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Care as a promoting agent in the construction of professional identity in nursing students
Cuidado como agente promotor en la construcción de la identidad profesional en estudiantes de enfermería
https://doi.org/10.47606/ACVEN/MV0303
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Teresa de Jesús Vivas-Durand1* Gladys
Carmela Santos-Falcón1 tvivasd@unmsm.edu.pe gsantosf@unmsm.edu.pe
Juana Matilde Cuba-Sancho1
Recibido: 18/09/2025 Aceptado: 12/11/2025
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ABSTRACT
Introduction: Professional identity in nursing has been defined throughout history, rooted in its essence: care. However, this concept remains abstract in academic training, disconnected from students' identity construction. Objective: To reveal how care is conceived from the experiences of nursing students. Methodology: Qualitative design using Straussian Grounded Theory at a public university in Peru. Fourteen intern students participated. In-depth interviews and focus groups were used. Systematicinterpretive analysis: open coding (25 codes), axial coding (5 subcategories), and selective coding (1 integrative category). Rigor ensured through multiple triangulations. Results: Five subcategories emerged: Care as a central phenomenon integrating all dimensions of identity formation in Nursing; Progressive cognitive construction of care (technical, humanized, holistic, ethical); Recognition of complexity that strengthens professional identity; Emotional burden that validates professional choice; Formation of identity through concrete experience of care. These converge into one integrative category: care as an existential organizer of professional identity in nursing. Conclusions: Care functions as a cognitive, ethical, emotional, and professional purpose axis. Curriculum design should position care as a central transversal element. Teachers and mentors are crucial in facilitating this identity formation through modeling and reflective accompaniment.
Keywords: Professional identity in Nursing, nursing care, university education, Grounded Theory, nursing students.
1. Universidad Nacional Mayor de San Marcos- Perú
Autor de correspondencia: tvivasd@unmsm.edu.pe
RESUMEN
Introducción: La identidad profesional en enfermería se ha definido a través de la historia, desde su esencia, que es el cuidado. Sin embargo, este concepto permanece abstracto en la formación académica, desconectado de la construcción de la identidad de los estudiantes. Objetivo: Revelar cómo es concebido el cuidado desde las experiencias de los estudiantes de enfermería. Metodología: Diseño cualitativo con Teoría Fundamentada Straussiana en universidad pública de Perú. Participaron 14 estudiantes de internado. Se utilizaron entrevistas en profundidad y grupos focales. Análisis interpretativo-sistemático: codificación abierta (25 códigos), axial (5 subcategorías) y selectiva (1 categoría integrativa). Rigor garantizado mediante triangulación múltiple. Resultados: Emergieron 5 subcategorías: El cuidado como fenómeno central que integra todas las dimensiones de la formación de la identidad en Enfermería; Construcción cognitiva progresiva del cuidado (técnico, humanizado, holístico, ético); Reconocimiento de complejidad que fortalece identidad profesional; Carga emocional que valida la elección profesional; (5) Formación de la identidad mediante vivencia concreta del cuidado. Estas convergen en una categoría integrativa: el cuidado como organizador existencial de la identidad profesional en enfermería. Conclusiones: El cuidado funciona como eje cognitivo, ético, emocional y de propósito profesional. El diseño curricular debe posicionar el cuidado como elemento central transversal. Docentes y mentores son cruciales en facilitar esta formación en la identidad mediante modelado y acompañamiento reflexivo.
Palabras clave: Identidad profesional en Enfermería, cuidado de Enfermería, formación universitaria, Teoría Fundamentada, estudiantes de Enfermería.
INTRODUCTION
Professional identity in nursing is represented by a complex construction process, which typically transcends the boundaries of technical competencies or disciplinary knowledge, to constitute itself as a profound transformation of being and existing in the profession. Over the past decades, various researchers have documented that nursing students experience significant transformations in their conceptions about the profession during their academic training.
This change evolves, from its beginning in the career to more advanced semesters, where more integral and reflective understandings of what it means to be a nurse are consolidated (1,3). However, references published in various sources have primarily emphasized aspects related to professional socialization, development of clinical competencies, or teaching influence, without systematically examining what element articulates and organizes all these dimensions within a coherent framework of professional identity specific to the nursing discipline.
Nursing as a discipline has historically defined its essence through the concept of care. Marie Françoise Colliére (4) resisted defining what care is. From her vision, care and the way one cares help increase or reduce the power to discover the world, to understand it and focus on it. This aligns with the ideas put forward by Jean Watson, who described care as a way of inhabiting the world (5); as well as with Leininger, to whose legacy the transcultural perspective of care in nursing is owed (6).
This phenomenon constitutes its object of study and professional reason for being (7,8). However, for students in training, care frequently remains an abstract concept taught in classrooms, without explicitly connecting to the construction of their emerging professional identity. This disconnection between the theorization of care and students' lived experience represents an important gap in understanding how professional identity in nursing is formed.
This study presents, concretely, one of the findings that emerged from a broader research project, which generated subsequent questions: What is the specific role that care plays in the formation of nursing students' identity? What are the conceptions about care that facilitate transformation in the nursing student? The examination of these questions is fundamental in the Peruvian context, where nursing education is constantly faced with challenges related to the limited social recognition of the profession, overcrowding in clinical settings, and the need to strengthen professional identity among new nurses who will join the health system (9).
International literature shows that previous research has examined professional identity in nursing from various theoretical perspectives. Some studies were based on socialization mechanisms through which students incorporate professional values and knowledge (10); others have analyzed the influence of contextual and structural factors in identity formation (11); and several have documented the importance of professional role models and interpersonal interactions (12). However, most of these studies have not explicitly identified care as an agent promoting identity integration in the nursing student. This factor causes all these dimensions to unite in a coherent theory about how identity is formed in nursing in a specific and differentiated manner with respect to other health disciplines. These reasons led us to propose as an objective to reveal how care is conceived from the experiences of nursing students.
METHODOLOGY
The present research utilized a qualitative design grounded in Straussian Grounded Theory, an approach that allowed for the inductive emergence of substantive theory from systematic analysis of empirical data. This methodological strategy proved particularly appropriate for studying and understanding the phenomenon, as it allowed for the unveiling of central conceptual categories emerging from the analysis of lived experiences by participants (13, 14).
The study was conducted in a professional nursing school, faculty of medicine, at a public higher education institution in Peru. Fourteen nursing students in their internship stage were selected through purposive convenience sampling, of which seventy-five percent were women and twenty-five percent men, reflecting typical demographic distributions of the profession. All participants completed preprofessional practice in health institutions of the Ministry of Health, Social Health Insurance, and first-level care centers. Theoretical saturation was achieved when new interviews did not provide further significant variations in the emerging categories.
Data collection was conducted through individual in-depth interviews and focus group sessions, both techniques guided by semi-structured question guides, which allowed for deep exploration of lived experiences while maintaining flexibility for unanticipated thematic emergences.
Data analysis followed the systematic procedure of Straussian Grounded Theory, beginning with open coding of transcriptions. From this emerged twenty-five preliminary codes organized by emerging thematic dimensions. Subsequently, axial coding reorganized these codes through application of the paradigm of causal conditions, context, central phenomenon, intervening conditions, strategies of action and interaction, and consequences, from which five subcategories emerged. Finally, in selective coding a core category was identified. These helped understand how the formation of professional identity is promoted by care, which functions as its central organizer.
Methodological rigor was ensured through the implementation of various triangulation and validation strategies. Source triangulation was achieved by including students at different moments of their internship and in varied practice contexts. Methodological triangulation combined individual interviews, focus groups, and informal observations recorded in field memos. Investigator triangulation was conducted through doctoral supervision and validation sessions with academic peers. Member validation was implemented by presenting preliminary results to a subgroup of participants to confirm the interpretive accuracy of the findings.
RESULTS
Care as a central phenomenon
Systematic analysis of students' narratives revealed an unexpected central finding that transformed the understanding of how professional identity is formed in nursing. Care transcends its conceptualization as a technical competency or pedagogical dimension to constitute itself as the central and differentiating element that gives coherence and meaning to the entire experience of identity in the student. While care initially appeared as one code among multiple emerging codes during open coding, axial and selective analysis progressively revealed that care functioned as a promoting agent that allowed for the integration and meaning-making of all other identified dimensions (see figure 1). A student expressed this centrality in a particularly eloquent manner when reflecting that the definition of professional identity in nursing lies in reaching the point at which a series of characteristics specific to the career are constructed, adopting them until considering oneself a legitimate part of the professional group. This reflection implicitly captured that care is what defines “what is adopted” and “what characteristics define” being a nurse (see figure 1).
Another participant explicitly articulated the differentiating character of care by noting that, in relation to care, it basically constitutes what defines nursing professionals, differentiating itself from the medical role where one cures, whereas in nursing one cares. This distinction, apparently simple in its formulation, contained profound significance, as it recognized care as an element that confers disciplinary specificity to nursing within the health system, fundamentally differentiating it from other health professions, particularly medicine. Care gives meaning and purpose to the professional existence of those who choose this career.
Figure 1.
Care as a central phenomenon
The Process of cognitive construction of care At this point, students experience a progressive transformation in their conceptual understanding of care during their training. Initially, many students perceive care in a fragmented manner, with disproportionate emphasis on technical or procedural dimensions. However, through the interaction between theoretical training and practical experiences, care is gradually reconceptualized toward an integral conceptualization that articulates different types and dimensions.
Students identified four primary forms of care that coexist and integrate: technical care, derived from the mastery of manual skills and procedures that require precision and scientific knowledge; humanized care, which emerges from the establishment of empathetic relationships with patient care, where recognition of the other as a person with dignity and particularity is central; holistic care, which involves integrally considering a person's health situation by considering biological, psychological, social, spiritual, and cultural dimensions; and ethical care, grounded in moral principles that govern professional practice such as autonomy, beneficence, non-maleficence, and justice (see figure 2).
Figure 2.
Cognitive construction of care
Although each of these forms of care possesses specific differentiable properties, students did not perceive them as separate categories but as dimensions that intertwine in practice. A student described how after each clinical rotation they always rescued something significant from the experience, reflecting on what they would change in their future approaches, based on what they had learned. This reflection captured the progressive integration in thinking about care in its multiple dimensions and the action of the future professional; while another participant articulated, with particular clarity, the possibility that care provided to integrate the scientific and human (see figure 2).
Progressive recognition of the complexity of care
The advancement of academic training, especially during the internship period, led students to experience a growing recognition of the difficulty inherent in the practice of integral care. This complexity did not discourage students; rather, paradoxically, it strengthened their professional identity. What was ultimately the driving force that accelerated their need to increase their capacities to respond to the demands that arise from care (see figure 3).
Figure 3.
Complexity of Care
Students narrated the challenge in clinical contexts where they had to simultaneously manage care and attention to different patients with diverse needs, a fact that generated tension between the ideal of integral care they had learned and the limitations of resources and time that characterized the reality of the health system. One of the nursing students expressed this tension when reflecting on how, while caring for various patients, she found herself attending to up to thirty patients at once. The overload in care compromised the quality of the care they yearned to provide.
However, rather than renouncing the ideal of integral care, students developed strategies to optimize care within contextual restrictions.Nevertheless, the greatest confrontations students faced were regarding ethical behavior in the practice of care. A student narrated their continuous reflection about moral dilemmas that presented themselves when caring for people who had committed serious crimes, requiring them to integrate ethical principles with personal values in order to respond assertively to care. These dilemmas ultimately represented opportunities for deepening that re-signified care along with its most complex ethical dimensions.
The emotional burden generated by care
Care is perceived by students as a concept with a profound emotional charge that connects with vocational motivations and sense of professional purpose. Experiences where students provided integral care produced a high impact on them. Because of this, intense positive emotions were generated, which significantly reinforced their professional identity (see figure 4).
Figure 4.
The emotional burden in care
A student described what she felt when she was sought out by a person she had previously cared for, who did so to express her sincere gratitude because her illness was controlled and she recognized her in every encounter. This act of gratitude transformed her understanding about the value and transcendence of her work. This existential experience validated, in her, care as a real differentiating factor in people's lives. Similar findings emerged in the narratives where other students expressed positive surprise at the care qualities they had observed in experienced nurses. The experiences described recounted the actions of the nurses, but emphasizing how the dedication and love invested in caring for each patient could be seen. These encounters with living examples of integral care produced emotions that helped deepen the consolidation of their emerging identity.
The formation of identity through the experience of care
The process of formation of professional identity is experienced, principally, through the experience of providing care. It does not occur through abstract incorporation of knowledge or isolated development of skills but is recreated in the moments where the student concretely perceives the meaning of caring in an integral manner (see figure 5).
Figure 5.
Experience offers care
Students described transformations in their self-perception as future professionals when exercising in their practice the action of care, which had repercussions with their values and ideals. Even, this interaction with care, by leading them to conscious reflection, contributed to redefining who they were professionally. An example of this was the expression of a student when pointing out that most of his professional identity had been constructed based on each reflection, he made from the care he gave to patients, because there he was able to realize the mistakes and successes he had made.
Disciplinary determination through care
Care functions as an element that allows students to experience the disciplinary specificity of nursing. While in the early stages of the career many students maintained generic perceptions about "working in health" without clear differentiation between professions, the progressive recognition of care as a central element allowed them to understand what nursing specifically was (see figure 6).
Figure 6.
Care, promoting organizing agent of identity in Nursing
This differentiation had components from both theory and practice that had been consolidated to form their identity. Students articulated a sense of "this is ours," referring to care as that which distinguished them in their profession from medicine, dentistry, and other health disciplines. Care emerges as the articulating axis that defines their belonging to a specific professional collective with shared history, values, purpose, and responsibilities.
DISCUSIÓN
Beyond the findings already documented about the central role of care in professional identity, this discussion delves into more subtle dynamics that emerged from the analysis, the unresolved tensions between the ideal and the real, the silent mechanisms through which reflexivity becomes a motor of transformation, and how professional identity is configured not only by what students accept, but by what they constantly resist and negotiate.
An aspect that merits deepening is how students do not “resolve” the contradictions between idealized integral care and the reality of saturated systems, but rather learn to inhabit them. When they spoke of the overload in care delivery, they were articulating a discovery about what it means to “be responsible” in contexts of limited resources.
According to Duchscher (15), the “transition shock” experienced by newly graduated nurses represents a critical period where the gap between academic idealism and professional reality generates identity crisis. However, the findings of the present study suggest that this gap can function as a space that forges identity. Students who were still in training were already developing sophisticated capacities for tolerance of ambiguity, which become a distinctive characteristic of their emerging professionalism.
To Franco-Agudelo (16), modern nursing has been conceptualized as a discipline of care precisely because in that practice scientific, technical, and humanistic dimensions are synthesized. What the data from the present study reveals is that this synthesis occurs in the permanent encounter with real limits that require constant negotiation. Professional identity is constructed, then, not despite the contradictions, but through the sophisticated integration of them as a constitutive datum of practice.
Although it was documented that students reflected on their practices, a less visible aspect is how that reflection does not occur in formal spaces but in micromoments of perception during the action itself. Satti and Ali (17) had explained the multidimensionality in the evolution of professional identity in nursing, which involves simultaneous transformations. The data present in this study adds that this multidimensional evolution occurs fundamentally through encounters with practice, where reflexivity operates at preverbal levels that exceed conscious articulation.
In health systems where medicine has historically occupied dominant positions, the affirmation of care as disciplinary specificity contains implicit political dimensions that students frequently navigate without full consciousness (18). It is for this reason that the confirmation derived from the observations made allows adopting an academic definition of care, but at the same time facilitates participation in a claim for disciplinary legitimacy within structures that have denied that specificity.
At this point, what was pointed out by Meseguer-Gancedo (19), in showing that the essence of this formation lies in the teaching role, specifically in the facilitation of the task, gives way to what emerges, students' formative learning is concretized in practice, in that intervention that helped them concrete the characteristic differences present in care.
The emotions that care generates in students function as a form of knowledge that existentially validates the professional choice. According to Velásquez-López (20), professional vocation in nursing is intrinsically linked to the perspective of humanized care, where emotional connection with the other is a constitutive element of practice. The findings of the present study expand this analysis, those emotions function epistemologically to reveal truths about practice and motivate with purpose and desire to contribute to others´ well-being (21), something that no academic text could communicate with the same transformative power.
Colliére (4) resisted defining care, arguing that every static definition impoverishes it. The data from the present study confirm this intuition at an empirical level: when care is taught as academic content, it remains abstract; when it is lived in concrete encounters with patients, it transforms into a central organizer of identity. Nursing education thus faces a dilemma: how to facilitate an approach to something that by nature cannot be completely taught, but that can be profoundly discovered.
CONCLUSION
The findings of this study help us understand the dimensionality encompassed by care in the Nursing career and demonstrate that it functions as a central, promoting, and differentiating element that articulates, organizes, and integrates the formation of professional identity. At the same time, care simultaneously acts as a cognitive axis, ethical framework, emotional motivation, and source of professional purpose.
In terms of implications for nursing education, the findings suggest the need to rethink how curricula are designed. If care is truly the central element of professional identity, then it should be the central and transversal element around which all learning experiences are organized, not one dimension among others.
The results also underscore the responsibility that falls on teachers and mentors to accompany this process of identity formation, as they facilitate change through their modeling role and because they accompany reflective processes, which benefits the understanding of care.
In conclusion, care emerges as the existential organizer of professional identity in nursing. Students who deeply understand and experience this centrality of care in their identity construct lasting meanings about why they chose this profession, what differentiates them from other professionals, and what their responsibility is in transforming healthcare in their communities.
Important limitations of this study include its specific context in a public university in Lima, which requires empirical validation in other contexts before generalizing broadly. Future research could examine other formative contexts, how the identity constructed during years of training evolves in real work contexts, how additional factors such as gender or socioeconomic characteristics influence the construction of identity centered on care, and how specific pedagogical interventions could be designed to strengthen this process.
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