 68 per cent of these individuals had tional needs for nurse practitioners.
been nurse practitioners for 5 years or less. Nationally,
74 per cent of NPs are employed outside hospitals and Education in a University Setting and Scientific
58 per cent list direct patient care as their dominant Background in Nursing
function (U.S. Department of Health and Human Ser- The basic domains and standards of the nurse prac-
vices, 1996). Half of the respondents specialized in titioner have been identified by the ANA guidelines
family or community health clinical practice areas, for advanced practice (ANA, 1980) and by the Na-
whereas the smallest area represented was psychiatric/ tional Organization of Nurse Practitioner Faculties
mental health (n ⫽ 6). The nurse practitioners were (NONPF, 1990). These criteria are congruent with
primarily employed in physician’s offices or clinics (46 the areas depicted in Miller’s model, the Wheel of Pro-
per cent); hospitals and freestanding clinics repre- fessionalism (Lindeke, Canedy, & Kay, 1997; Miller,
sented the next most popular places of employment. 1988). Where the model depicts a university education
Eighty-three marked other without identifying their and an accompanying scientific background as the cen-
place of employment. ter or hub of the Wheel holding all of the eight spokes
206
together, NONPF states nurse practitioner curricular
needs to be grounded in graduate level preparation,
which includes research and theory. The Academy’s
Scope of Practice for Nurse Practitioners (1998) spec-
ifies that a master’s degree is the requisite entry-level
preparation for a NP. Thus, advanced education in a
university setting with its inherent scientific focus is
generally agreed on as necessary for nurse practitioners
to function effectively.
The majority of respondents (78 per cent) had re-
ceived their master’s degrees from schools with nurse
practitioner curricula. Another 18 possessed other
types of master’s degrees. Doctorates were held by 38
(8 per cent). Nationally, two thirds of NPs have grad-
uate degrees (U.S. Department of Health and Human
Services, 1996). The remainder of the sample reported
other types of educational preparation. As a group, the
subjects had possessed their highest degree for less than
5 years. However, 67 per cent (68 per cent, nationally)
had received their basic RN degree more than 15 years
earlier.
Research and Theory Development, Use,
and Evaluation
Two spokes of the Wheel represent research and
theory issues. NONPF constructed the guidelines for
nurse practitioner curricula based on the National
League for Nursing’s criteria for including theory and
the application of theory to practice in practitioner
programs (National League for Nursing, 1989). NPs
possessing abilities to identify questions in nursing
practice as researchable topics is one of the NLN crite-
ria as well. The Academy’s Scope of Practice document
includes conducting and participating in research as
part of a nurse practitioner’s accountability for the out-
comes of care that is rendered (American Academy of
Nurse Practitioners, 1998). Graduates of nurse practi-
tioner programs should be able to evaluate and use
theory and research as well (American Association of
Colleges of Nursing, 1996).
The close proximity of nurse practitioners to client
and organizational problems places them in a position
to test theories and identify problems in practice that
need to be studied. For many years, however, there was
a dearth of research conducted by NPs. The time and
energy needed to establish the NP role meant less time
to devote to research efforts, especially in the clinical
areas. Thus, researchers in other disciplines conducted
studies involving NPs that often did not adequately
represent the nursing profession’s research require-
ments or client problems (Shamansky, 1985). Fortu-
ADAMS AND MILLER
nately, NPs are continuously increasing their research
efforts on clinical problems in the primary care arena
(Bullough, 1995), and this current study supports the
interest of NPs in research.
Findings indicated that 136 (27 per cent) of the
respondents were currently involved in a research
project, with 65 functioning as principal investigators.
The majority of subjects had acquired additional re-
search knowledge by taking a research course or attend-
ing a research seminar during the past 2 years. Fifty-
two per cent of the nurse practitioner participants had
written a proposal or participated in a research project
within that time period. The majority of respondents
expressed a familiarity with numerous nursing and ed-
ucational theories as well as nurse practitioner models,
and indicated they applied them in their practices.
Most respondents (84 per cent) used the nursing pro-
cess to guide the care of clients.
Self-Regulation and Autonomy
The knowledge derived from advanced education
provides a foundation for professionals to acquire
authority to make decisions in their area of expertise
(Freidson, 1970). The profession of nursing has cre-
ated and endorsed a licensing method for nurses who
meet requirements for curricular and clinical activities.
Possessing a registered nurse (RN) license signifies a
nurse has successfully completed a standardized na-
tional examination and can therefore render safe nurs-
ing care to the public. The certified NP has taken an
additional credentialing test, which shows the knowl-
edge gained during advanced education and clinical
practice. The extra certification contributes to the
power of nurse practitioners to self-regulate and to
practice autonomously. It is now accepted in health
care that nurse practitioners are autonomous and can
function as direct providers of care in many settings
(American Academy of Nurse Practitioners, 1996;
1997; American Association of Colleges of Nursing,
1996; National Organization of Nurse Practitioner
Faculties, 1990).
NP credentials, received from national nursing or-
ganizations, were held by 427 (85 per cent). One hun-
dred and thirty-nine participants were credentialed by
more than one entity. In the study, the majority of
respondents were making clinical decisions autono-
mously, accountable for direct client outcomes, collab-
orating with physicians, and independently determin-
ing what their positions involved. In fact, almost half of
the nurse practitioners had written their own job de-
scriptions.
PROFESSIONALISM IN NURSING BEHAVIORS
TABLE 2. Autonomous Activities of Nurse
Practitioners Other Than Direct
Patient Care
Activity Total N ⫽ 502 % bers in other nursing organizations, including Sigma
Self-evaluation 373 74
Quality assurance 326 65
Nursing audits/patient audits 283 56
Peer review 226 45
Consultation 165 33
Budgeting 149 30
Performance evaluations 110 22
Hiring personnel 87 17
Ethics committee 59 12
Other autonomous activities of the NPs included
peer review, nursing care/client audits, quality assur-
ance activities, agency budgets, and individual or
group consultations. Participation in formal ethical de-
liberations concerning practice was the weakest com-
ponent in this area. Only 346 subjects answered the
question about participation on an ethics committee,
and, of those, 59 responded yes. Nevertheless, many of
these nurse practitioners were participating in the des-
ignated autonomous activities that are believed to help
professionals regulate and guide their practices. Nearly
74 per cent of the NPs regularly engaged in self-evalu-
ation of the way they practiced (see Table 2).
Participation in Professional Organizations
Professional organizations provide a sense of com-
munity among nurses as well as furnish resources and
guidance for practice. They promote collegiality,
which not only fosters trust and respect with each
other, but advances the interests of professional nurs-
ing as an entity. The American Nurses Association is
the primary referent professional organization for
nurses and is recognized by the government, health
care agencies, and society as the official representative
of registered nurses. ANA defines the scope of practice
for registered nurses, formulates and disseminates gen-
eral standards, and promotes a code of ethics as the
foundation for any nursing practice. In addition to
protecting consumer interests, the ANA and specialty
organizations, such as the American Academy of Nurse
Practitioners, lobby for autonomy for nurses in rela-
tion to the appropriate use of their skills and knowl-
edge. Membership in these groups allows nurses a fo-
rum where they can use the skills gained in NP
education to advocate for clients as well as for the nurs-
ing profession and to serve as change agents within the
health care arena.
In the current study, more than one half of the NP
207
respondents were members of the ANA, and 93 per
cent belonged to the Academy, which sponsored the
conference. The majority of respondents were mem-
Theta Tau International and others. This group of
nurses evidenced a high rate of belonging to nursing
organizations, and more than one-third held an office
or participated on committees in organizations (see
Table 3).
Competence and Continuing Education
A commitment to life-long learning and self-devel-
opment is an expectation for members of any profes-
sion (Flexner, 1972; Hall, 1982). Participating in con-
tinuing education activities aids nurse practitioners in
their credentialing and certification efforts as well as
keeping them informed of new developments that have
an impact on their practices. Thus, the Academy and
other professional organizations encourage, support,
and provide forums for continuing education. In addi-
tion, achieving and maintaining certification motivates
NPs to continue to develop professionally. Behaviors
measured in this category included attending work-
shops relevant to the practice area of the NP, reading or
subscribing to professional journals, or purchasing
books associated with their practices. Educational ses-
sions attended by participants within the past 2 years
included content related to clinical issues, promotion
of leadership and management, analyses of health pol-
icies, and studying components of the NP role.
During the previous 2-year period addressed by the
professionalism questionnaire, nearly all (98 per cent)
of the respondents reported attending seminars or
workshops. The NPs (97 per cent) also subscribed to
and read nursing and related journals. More than 90
per cent had purchased a book concerning nursing or
the practice of the NP. Administrative and supervisory
activities were part of some of the subject’s practices,
38 per cent attended seminars concerning manage-
ment, and 134 had purchased a book on management
in the prior 2-year period.
TABLE 3. Participation in Professional
Organizations
Organizational Membership Total N ⫽ 502 %
ANA 258 51
AANP* 466 93
Sigma Theta Tau 317 63
Others 264 53
Hold office or committee service 169 34
*American Academy of Nurse Practitioners.
208
Community Service
One of the original and continuing aspects of pro-
fessionalism is the altruistic factor of providing exper-
tise without thought of remuneration. Throughout the
decades, and especially in the nursing community,
nurses as employees in health care agencies were
“trained” to abstain from discussing wages and salaries
because nurses were to be solely committed to caring
for others (Melosh, 1982). This attitude constituted nurs-
ing altruism, which was based on the fact that nurses were
educated in hospitals. However, when nursing education
moved away from agencies and into higher education,
altruism was not defined in the same manner. A profes-
sional does have an obligation to serve the public, but
primarily as a volunteer in nonprofit situations.
In previous studies that used the Professionalism in
Nursing Behavior Inventory, the majority of nurse re-
spondents reported an interest and participation in
community service (Miller, Adams, & Beck, 1993). In
the current study, service was also a priority with 430
(88 per cent) reporting involvement in community ac-
tivities. One third of the respondents functioned as
leaders in their communities by serving on advisory
boards and committees of various organizations.
Publication and Communication
Sharing knowledge with colleagues is a behavior in-
cluded in the Wheel of Professionalism. Communica-
tion and dissemination of nursing practice issues and
interventions is a method of showing collegiality, col-
laboration, and support for all nurses. Whether the
communication is through professional organizations
or publications, this behavior is essential to profession-
alism in nursing. Most nurses do not learn the publi-
cation process until pursuing a graduate degree, so the
skills needed to publish are an outcome of advanced
education. In addition, the mentoring of every RN’s
publication efforts by skilled nursing authors and val-
uing such activities would enhance nursing practice by
increasing communication among nurses.
For many years, NP’s publishing efforts in relation
to clinical research went largely unrecognized because
they were subsumed under doctors’ names on articles.
Now, NPs write about many topics, including client
problems, and are frequently first-listed authors (Bul-
lough, 1995). Respondents in this study were asked if
they had published or submitted manuscripts to nurs-
ing or other professional journals. Nearly 100 (20 per
cent) had submitted manuscripts for publication in
nursing journals, and 63 had been published in peri-
odicals other than nursing. Although this was not a
ADAMS AND MILLER
major activity for these respondents, the findings were
congruent with other studies that used the same pro-
fessionalism tool and involving nurse managers, staff
nurses, and other types of nurses. Shamansky (1985)
determined that 73 per cent of a NP’s time is spent
caring for clients, thus, a lack of time needed to write
articles and papers may hinder nurse practitioners’ ef-
forts in this area.
Adherence to the ANA Code of Ethics
The Code for Nurses with Interpretive Statements
(ANA, 1985) includes behaviors that protect consum-
ers and enhance the well being of those individuals as
nursing care is delivered. The Code is a vehicle for peer
and self-evaluation of the quality of care rendered to
consumers by RNs. In addition to evaluation, the
Code guides and assists RNs in all phases of nursing
practice. It forms the ethical framework for any nurs-
ing practice and is the body of work on which stan-
dards for practice are based. Unfortunately, not all
nurses are aware the Code exists, whereas others believe
agency and various forms of regulatory bodies are more
essential than the profession’s generally accepted ethi-
cal code (Beck, Miller, & Adams, 1993). A profession
possessing a code of ethics with well-articulated behav-
iors that are enforced legally by standards is considered
to have an advanced professionalization process (Bern-
hard & Walsh, 1990). Therefore, students in all types
of nursing programs need to become knowledgeable
about the ANA Code for Nurses.
Respondents were asked if they used the ANA
Code or some other specific ethical framework for
their practices. Almost half (48 per cent) of the sub-
jects indicated a positive response. The fact that 52
per cent did not use an ethical framework indicates
more attention needs to be paid to ethics in nurse
practitioner curricula.
Total Score
A composite score of 27 is possible on the Profes-
sionalism in Nursing Behaviors’ Inventory. The mean
composite score achieved by 279 nurse managers in a
similar study using the inventory was 13.4 (Adams et
al., 1996). A group of nurses in various practice settings
obtained a score of 10.13, on average. In other research
using the inventory, 161 nurse executives scored 14.90
(Stoltz, 1991). The range for the NPs in this study was
6.5 to the highest, 27. Their mean composite score was
16.7, making their levels of professionalism the highest
of any group tested with the Professionalism in Nurs-
ing Inventory thus far, except for a group of nurse
PROFESSIONALISM IN NURSING BEHAVIORS 209

educators who averaged 18.7 (Miller et al., 1993). For
the nurse practitioners, highest category scores were
obtained in competence, education, and the use of the-
ories. The lowest category scores were publication and
research (see Table 4).
Discussion
This study serves to identify aspects of nursing pro-
fessionalism in nurse practitioners. Though the Profes-
sionalism in Nursing Behaviors’ Inventory can be used
to determine levels of behaviors indicative of profes-
sionalism in groups of nurses as it was in this research,
it is to be primarily used at regular intervals by individ-
ual nurses to help them aim their careers toward the
most productive paths. The specific behaviors of pro-
fessionalism, delineated in the Wheel, can help NPs
evaluate their career goals by identifying personal
strengths and weaknesses.
The use of ethics becomes increasingly important as
the number of patient dilemmas increases during the
NP’s career. In addition, NPs frequently practice alone
and most monitor their own work, thereby needing
some consistent framework on which to base their eval-
uations. Results from this study indicate a need for
emphasizing ethical frameworks in NP curricula and
teaching students how to use the frameworks in the
clinical courses.
NPs and other nurses, who need continuing educa-
tion to meet certain certification and regulatory crite-
ria, tend to achieve higher levels of professionalism.
Because they render primary care autonomously and
aim to deliver quality care to clients, required and con-
tinuous certification and credentialing of NPs appears
to be influencing client outcomes by NPs’ exposure to
new ideas and methods of practice.
TABLE 4. Professional in Nursing Behaviors’
Inventory Scores for NPs
Total N ⫽ 502
Professionalism Inventory
Subscales Range Mean*
A major finding of this research is the need to pro-
duce new nurse practitioners because more than half of
the individuals were 41 years of age or older. Another
need is for NPs to share information more with col-
leagues. As younger nurses become NPs, their levels of
publication and research may increase because of the
longer period they will have to be socialized into their
roles. Certainly, teaching NPs how to conduct re-
search, write articles, and present at conferences needs
to be increasingly emphasized in NP programs to dis-
seminate information about practice. NP educators
must take more prominent roles as mentors of NP
students and those newly graduated. Knowing that
support and assistance was readily available from on-
going mentoring could increase productivity with
NPs’ research and publication efforts. In addition,
some leadership and management content needs to be
included in programs because these NPs indicated they
were starting to incorporate those elements into their
roles, especially in independent facilities.
It was apparent in the study that the NPs delivered
care relatively autonomously. At the present time, the
autonomy scores on the Professionalism Inventory in-
dicate that NPs generally do not hire, evaluate, and
dismiss employees, but instead concentrate on care de-
livery. This behavior may change for some NPs in the
future as they establish and administer their own clin-
ics. One result that is relatively new for nursing is the
fact that many NPs decide what they will do in practice
by writing their own job descriptions. Up until now,
the only nurses who wrote their own job descriptions
consistently were nurse executives.
Like other nurses who completed the Professionalism
Inventory, the NPs were active in community service.
These activities contribute to the well being of members
of society. They show the public that NPs, and nurses in
general, are knowledgeable and can become leaders in
guiding and determining health policy. Community ser-
vice helps NPs gain the trust of other health professionals
as well. Maintaining a high level of professionalism can
promote this trust in NPs, nurses, and nursing in general.
SD

Educational preparation .5–3.00 2.75 .64 Note

Publication .0–3.00 0.37 .75
Research .0–3.00 0.98 .96 For information about the Professionalism in Nurs-
Professional organizations .0–3.00 1.98 .75 ing Behaviors’ Inventory, contact Donna Adams, RN,
Community service 0.–3.00 2.36 .92
Competence 1.0–3.00 2.79 .39 DNSc, College of Nursing, Arizona State University,
Code of ethics 0.–3.00 1.51 1.50 Tempe, AZ, 85287-2602.
Theory 0.–3.00 2.68 .68
Autonomy 0.–3.00 1.40 .76
Total scale score† 6.5–27.00 16.70 3.60 Acknowledgment
*Possible range 0 –3. The authors thank Lori Weaver, MS, Research Assistant, for her
†Possible range 2–27. statistical support.
210
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