Revisiting The Meaning of A Good Nurse

This study provides basic data for exploring nurses’ self-image as a professional. Specifically, social role and macro level responsibilities were identified with nurses’ internal aspects such as a positive attitude, and nursing philosophy. The necessity of socio-environmental support for nurses was also emphasized. In addition, the results of this study can be used at the policy level to provide a better balance for development of good nursing.


INTRODUCTION
Korea entered an aged society with a population of 14 percent of senior citizens in 2017 and is planning to enter the world's super-aged country by increasing to 32.3 percent by 2050 [1].The health care environment in this rapidly changing Korean society is emphasizing the promotion of preventive and customized healthcare, and improved communication and emotional connection between patients and healthcare prov medical assistance, and public health activities as nursing [7].Therefore, we want to find out what the role of a Korean nurse is at this point.
A nurse is a practitioner who creates a caring relationship by giving patients holistic care [8].The roles of nurses in all healthcare settings such as hospitals and communities have changed considerably.Nurses were involved in nursing care, intervention and evaluation, emotional support, spiritual care, comfort, safety, medication, examination, surgery, emergency, rehabilitation, and delivery [9] and were required to act as a therapeutic role.As the health care environment changes, the role of nurses is becoming more specialized and subdivided, as shown by its importance in various settings such as highly specialized units within the hospital (e.g., bone marrow transplant unit, ambulatory chemotherapy units, various areas of intensive care, etc.) as well as greater roles in the community, schools, the military, and international health.In this way, it is necessary to identify how the meaning of nurses is changing in the health care environment where the role of the nurse is increasing.
Previous studies suggested the meaning of a good nurse according to the perspective of patients subject to care, nursing students, and nurses who provide care.From the patients' perspective in one study, a good nurse meant one who has expertise in caring for patients and is quick to deal with patients' needs.Also, they believed a good nurse cares for the patient with understanding and provides emotional support [10].Nursing students have considered the role to be one of emotionally supporting patients and flexibly providing interventions among other healthcare providers, while working quickly with expertise to restore patient health [11].From the nurses' perspective, a good nurse meant one who provides satisfactory support by performing patient centered care with comprehensive, professional, and autonomous nursing through a therapeutic relationship with patients [12].The word 'good' is subjective so we applied the qualitative research method to understand what nurses think of good nurse.
Qualitative content analysis is a research method that explores phenomena centered on a subject.This is an effective way to describe the meaning and experience of a good nurse.The current study aimed to explore and describe what it means to be a good nurse by applying qualitative content analysis.
The research question was, "What is the meaning of a good nurse?".

MATERIALS AND METHODS
This qualitative study used in-depth interviews to explore and describe the meaning of a good nurse from the perspective of nurses.

Participants and Sampling
Nurses who had at least one year of experience were invited to participate in the study by purposive sampling.The sample comprised 10 nurses working in general hospitals or health-related national organizations in Korea.Participants had from 1 to 14 years of work experience as nurses.They were working as nurse managers, staff nurses, airport clinical nurse, government agency staff, and one was currently a doctoral student (Table 1).
Researchers selectively recruited participants using a personal network.Participants were selected as people who had a good understanding of the subject of the interview and who were able to organize and explain their experiences well.The study's aim was explained and those agreeing to participate voluntarily signed a consent form.The interviewees were well informed about the role of nurses and were evaluated for proficiency in their work and carried out their tasks responsibly and expertly.

Procedure
One-on-one in-depth interviews were conducted in October 2017.Participants participated in 1-2 interviews, each lasting 60-70 minutes.The interviews were held in a quiet place that was comfortable for participants, such as a meeting room or a quiet cafe.
During data collection, participants were given detailed explanations of the research purpose, methods, and the participants' rights and how personal information would be protected, including confidentiality and anonymity.Study participants were informed that even if they agreed to participate in the study on their own, they could stop participating and refuse to continue at any time during the study, and there was no disadvantage in doing so.Consent to audio-taping the interview was also obtained.The researchers informed participants that the interviewer would transcribe the interview recordings and that all data would be kept in a cabinet with double-locking devices for security and would be discarded 3 years after the research was completed, according to regulations.
The interview began with an open question such as, "What does a good nurse mean to you?" followed by questions such as, "What kind of qualities does a good nurse have?","What do you think are the requirements for being a good nurse?","What do you think about the role model of a good nurse?","What do you think is the obstacle to becoming a good nurse?", and "How do you think you are becoming a good nurse?".During the interview, the researchers maintained a listening attitude so that participants could speak freely and naturally.In addition, researchers ask questions using the terms expressed by the participants and encouraged participants to speak voluntarily.Data sampling collection ended when there was no longer a new topic and the data was saturated.
Interviews and analyses of this study were conducted in Korean through several discussions with the research team.The themes and statements drawn up in the course of writing the paper were described in English.The research team conducted more than 10 reviews and discussions to confirm whether the meaning of the Korean language was properly expressed in the process of changing the Korean into English.

Analysis
The data were analyzed through conventional content analysis, as proposed by Hsieh and Shanon [13].This method analyzes the meaning of data inductively to gain understanding and knowledge of a phenomenon without existing theoretical and philosophical background: The researchers read the transcripts repeatedly to grasp the overall meaning.In the data, we chose words, sentences, and paragraphs representing the key ideas or concepts expressed by participants.The codes were grouped into subcategories, and the final categories were classified into a hierarchical structure.Moreover, during categorization, the data were analyzed using the field notes compiled at the interview.The researchers determined concepts and categories not included, by comparing the classified results and repeated the process of modifying them until consensus was reached.The research team discussed the analysis process several times and reached a final conclusion.

Rigor of Research
In this study, the following steps were taken to ensure the rigor of qualitative research based on credibility, transferability, dependability, and conformability, as proposed by Lincoln & Guba [14].

Credibility
To ensure credibility, the researchers began interviews with an open question and conducted the rest of the interview with a neutral and uncritical attitude.Researchers also listened to participants and tried to avoid prejudice.The recorded contents were immediately transcribed on the day of the interview to eliminate any ambiguity.If necessary, additional questions were asked to clarify the details.The results of the analysis were compared with the original statements and frequently checked and discussed with our researchers to further establish credibility.

Transferability
To establish transferability, the researchers selected nurses with practical experience in various health care environments as participants who could give a rich account based on their experience of nursing.One or two interviews were conducted with each participant until saturation was noted.In addition, the results of the study were presented to two experienced nurses who did not participate in the study to confirm the significance of the results in light of their experience.

Dependability
To ensure dependability, the data were analyzed according to content analysis methods proposed by Hsieh and Shannon [13], verified with other researchers, and further verified to confirm the validity of the participants.The research procedures were unified among researchers, who recorded step by step procedures and followed them thoroughly.

Conformability
To ensure conformability, the researchers cited the words of the participants so that the reader can check the analysis results.During the interview, the researchers asked participants to restate any unclear statements and clarified them.

Trustworthiness
This study has developed the task progressed through the class time of qualitative research methodology in a doctoral course at Y university.We thought it was meaningful to share the final results identified during the class.The professor and her colleagues had a discussion and confirmation process to ensure progress in accordance with the ethical principles throughout the course of the study.The researchers also considered the Helsinki Declaration, so as to balance the study's risks and benefits, as should be considered in human studies.Although the researchers were not approved by the institutional review board before the interview began, we explained its purpose and gathered written informed consent.Interviews were recorded with interviewee consent to prevent omission of data, and field notes were taken to note contextual details.We also tried to ensure accuracy and validity of interview contents by clarifying unclear statements and aligning them with the core contents.

RESULTS
From reading the interview transcripts line by line, we compiled categories and themes relating to what it means to be a good nurse.A total of 265 significant statements were derived from the original data.Through repeated reading and exclusion of repetitive statements or those less relevant to the topic, we reduced the 265 statements to 103 over several meetings.We re confirmed the relevance of the original data and generated 35 codes, which we then structured into 6 categories and 16 subcategories to reflect a more abstract and inclusive meaning (Table 2).

Having Warm Emotions and Love for the Patient
This is related to the frame of mind and behavior of the nurse when responding to a patient.Participants considered the nurse as a caregiver full of warmth and sensitivity, aiming to promote patient well being.To this end, nurses made an effort to respect the patient as an individual and to have a sense of altruism.
The role of a nurse is irreplaceable.Whether there is rain or wind, the nurse is always at the patient's side, and once it starts to snow, the nurse does not move and is always there.A nurse is like springtime with the hope of new life and I do think that's a good nurse: One who is like a tree, giving shade to people in a tough spot.(P1)

Establishing Good Rapport with the Patient
A nurse caring for a patient for 24 hours hears a variety of stories, including the patient's personal and family problems.Participants tried not to ignore patients, but to listen as much as possible and to sympathize.In addition, they focused on inconvenience by talking to patients first.This communication process allowed the patient to establish a trusting relationship in which he/she could trust and rely on the nurse.
I give them the message that I care about them.When I ask, "Is your family not coming today?""How are you today?I heard that you had a hard time last night.Are you okay?" they keep talking about their difficulties.(P4)

Advocating for the Patient
Participants reflected on the role of representing those who could not speak their mind while carefully checking patients' pain.To this end, they emphasized that they should endeavor to eliminate prejudice against patients' conditions and to be fair and objective.

Providing Information to the Patient
Patients have anxiety because they do not know the details of their diseases and treatment processes.Participants deemed it important to answer these patients' questions accurately and provide them with sufficient explanations and information.
If the patient's medication changes, the nurse will explain what the side effects of the drug are and what the precautions are.When a new treatment is initiated, the nurse will explain what treatment plan has been set, how meals will be taken, and what the planned procedure is.I think it is important to take care of patients and be someone who can 'scratch where they are itching'.(P6)

Providing Evidence-Based Care
It is important to know the patient's condition well and to provide the necessary, relevant nursing care.Having sufficient knowledge of the patient's condition facilitates efficient nursing care based on scientific evidence.To this end, participants emphasized the role of a nurse who practices continuous self-development, such as enrolling in graduate school to improve expertise in one's field.
I think nurses should know why they should perform nursing activities when they do nursing.Patients do not like putting something in their bodies and feeling uncomfortable, even for therapeutic purposes.When the nurse gives a clear explanation at the time, patients will cooperate, even if it is difficult.(P7)

Providing Prompt, Skillful, and Accurate Care
Nurses should quickly assess situations, then carry out various tasks, and handle emergency situations.Participants regarded a good nurse as one performing a given task There is a saying that "a skillful nurse is a good person."In my experience, I think that someone who is skilled in working in an emergency situation is capable of working in any situation.At such a crucial moment, people who work in this way are more persuasive and appreciated.But no matter how "kind" you are, it's meaningless if you cannot function in a decisive moment.If someone comes to the ward and requests a specific nurse, we should be "that nurse" (asked for by name).(P10)

Providing Patients Holistic Care
Participants emphasized that nurses should strive to improve patients' quality of life by providing holistic care that machines cannot.To do this, participants worked hard not only to provide physical care, but also spiritual care pertaining to the individual's religion.They were also mindful of the pain and difficulties of the caregiver, who ultimately influenced the patient.

I think nursing interventions considering the patient holistically is important. Patients' illness is influenced by various factors. When I think only in relation to the present disease, sometimes I do not find the fundamental reason as to why the patient is uncomfortable. (P2)
I think I need some kind of activity to improve the soldiers' awareness.When I first started a smoking cessation program, I thought, "Why did they smoke, even though I conducted this (smoking cessation program)?"So, every time I sa w a soldier who smoked, I said "Do not smoke!"like an obsessive person.But the success rate was not that high.So, I practiced the awareness improvement activity consistently for about three years.Now the soldiers come and talk first: "I think I should quit smoking now."(P3)

Providing Solid Care that is Interlinked to Socio-Environmental Support
This relates to the need for an environment that is backed by social and legal support in keeping with the changing health care environment.In order to build a good nurse, it is necessary to minimize prejudice among current nurses and to improve the medical environment, so as to enable quality nursing services provision.
Nurses study to become advanced practice nurses while continuing to work at the hospital, but when they finish, they are transferred to another department.Even though the advanced practice nurse system was established, I wonder where all those nurses are, what they are doing.Because the role and position of the nurse is not clear at the legal level, the hospital seeks out cheaper staff than nurses.So, if the role of the nurse does not change in 10 or 20 years, the demand for what nurses currently do will disappear.First of all, I think that if the status and role of nurses are legally guaranteed, patient safety and high quality medical services will naturally increase.(P4)

Self-Management
Nurses are more likely to hear negative stories while tending to sick and tired patients and their caregivers.This could, in turn, exhaust the nurses.Participants emphasized that nurses should try to control their own health and emotions, and sometimes take time to recharge and be re-energized.

When I deal with patients, I always try to be the nurse with a smile and a good sense of humor. When you treat patients with a bright and lively expression, you help them think, "I can get better if I get care from that person."
The positive attitude of the nurse also affects the patient; so, it is important for nurses to self-manage.(P3)

Being Responsible for Maintaining a Positive Outlook
Participants regarded acting responsibly and consciously an important characteristic of a good nurse, even without anyone's validation and supervision.Nurses often perform duties independently; so, it is up to their conscience to judge whether an action is right or wrong.Therefore, it was considered very important for nurses to perform their tasks responsibly and take initiative, with a clear conscience.
When patients ask for something, the nurse simply answers, "Yes, I will do it," but when she is busy, she forgets.But some nurses try to resolve issues without forgetting.No matter how simple a task is, it is necessary for nurses to have a sense of responsibility towards their work when related to a patient's health.(P5)

Having Positive Partnerships with other Therapists
Participants emphasized that nurses form friendly relationships with their colleagues.Nurses act as mediators between patients and caregivers, other medical staff, and hospital personnel.Participants stated that it is important for nurses at the center of these relationships to communicate clearly with an open attitude at all times.

Having Comradeship
Participants stated that the senior nurse should be a model for junior nurses in embarrassing situations, and should give them time to grow while trusting them.They stated that when a nurse showed mutual consideration by mediating between colleagues when there is conflict, then they appreciated and trusted him/her.
When I was in my fourth year, the chief of the department was always on the side of the nurses.I think I was able to gain a lot of strength and courage when witnessing this.I am not sure as to when the year is low, but I often get in the corner and get frustrated.At such times, my greatest strength was that I had seniors, colleagues, and junior nurses who appreciated and trusted me and helped me.If you wait and give it a chance, the nurse will bloom.(P8)

Establishing an Identity as a Nurse
In the nurses' work, there are many tasks that others avoid and are reluctant to do.Participants tried to give meaning to their work and provide the best care with a sense of mission.To do this, the nurses emphasized the importance of having a professional attitude with one's vision and goals.
A good nurse needs to take time to think about how he/she is affecting the patient.We meet a sick patient every day, but each patient's experience of a disease is a big event that happens once in a while.A nurse who meets patients during such situations can also serve as a model for patients' health.So, it's important for nurses to have a professional attitude in nursing care.(P5)

Having One's Own Nursing Philosophy
Participants regarded a good nurse as one who created his/her own "nursing philosophy," while remaining on the side of patients complaining about physical and mental problems.Developing a nursing philosophy appeared to be facilitated by longer experience and participants stated that the art of nursing can be realized through the generation of one's own nursing philosophy.
I think that a good nurse has his/her own nursing philosophy.I have my own philosophy through my own experience of being at patients' bedsides.I am not conscious of this, but it seems to be brought about by the patient.I have spent 10 years doing this; so, even if the patient does not speak, there is an art to understanding and healing their heart.I came to realize that this is a high level of work.(P9)

Growing Through Change
The health care environment is busy and rapidly changing according to the demands of the times.Participants stated that nurses who have overcome the changing process become good nurses when adapting to change and do their work silently.Particularly, participants emphasized that they learn and mature further through caring for ill patients.

I am doing car insurance screening work now.
For expensive medical screening such as CT and MRI, the panel and I review the video and medical records together.If the patients feel the insurance screening results to be unfair, they file complaints.In this process, I need to study constantly and cooperate with professionals to build a systematic collaborative network.I think it is necessary for members of the general public who file complaints to be able to explain the problem and solve it easily.As insurance assessment continues to evolve in line with changing social conditions, I have to prepare myself accordingly.Even if the process towards becoming an expert is difficult, I think overcoming it is good.I think that as my career advances, I gradually grow step by step according to change.(P8)

Various Roles and Activities that Nurses Perform
This relates to the various roles and activities that nurses perform and their contribution to various fields.Participants performed nursing roles in fields such as healthcare, insurance screening, nursing policy, working overseas contributing towards the development of countries, as well as hospitals.Based on this experience, participants believed that nurses who actively contributed to society by giving advice or lectures about medical care and health in the community, and participated in social activities such as medical service, exemplified good nursing.

DISCUSSION
This qualitative study applied conventional content analysis to understand the meaning of a good nurse.The meaning of a good nurse was classified into 6 categories and 16 subcategories.Nurses in Korea said that a good nurse was someone who "leans in toward the patient", "keeps the cornerstone of one's mind with a positive attitude", "provides professional care", "maintains a good relationship with colleagues", "matures with her/his nursing philosophy and conviction", and "contributes to society".These categories were framed within the health care environment and social situations of Korea.
Patient-centered care has been consistently emphasized.For the participants, a good nurse emphasizes the relationship with the patient and loving the patient should be the basis of this relationship.Similar to the literature [15], we found that nurses try to ease patients' suffering by providing relief and comfort.Nurses are encouraged to recognize the patients' unique characteristics [16].Therefore, a nurse who seemingly ignores a patient and is characterized by bluntness, expressionlessness, and chilling behavior, is not considered a good nurse [17].This can be seen as a constant point of emphasis in the emotional aspect of nursing care.Nursing students and nurses also believe that nurses can build mutual trust with patients and advocate for the latter through nursing care involving, for example, understanding and caring for patients [7,18].As such, nurses and patients thought that good nurses seemed to relieve inconvenience while communicating with patients.Since the communication between nurses and patients contributes towards the healing process, it should be based on sympathy, compassion, and altruistic commitment.This underscores the importance of education at an institutional level, that can improve nurses' attitudes and personality.
Nurses' provision of professional nursing care is a longstanding basic requirement for nurses.Professional nursing entails the provision of nursing care to patients with proficiency in nursing skills, accurately, scientifically, objectively, and responsibly, based on expert knowledge [19].Patients thought that nurses should obtain continuing education so as to improve their knowledge and professional nursing skills [15,16].This represents a nurse's ability to quickly and accurately provide evidence based nursing to patients.Evidence-based nursing is the basis for patient safety, which is a theoretical basis for providing customized healthcare [20].
Participants emphasized the need for social and environmental support such as greater social recognition, the development of advanced nursing roles, and remuneration for nursing care in order for nurses to provide such professional care.This is reflected by data on Korea, such as the poor ratio of 6.9 nurses per population of 1,000 in Korea, compared to the average of 9.3 nurses in OECD countries [21].In Korea, because there is no independent nursing law that states the role of nurses, the medical law specifies it [22].The nurses in our study also thought that it is necessary to have patient holistic care in order to be able to manage their work efficiently, and to understand a given problem from various angles and to think critically based on the continue providing social and environmental support.
The nurse who filled the cornerstone of his/her mind with a positive attitude was responsible for the work through selfmanagement.This has been continuously emphasized to healthcare providers in the health care environment for patients who are physically and mentally uncomfortable.Participants in the study also stressed that in a health care environment where unexpected situations occur suddenly, nurses who take care of their patients should provide patient induced care while controlling their health and emotions.This is similar to previous literature indicating that patients responded positively to nurses who had bright expressions and were humorous, confident, motivated, diligent, and self reliant [17,23].Providing care that is not harmful to patients is an important issue related to ethical conscience for nurses with professional and independent activities in this study.Nursing students also stated that honesty was most important for nurses who work independently [24].In Korea, "the code ethics of nurses" was enacted to respect and defend the dignity and basic rights of human life in 1972.The 4th revision in 2013 highlighted the responsibilities of nurses and patients, nurses' professional nursing obligations, and ethics as nurses [25].Participants emphasized that maintaining an impression of trustworthiness as a nurse involves a continuous effort to control oneself and the maintenance of a positive attitude.Therefore, strengthening these ethical competencies will be necessary not only in undergraduate nursing programs but also in clinical nurses who have various ethical problems from the viewpoint of preventive ethics [26].
It is important to maintain good relationships with colleagues because nurses play a central role in complex human relationships in the health care setting.In particular, previous research emphasized the relationships between nurses and other medical staff such as doctors, radiologists, physiotherapists, and nutritionists [18].This emphasizes the role of nurses as mediator who maintains balance and provides care at the center of the complex structure of the hospital.Also the relationship among nurses is a problem in the recent nursing organizational culture in Korea.15.8% of Korean nurses experienced bullying in their workplace and thought that nursing organizations were more hierarchical than relationshiporiented [27].The participants in this study emphasized the importance of not only the relationship with other therapies but also the nurse friendly relationship.Therefore, it is necessary to understand each specialist's characteristics, so that effective treatment can be provided to patients, and to establish communication and a work process system centered on nurses.
Participants developed alongside patients in the health care environment and had their own career outlook.This developed further and participants experienced nursing as an art and developed their own nursing philosophy.One study stated that nursing is not the treatment of illness, but a series of acts that help patients recover and provides relief by preventing various inconveniences caused by illness [19].Nursing activities centering on patients can demonstrate the nature of nursing as an art through an aesthetic approach to identifying the moral characteristics of care [28].Our participants also noted that nurses should continue their efforts to mature and discover their uniqueness while reflecting on their philosophy.
A final destination of the good nurse experienced by participants was contribution to society.This finding seemingly emphasized a role that is gaining importance, with civil and social responsibilities, and newly emerging fields of practice.These nurses are involved in policy development in various fields and seem to emphasize the integrated role for promoting and maintaining individuals' health in the social environment.The nurse's insurance screening work includes requesting medical records, checking medical use, handling objections, and screening result notifications [29].In addition, in the international health field, it was possible to identify the role of nursing in cooperation with the institutions while accepting the local culture [30].Our participants referred to the active role of nurses as civil contributors, thereby challenging them to use their clinical experience to demonstrate their competence in schools, communities, and international health sites based on clinical experience.
The limitations of this study are as follows: First, interviews were conducted nurses at the senior general hospi-tal, which takes care of serious patients, so the role of hospital centered nurses was emphasized.Second, the role of male nurses is not confirmed because the role of women in cultural and ideological roles in Korean society with Confucian culture that divides men and women is reflected in the image of nurses.
This study has the following significance.It could be a basic data for policy strategy research to provide good nursing care in terms of nursing research.We will provide basic data for establishing strategies for nursing coaching and positive nursing work environment and contribute to expanding the nurse 's self image in terms of nursing practice.Students will have the opportunity to identify the meaning of a good nurse image as a nurse in terms of nursing education.

CONCLUSION
This study examines the meaning of good nurses from the perspective of nurses in a rapidly changing Korean society.We can confirm that the meaning of good nurses has changed from that of nurses assuming a historically therapeutic role to an integrated role.This result presents a reaffirmation of the social position and role of nurses working in healthcare sectors.In addition, to strengthen nurses' abilities as competent practitioners, it is necessary to provide social and legal support for nurses and to create appropriate environments.It is important to provide basic data that shape the identity of a professional nurse, presenting qualities that make up a good nurse.The results of this study can be used for policy research to enable good nursing practice, and to develop strategies for improving nursing education and nursing work environments.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Not applicable.

HUMAN AND ANIMAL RIGHTS
No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION
Researchers obtained the participants' written informed consent before the interview took place.


Leans in toward the patient  Provides professional care  Fill the cornerstone of one's mind with a positive attitude  Maintaining a good relationship with colleagues  Developing one's own nursing philosophy and conviction  Contributes to societyPatient-centered therapeutic roleaccurately and competently by setting priorities in the situation.Participants emphasized that the nurse should do the work consistently while minimizing impatience and calmly addressing the situation.

Table 2 . Meaning of a good nurse.
want to be a nurse who can contribute to society.I think that is the role of a good nurse.