Midwifery Professionalism: An Integrative Review

Currently, professionalism has a special meaning and significance in various fields of medical science. There is no single definition for professionalism in the literature, and it mainly includes a set of behaviours that create trust and confidence in interactions between different medical groups with the patient and the community [1]. A professionalism charter was drafted by the American Board of Internal Medicine, European Federation of Internal Medicine and the American College of Physicians in 1995, which recommended the establishment of professionalism in all disciplines, cultures, laws and religions [2,3]. Many researchers have emphasised the culture-based nature of professionalism that is within the framework of each profession and it requires a specialised knowledge [4,5].

Midwifery is a profession that integrates science, art, and ethical values during the most critical moments of one’s life. The midwife cares for mothers’ holistic health and applies her knowledge, abilities and skills to build positive experiences for them [6,7]. This profession requires deep knowledge with practical skills since it has a unique body of science and art. Obviously, achieving the high goals of this profession requires adherence to the professionalism, since the capabilities of a midwife not only depend on her skills in performing professional activities, but also on adherence to professionalism [8]. Considering the influential role of midwives in women’s health, such a profession deserves those who are committed to it [8,9]. Adherence with the principles of professionalism promotes desirable care and respect for women, whereby steps can be taken to improve women’s health as the key to the health of the community [10]. Although the professional behaviour of students and midwifery professionals is very important, the concept of professionalism in this field is not explained using a scientific and structured approach, which creates challenges in the training and assessment of professionalism in the midwifery field. In the Ottawa International Conference, Hodges BD et al., recommended the need to provide a definition and explanation for the components of professionalism in various disciplines of medical sciences and compare them with the definitions of medical field. They believe that professionalism is a remarkable subject in medicine, and its measurement has become an important concern in medical education in recent years, although it is difficult to define its components that precede its evaluation [11]. An updated definition of these professions, which are regularly reviewed, is one of the important duties of the owners of these professions [11].

Professionalism, which is one of the most important pillars in medical practice has been neglected in many cases [12,13]; while international associations have emphasised importance of professionalism in caring for women [14], which clarifies the need to explain this concept in the midwifery.

Although many researchers have defined professionalism, some of the definitions are very complex and some are ambiguous, so there is still no definition of professionalism. Given that the focus of this study is on various definitions and characteristics of professionalism, integrative review has been used as one of the concept analysis methods. According to Whittemore R et al., in order to achieve better understanding of a phenomenon, this method allows the simultaneous entry of different methodologies [15]. The present study was designed to clarify the concept of professionalism in midwifery and to determine its characteristics.

Materials and Methods

The present study was a concept analysis based on the Whittemore R et al., method. To increase the credibility of this method, they recommended a five-step process [15] that includes the following:

1. Problem Identification Stage

This stage creates a clear picture of the issue under study, in other words, the purpose of this method is to perform an integrative review [15]. Given that the purpose of this study was to provide a comprehensive professionalism framework in the midwifery profession, the following questions were designed to guide the study:

Why has professionalism in midwifery been studied?

What factors contribute to the development of professionalism in midwifery?

What are the components contributing to the development of the professionalism in midwifery?

2. Literature Review Stage

We performed the electronic databases in six databases without methodological constraints: MEDLINE (1946 to 6 Feb), Embase (1974 to 7 Feb), PsycINFO (1967 to 8 Feb), CINAHL Plus (EBSCO) (1937 to 9 Feb), Web of Science Core Collection (Indexes=SCI-EXPANDED, SSCI, A&HCI Timespan) (All years to 10 Feb) and Scopus (All years to 10 Feb). To identify further studies, the authors carried out manual search on validated journals and full-text article references as well as relevant systematic review articles. All retrieved articles were entered into the Endnote X7. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the guide recommended by Moher D et al., were used in order to reduce errors during the review process [16].

2.1: Search Strategy

Search of the articles was performed using the key words: “professional behaviour”, “professionalism”, “professional competence”, “professional conduct”, professional practice” and midwifery.

3. Data Evaluation Stage

Authors independently studied titles and abstracts of articles. Then, the full text of the articles that met the inclusion criteria was prepared and investigated in this review. Each article was reviewed in terms of subject, definition and dimensions of professionalism, and tried to answer these questions:

What is the nature and essence of professionalism in midwifery?

What are the dimensions of professionalism in midwifery?

How can this concept be clearly defined?

How can this concept be measured accurately?

3.1: Inclusion Criteria

1) English or persian language articles that contained the keywords in their title, abstract or keywords.

2) Availability of abstracts

3) Qualitative, quantitative, review, mixed method studies, published on scientific sites or journals after peer review.

4) Articles that address definition, dimension, and measurement of professionalism in medical sciences and specifically midwifery.

*Considering lack of relevant articles in the midwifery field, articles of the related fields were also used.

3.2: Exclusion Criteria

1) Articles with no full text.

2) Articles that were letters to the editor or introduction of a book.

3) Articles focusing a well-known component of professionalism based on the previous literature (such as empathy, humanism, altruism).

4) Dissertations and conference papers.

3.3: Qualitative Evaluation of Articles

One of the authors Zohre Momenimovahed independently evaluated the quality of all imported qualitative studies using the Critical Appraisal Skills Program (CASP, 2014) tool for qualitative research [17]. This tool consists of 10 questions designed to assess the purpose, methodology, study design, strategy used, data collection, data analysis, reflexivity, ethical considerations, findings and study value. Studies are classified in three categories in terms of quality, including high, medium and low [17]. The quality of quantitative articles was measured using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) [18]. The quality of systematic review reports was evaluated using the PRISMA statement [19]. In order to increase the reliability of the integrative review, the articles as well as evaluation forms completed for each article were given to two other authors and consensus was reached.

4. Data Analysis Stage

The qualitative content analysis and categorisation approach was used to manage information obtained from different methods.

5. Data Display Stage

This is the final stage in the integrative review that provides readers with a clear picture of the resources in question [15]. In this review, the results are categorised according to their main themes and categories.

Data Validation

Data validation was carried out at the theoretical stage according to the integrative review stages proposed by Whittemore R et al., [15]; further, in order to confirm the reliability, an expert external observer in qualitative researches was used so that the data collection and analysis processes would be investigated. All the research stages, including the initial intention of the study, the search for studies, the analysed data, the study findings, the extracted meanings, the codes, the themes classifications, and the details of the study process, were given to two external observers who were requested to review the reports and report their results.

Ethical consideration

In this study, permission of the Ethics Committee of Tehran University of Medical Sciences with the number: IR.TUMS.FNM.REC.1396.3234 was obtained.

Results

Selection of Articles

In the initial search, 1983 articles were obtained from six databases and 48 articles were obtained using manual search. After removing duplicates using Endnote (n=1034), the title and abstract of 997 articles were reviewed. According to initial screening of titles and abstracts and applying inclusion and exclusion criteria, 819 articles which did not have the inclusion criteria or were not relevant to the subject were excluded, so 178 articles were included in the study. In this phase, 137 articles were removed for scientific reasons. The full text of 9 articles was not available, of which 2 articles were sent after corresponding with their original authors, and no reply was received from the other 7 authors; therefore, these articles were deleted. Finally, 41 english articles were included in the study [Table/Fig-1].

[Table/Fig-1]:

PRISMA diagram.

Specifications of the studies included

The studies that were entered in this study are summarised in [Table/Fig-2] [1,5,6,8,20-56].

[Table/Fig-2]:

Characteristics of studies that were included [1,5,6,8,20-55].

Row	Article	Country	Design	Objective (s)	Main outcome(s)
1	Wynia MK et al., [20]	Chicago	Perspective	Reviewing the dimensions of professionalism and determining its scope.	Professionalism means holding the conviction that medical professionals can come together to establish and enforce standards for competence and ethics.
2	Kearney RA et al., [21]	Canada	Qualitative	Identifying key elements of professionalism.	Key elements of professionalism are humanistic qualities, professional development qualities and meta competences such as vigilance, management skills and leadership.
3	Crues SR et al., [22]	Canada	Review	Creating a clear understanding of profession and professionalism.	Professionalism is beyond knowledge and clinical practice and need to be thought explicitly. In this regard, different cultures and professions should be considered.
4	Wagner P [23]	USA	Qualitative	Investigating the meaning of medical professionalism to medical students, residents, academic faculty and patients.	Professionalism consists of knowledge and technical skills, patient relationship and character virtues.
5	Member of medical professionalism project [24]	Multi Country	Perspective	Setting of professionalism principles for all medical profession.	Patient welfare, patient autonomy and social justice are the main principles of professionalism.
6	Kennedy HP [25]	Island	Delphi method	Describing essential characteristic of exemplary midwifery practice.	A typical midwife should have a desirable performance in treatment (the desired maternal-neonate health status), care (receiving maternal care and a respectable childbirth experience with maternal empowerment), and a professional practice (career enhancement).
7	Evetts J [26]	UK	book	Defining professionalism and professional work, challenges and opportunities.	Professionalism is a normative value which is difficult to define. Definition of this concept usually relies on profession attributes such as knowledge and skill. Trust, prioritizing the patient and maintaining confidentiality are among the most important features of professionalism.
8	Bossers A et al., [27]	Canada	Qualitative	Defining and developing professionalism.	Professionalism is defined in three components: professional parameters (aware of ethical and legal issues), professional behaviour (skills, relationship with client and team and professional presentation) and professional responsibility (responsibility against profession, self, community and employer/client).
9	Butler MM et al., [28]	England	Qualitative	Identifying essential competencies of midwife.	Safe practice, right attitude and effective communication are essential competencies of midwife.
10	van Mook WN et al., [29]	Netherlands	Review	Reviewing the concept of professionalism over time.	Professionalism is a context- dependent concept which is reflected in several features such as self-regulation, autonomy, altruism, accountability, duty, excellence, honor and integrity.
11	Willis E [30]	New Zealand	Qualitative	Investigating role of autonomy in professionalism.	Professionalism has long been a tool for professional control that is essential for effective professional performance. Lack of self interest in decision making is an important aspect of professionalism.
12	Lesser CS et al., [31]	USA	Review	Providing practical approach of professionalism.	Professionalism should be considered as a dynamic and behavioural concept. Professionalism is a multidimensional concept which contains various components such as effective communication skills, cultural competence, empathy, self-awareness, and conflict resolution.
13	Adkoli B [32]	India	Review	Providing some insights on the teaching of professional values in medical education.	Professionalism is shaped by several factors: heredity, parental influence, upbringing and schooling, which are beyond the control of medical education.
14	Borrelli SE [6]	UK	Review	Identifying essential competencies of a good midwife.	Essential competencies of a midwife lie within theoretical knowledge, professional competencies, personal qualities, communication skills, moral and ethical values.
15	Halldorsdottir S et al., [8]	Iceland	Theoretical	Developing professionalism in midwifery	Professionalism in midwifery comprises professional competence, professional caring, professional wisdom, interpersonal competence and midwifery development.
16	Borgstrom E et al., [33]	UK	Qualitative	Understanding the professionalism challenges in view of medical students.	Empathy, emotional engagement, open communication, patient centered care and patient autonomy are among the most important features of professionalism in new era.
17	Al-Eraky MM et al., [34]	Arabian countries	Qualitative	Providing professionalism framework for healthcare personnel.	In Arabian countries, professionalism reflects in dealing with self, dealing with tasks, dealing with others and dealing with God.
18	West CP et al., [35]	USA	Review	Understanding of the factor contributing to professionalism.	Personal factors such as distress, wellbeing, individual characteristics, and interpersonal qualities alongside with environmental factors such as institutional culture, formal and informal curricula, and practice characteristics contribute in formation of professionalism.
19	Ratanawongsa N et al., [36]	USA	Quantitative	Understanding resident perception about professionalism.	Time constraints, high workload and working with difficult patients are important obstacles to professionalism. Role modelling, culture of professionalism in fieldwork and integrity to personal values are important promoters which guide people to follow professionalism principles.
20	Wilkinson TJ et al., [37]	New Zealand	Review	Definition of professionalism.	Adherence to ethical practice principles, effective interactions with patients, effective interactions with healthcare providers, reliability, autonomy, improvement of competence in oneself, others, and systems are among the most important professionalism components.
21	Stern DT et al., [38]	USA	Quantitative	Establishing valid outcome measure for professional behaviour.	Bottom-up approach for professionalism measurement can promote students for their professional behaviour. Humility in self-assessment is a significant predictor of professional behaviour.Moral reasoning skills, communication skills, interpersonal skill, compassion, responsibility and altruism are among the most important components of professionalism.
22	Hwang JI et al., [39]	Korea	Quantitative	Comparing the factor influencing job satisfaction.	Professionalism is the most important factor in promoting job satisfaction.
23	Kaufman KJ [40]	Canada	Review	Examining important factors in effective care.	The foundation of professionalism in midwifery lie within beliefs and values and personalized, respectful, supportive, and continuous care.
24	Ergin AB et al., [41]	Turkey	Qualitative	Identifying professional values of midwives.	Professional competence, trustworthiness, respect for human dignity, protection of privacy, empathy, sympathy, good communication skills, altruism, professional competence, and responsibility are the most important characteristics of professional values.
25	Al-Eraky MM et al., [42]	Arabian countries	Validation study	Validation of professionalism components to Arabian context	Communication, compassion, competence, confidentiality, cross cultural understanding, education, empathy, equity, fairness, openness, self-confidence, self-evaluation, teamwork, sympathy, transparency are element of professionalism for Arabian context.
26	Kinsinger S et al., [43]	Canada	Review	Describing the set of professionalism	The characteristics of professionalism are summarized as follows: prioritizing the patient, commitment to high ethical and moral standards, respond to the needs of society, honesty, caring, respect, and trustworthy, accountability, commitment to life-long learning, following higher standards in competence, behaviour, decision making, and accountability.
27	Swick HM [1]	USA	Review	Definition of medical professionalism	Professionalism is manifested by attaching to the interests of patients than personal interests, adhering to high ethical standards, meeting social needs, showing human core values, including honesty, integrity, care, compassion, altruism, empathy, respect for others and trust, accountability, commitment to excellence, education and development of the field of work, reflection of activities and decisions.
28	Cohen JJ et al., [44]	USA	Perspective	Definition of professionalism and humanism.	Professionalism means acting in the direction of normative values. Humanism and professionalism are strongly linked to each other
29	Ginsburg S et al., [45]	Canada	Review	Introducing a new conceptual framework for evaluating professionalism	Professional behaviour is a context- dependent concept. Understanding and evaluating of professionalism should focus on behaviours rather than individuals or personality traits.
30	Van De Camp K et al., [5]	Netherlands	Qualitative	Clarifying elements of professionalism in medicine.	Interpersonal professionalism (such as altruism, respect, integrity, honor, honesty, compassion, relationships with colleagues or team, trust, educate patients, caring, responsibility) public professionalism (such as accountability, excellence, self-regulation, duty, justice) and intrapersonal professionalism (such as lifelong learning, humility, clinical judgment, flexibility) are features of professionalism.
31	Worth- Butler MM et al., [46]	UK	review	Introducing an integrated model of competency in midwifery.	Competency in midwifery includes knowledge, skills, abilities, safe care, self-confidence, autonomy, participation, effective communication, responsibility and critical thinking.
32	Jette DU et al., [47]	USA	Validation	Assessment of construct validation of professional behaviour model in physical therapy.	Professional behaviour in physical therapy constitutes professionalism, critical thinking, professional development, communication management, personal balance, interpersonal skills, and working relationships.
33	Lockman JL et al., [48]	USA	Qualitative	Defining professionalism in pediatric anesthesiology.	Patient ownership, continuous team improvement, expressive communication, active listening, care coordination, medical hierarchy, leadership, teamwork, personality traits, and physical image are domains of professionalism in pediatric anaesthesiology.
34	Jafaragaee F et al., [49]	Iran	Concept analysis	Defining professionalism in Iranian nursing.	Commitment to offering the best nursing care and commitment to promotion of the nursing profession are two main features of professionalism in nursing.
35	Dehghani A et al., [50]	Iran	Concept analysis	Clarifying the concept of professionalism	Care, communication and ethics are three important aspects of professionalism.
36	Jha V et al., [51]	UK	Qualitative	Providing a comprehensive definition of professionalism in medicine.	Professionalism in medicine has two main pillars: conceptual (integrity, empathy), behavioural (effective communication, team working).
37	Renfrew MJ et al., [52]	UK	Mixed method	Defining quality of midwifery care.	Available, accessible, acceptable and high quality care, as well as respect, communication, community knowledge, and providing care according to women’s circumstances and needs are among the most important features of high quality midwifery care.
38	Rogers W et al., [53]	New Zealand	Review	Clarifying definition of professionalism.	Responsibility, respectful relationships with patients, probity and honesty, self-awareness and collaboration and working with colleagues are basis of professionalism.
38	Chandratilake M et al., [54]	UK	Mixed method	Identifying universal and cultural specific features of professionalism.	Personal characteristics (e.g., honesty and integrity), relationships with patients (e.g., respect for patients’ autonomy), workplace practices (e.g., responsibility) and society related behaviours (e.g., avoidance of substance and alcohol misuse) are among the essential components of professionalism in all cultures and professions.Patient-centered practice, workplace values and attributes related to social well- being are not similar in different cultures and professions.
40	Hampton DL et al., [55]	USA	Exploratory study	Examining elements of professionalism in midwifery	High quality performance, high concern for clients, professional behaviour, independent practice, ethical behaviour, participation in professional association, continuous learning, keep up to date and professional coverage are elements of professionalism in midwifery.
41	Morgan J et al., [56]	UK	Qualitative	Definition of professionalism in nursing and midwifery in wales	Professionalism in nursing and midwifery includes personal characteristics (attitudes and behaviours) which provide constancy in personal integrity, humanism, effective relationship, continues empowerment and education, patient and family centered care.

Characteristics of Professionalism in Midwifery

Based on the aggregation of the results from the literature review, three main themes of personal requirements, professional requirements, and intra-professional morality were extracted, which are referred to below.

Theme 1: Personal Requirements

1-1: Personal characteristics: Personal characteristics play an important role in professionalism. Individual characteristics such as self-confidence [42], wisdom [25], optimism [25], flexibility (1,2) [21,44,25], and motivation [5,25,51] have been referred to in various studies as the requirements of the professionalism.

1-2: Self-leadership: The present study referred to self-awareness (3-9) [27,38,42,44,46,55,57], self-control [25,44], self-management [34,47] and self-development [5,47] as components of self-leadership to realise the professionalism. In this regard, studies have emphasised on self-awareness and individual limitations [23,25,34], control of internal conflicts, effective and transparent self-regulation [5], preservation and promotion of knowledge [8,25,37] and professional qualifications [58] and lifelong training[1,23,37,58].

Theme 2: Professional Requirements

2-1: Professional Scientism: The basis of each discipline is the body of knowledge that manifests in the form of an academic and professional system and is based on the functions of the profession. Many researchers have considered theoretical knowledge and professional skills as one of the most important characteristics of professionalism [8,28,34,44,46].

2-2: Professional communication: The midwife must pay particular attention to professional communication and its role in providing care [10]. The importance of communication in the formation of professionalism has been of interest to many researchers [23,28,33,42,46,47,50-53]. Wagner P et al., referred to the importance of patient communication with reliance on trust and confidence [23].

2-3: Sympathetic and trust-based interactions: The sympathetic interactions are an expression mentioned in the literature in various forms [23,42]. Providing care with compassion and kindness [23,42], altruism [5,25,58], empathy [1,25,33,42] and physical, emotional and psychological accompaniment [40] during delivery [25] and compassion [1,5,25,42] are among the cases involved in sympathetic interactions. The trust is the heart of the patient-doctor relationship [58]. When a relationship is formed based on mutual trust and confidence and the credibility to the midwife is achieved, one can help establish a professionalism [1,40].

2-4: Patient-centered care: The response to the preferences and needs of the patient in line with his/her values is one of the cases that are clearly seen in the literature on the professionalism [33,48]. Giving priority importance to the interests of patients over personal interests [22,30,58], providing care according to the patient’s needs [25,52], avoiding routine care [25,40] and patient-centered care [27] are among the requirements of the professionalism mentioned in the literature.

2-5: Team-focused care: Team-focused and teamwork approach is a thoughtful method of cost-effective care and one of the qualifications required by a midwife [59]. In various texts, the teamwork is considered as one of the keys to improving the quality of care followed by the formation of professionalism [37,42,58].

2-6: Professional responsibility: As part of a major health system, the midwife must be responsive to society by providing optimal clinical care according to the standards [1,5,34,37,53]. Briefly, this person is responsible for her own profession and should do her best to promote it [1,41,47].

2-7: Commitment to the profession: The person’s identity and attachment to the profession, while showing loyalty to it, are components which should be adhered to by each member of the profession [60]. Professional field development is one of the components of the professionalism that should be realised by the business owners [1,49].

Theme 3: Intra-Professional Morality

Morality is an undeniable necessity for the realisation of professional behaviour that sometimes surpasses technical skills. Numerous articles have referred to morality as one of the essential pillars of professionalism [23,25,34,50].

3-1: Value-Based Approach: Researchers have identified ethical characteristics as one of the most important characteristics of professionalism [1,6,23,43] and emphasised the proper functioning of the treatment consistent with morality [58]. Morality should be respected by the midwife while performing her duties and responsibilities, as well as providing care for every woman in the context of human rights [10]. Honesty [1,5,21,27,51], respect for human beings [1,5,44,51,52] and their dignity [21,27,34,41], respect for the privacy of individuals [41], patience [25,37], confidentiality [21], confidential care [25,34,42], justice [44, 58], fair distribution of limited resources [58], showing honesty with patients [44,58] and removing discrimination in providing care based on race, gender, socioeconomic status, religion, or any social class (charter) are among the most important examples of value-based approach.

3-2: Compliance with ethical codes: Adherence to professional codes and their preservation and dissemination is of particular importance. According to the literature, the commitment to ethical codes (2, 10) [44,61] and ethical laws, as well as the commitment to ethical development and the development of ethical virtues are among the basic factors in the formation of the professionalism (9, 11) [58,62].

Antecedents

Antecedents are events that occur before the concept event (conditions that are necessary for the concept to occur) (12) [63]. Individual, professional and organisational factors are known as antecedents of the professionalism in this study.

Individual factors: Various studies have referred to some of the individual factors that interfere with the occurrence of the professionalism. The balance between personal and professional life [25], personality traits [35], quality of life, and factors such as stress and depression [35] are the individual factors that interfere with the occurrence of the professionalism.

Professional factors: Researchers considered the tools for development of professional capabilities [35], such as formal and informal programs to promote professional behaviour and professional conditions [31] as effective precursors in the formation of the professionalism. They considered workload [35], time constraints [64], working hours [35,36], job burnout, and earnings and salaries (13) [30] as factors that make professional conditions favourable or unfavourable for the development of the professionalism.

Organisational factors: Some researchers have taken into account the role of organisational factors in professionalism. The results of this study extracted the organisation’s value-based culture [64] and organisational guidance [31] as effective organisational factors in the development of professionalism.

Outcome

Outcomes are events that are created as the result of the concept event; in other words, they are considered as outputs of the concept [36]. Based on the integration and aggregation of the results of the studied texts, the outcomes of professionalism were explained as the theme of improving the beneficiaries’ satisfaction and caring outcomes. Therefore, promoting the quality of care, respecting the patient, increasing patient’s satisfaction and improving the quality of care are among achievements of the midwife’s professionalism in the health system.

Promoting the Quality of Care

Various studies have highlighted the role of professionalism in promoting the quality of care. They referred to the positive relationship between mother-neonate-family [25], reduction of errors, and increased patient safety and prevention of complications [25], and therefore emphasised on observance of professionalism as one of the ways to improve midwifery function.

Increasing Patient Satisfaction

Studies have shown that compliance with the professionalism not only improves the level of respect paid to the patient, but also greatly affects the satisfaction of the patient and his or her family [25,62].

Improvement of Personnel Performance and Satisfaction

Compliance with the professionalism leads to better satisfaction of personnel [39,62], promotion of midwife-focused care [25], provision of cost-effective care [25], and more approval rating of midwifery care models [25].

Discussion

In this integrative review, three themes were extracted in order to achieve better understanding of the professionalism concept in midwifery: personal requirements, professional requirements and intra-professional morality. Over the past decade, special attention has been paid to midwife as a key person in promoting the maternal and neonatal health considering the emphasis on maternal mortality and morbidity in the Millennium Development Goals [7]. Currently, there is no accepted single definition for professionalism. Professionalism has lost or, in other words, never gained its true meaning due to its widespread use or misuse [1].

The results of present study confirmed the lack of a well-defined definition of professionalism in literature. However, the existence of a single accepted definition can be fruitful in designing researches in this area. The lack of this definition is one of the reasons justifying the lack of appropriate instruments [62]; because professionalism cannot be accurately, completely and comprehensively measured before being defined [63].

In recent years, many efforts have been made to improve midwifery education. However, midwife-based care in Iran, which is based on professional conduct in midwifery, is not trained, and therefore different midwifery practice in Iran can affect many aspects of professionalism in midwifery [65]. The findings of this study showed that the concept of professionalism is context-dependent. Every field and every culture puts more emphasis on one component of the professionalism; or it is possible that new components manifest for the professionalism in every culture; so, it is recommended to explain the concept of professionalism based on Iranian context using qualitative approach. The results of this study can be used for design instrument and educational programs to measure and promote professionalism among midwives.

Limitation

This study had its own limitations that should be mentioned. In this study only english articles were included, so this could cause in limited results. Therefore, the inclusion of further studies in other languages can be useful in providing a deeper understanding of professionalism. One of the strengths of this research seems to be the study of the analysis of various methodologies, since it may give us a more comprehensive definition of professionalism.

Conclusion

Professionalism in midwifery is a set of personal requirements, professional requirements and intra-professional morality. In order to maintain professionalism, a midwife should use her personality characteristics and self-leadership as well as adhere to ethical codes in direction of professional scientism, professional communication, sympathetic and trust-based interactions, patient-centered care, team-focused care, professional responsibility and commitment to the profession.

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