Development of nursing professionalization elements in Slovenia : the group interview technique

Introduction: An occupation becomes a profession once it uses a systematic approach to generate new knowledge and transfer it directly into professional work. The aim of this paper is to show the attitudes of nursing care professionals towards the professionalization of nursing care and make a contribution by means of identifying the factors that are important for the development of the professionalization of nursing in Slovenia. Methods: The group interview technique was used with two rounds. Participants responded to 15 open premises/questions. Purposive sampling was used and groups were comprised of professionals from all levels of clinical environments, secondary and higher education teachers and master's and doctoral degree students (n = 48). Results: The results of the first round produced 3 themes, while the second round generated findings related to 4 themes. The synthesis of the findings from both rounds resulted in two overarching themes. The first is "National responsibility" which includes the responsibility of the nursing care management and the management of higher education institutions as well as the responsibility of the Nurses and Midwives Association of Slovenia for developing nursing care as a scientific discipline. The second theme is "National indicators for the realization of national responsibility" which includes (1) Classification of jobs in nursing care to reflect the 4 levels of nursing care competencies, (2) research and development as work tools in nursing care, and (3) the national institute for nursing care research. Discussion and conclusion: The responsibility for the development of professionalization lies with several sectors. A clear and ambitious vision, and a strategy for the development of nursing care that should include responsibility for setting a new paradigm for the development of nursing care as a response to the needs of the society, occupation and science, are needed. The strategy should be supported by means of a planned distribution of means to facilitate its realisation.


Introduction
Many of those in Slovenia who are involved in the research and development of nursing feel that the professionalization of nursing has been developing too slowly.Therefore, the issue is how well do we understand the concepts related to professionalization and the related factors?Carvalho (2014) states that nursing is often referred to as a 'half profession' or a 'virtual' profession in the discourse related to the professionalization of healthcare occupations.

Definitions
The concept of professionalization is an issue in many occupational groups and has a long history and social context.Consequently, several interpretations and definitions of this concept developed related to different use and needs (Demirkasimoğlu, 2010).An often-cited definition of professionalization states that professionalization is a social process that involves an institutionalised manner of preparing individuals for conducting professional tasks.During the process of professionalization, norms and qualifications for the representatives of the profession are established, and there is also responsibility for obtaining and transferring knowledge, certifying competencies, looking after relations among the members of the profession on the inside and on the outside (Wilensky & Harold, 1994).The Slovenian author Svetlik (1999) thinks that the process of professionalization of a certain occupation depends on several factors such as the area of work, the reasons for work, the resources that an occupation has available, as well as selfawareness and self-regulation of the occupation.That is why professionalization of various professions also differs amongst each other themselves.

Defining professionalization and professionalism in nursing
Many researchers have studied the professionalism of nursing through the years, so there are many definitions and descriptions of characteristics (Adams & Mikker, 2001;Manojlovich & Ketefian, 2002) and researchers use different methods and tools for evaluating it (Ghadirian, et al., 2014).
Professionalization is a multi-dimensional concept that ensures nurses develop personally and professionally.This process requires knowledge, skills, development of the characteristics of a professional identity related to a particular profession and internationalization of the values and norms of the professional group (Alidina, 2013).Professionalism is assessed according to individual characteristics and behaviour, relations with other individuals and the context of operation, as well as social dimensions such as social responsibility, morals, and political and economic responsibility.In addition, professionalism also includes following standards and competencies (Keeling & Templeman, 2013;Fantahun, et al., 2014).The concept of professionalism itself demonstrates dedication to the profession, so nurses are expected to educate themselves, publish their research, improve the practical and theoretical concepts of nursing and work independently (Çelik & Hisar, 2012).Their own professional perception and understanding of the concept of nursing, as well as their implementation in the social context, are of the utmost importance.Both their own professional perception and the understanding of the significance of nursing, affect the development and growth of nursing as a scientific discipline (Viitanen, 2007).
Watkins (2011) describes professionalism as a concept by means of three variables.The first one is the formation of profession, that involves a professional group, defined knowledge of the area of operation, established self-regulation and a continuing development of professional knowledge and skills for continuous improvement of the quality of work.The second variable of professionalism is recognition of profession, that includes core components such as knowledge, independence, responsibility of a professional judgement and their joined effect on the effectiveness of clinical work.The third variable is success of the profession, that can only be achieved by means of formal education and must include knowledge obtained by systematic research and professional review that is formed through critical thinking and decisions based on evidence.Watkins (2011) states that education on the master's level is a key element that uses the findings of research studies on professionalization in order to reach it.The reason for this is that research increases trust in graduates' own work, so that it is meaningful: the abilities of graduates to make decisions and their other cognitive abilities contribute to the implementation of evidence-based practice, thus achieving professionalism.Carvalho (2014) has found that professions in healthcare differ the most in terms of research-obtained knowledge.However, some nurses understand new knowledge as moving away from nursing care and support the local context of knowledge in practice.

Researching professionalization in Slovenia
Professionalization of nursing has been researched by Slovenian authors in original scientific works such as a dissertation, scientific or professional monograph or original scientific article (Pahor, 1998;Cvetek, 1999;Starc;Starc, 2009Starc, , 2016)).An important contribution to understanding the professionalization of nursing in Slovenia is the scientific monograph Medicinske sestre in univerza (Pahor, 2006) ('Nurses and the University' transl.) in which the author summarises and reflects on the development of nursing education since 1990, thus demonstrating an important part of professionalization that, according to Watkins (2011), belongs to forming the profession.An important contribution to understanding the professionalization is a monograph by Starc (2014) that finds three main characteristics of nursing professionalization in Slovenia, which are knowledge, power and ethics.In a quantitative analysis, Starc defines the concept of professionalization as nursing independence, which participants understand as knowledge, education, training, competencies and life-long learning.
The research conducted by Skela-Savič and colleagues (2016a; 2017a) focuses on professionalization from the aspect of professional values, competencies and evidence-based practice.The research has shown that the established values in nursing can only be understood as (1) values of nursing care, trust and fairness, and (2) values of development, professionalism and activism.The research has shown that the values of development, professionalism and activism are less important, which explains the success of the implementation of evidencebased practice.Nurses with a higher education degree in Slovenian hospitals understand competencies as "expected competencies for practical work" and as "competencies of development and professionalism".Knowledge and beliefs of evidence-based practice are present, but those included in the study are not convinced that they know evidence-based work well enough to incorporate it in practice.That is why evidence-based practice is rarely conducted .The causal non-experimental model shows that the beliefs and implementation of evidence-based practice may be explained by (1) values of development, professionalism and activism, (2) competencies of development and professionalism, (3) knowledge of research work, (4) knowledge of evidence-based practice, (5) education or training on evidence-based practice and (6) access to databases.

Aims and objectives
The purpose of the study was to verify the attitudes and understanding of certain elements of professionalization among experts of nursing in Slovenia.The aim of the study was to make a contribution towards recognising the factors that are important for the development of the professionalization of nursing care and that can contribute to the strategic planning of its development.
The research question: Which strategic factors are necessary in order to − develop elements of professionalization in nursing in Slovenia, in the areas of education, professional competencies, and research related to the development of the occupation and nursing science?

Methods
A quantitative research paradigm was used and data was collected using a group interview technique and processed using a thematic analysis method, which is one of the approaches of analysing the content of a text (Gomm, 2008).A group interview is used when we wish to obtain data for strategic planning, whereby we are interested in opinions and answers to pre-prepared open questions.The group interview might be more successful if the participants know each other as the interaction between them and the host improves.The discussion is managed by the host who knows the topic of the discussion well (Kumar, 2011).Since the participants of the group interview also know the topic, Green and Thorogood (2004) refer to such a group as a natural group -a researcher can detect cultural dynamics on topics of interest and responses from practice, which forms the course of the group interviews and data processing.

Description of the research instrument
A group interview was conducted in two rounds.The first one, entitled "Development of a competence model for all levels of education in nursing", was conducted in October 2016, while the second round, entitled "The national model of development and consolidating nursing as a scientific discipline", was conducted in March 2017.Seven days before both meetings, the participants were sent questions/ premises.The first round contained 5, while the second round was composed of 10 open questions/premises.
A sample of open questions from the first round: On the day of the study the participants were placed in two groups in order to secure better conditions for active participation.We ensured that each group was equally comprised of the different professional groups attending.The discussion was held simultaneously in separate rooms, according to the schedule, for five hours with two breaks, alongside an introductory presentation of the starting points for the discussion, that were related to findings of previous parts of the research project (Skela-Savič, et al., 2017b) whose part is also formed by this study.Before starting, we notified all the participants about the anonymity of the data processing and the voluntary participation in the study.The participants gave a written consent alongside the recording of the discussion.The groups of the first and second round were hosted by higher education teachers that are involved in the scientific research of nursing care in Slovenia.They had a uniform previously designed protocol of managing an interview with defined open questions.The discussion in both rounds was conducted according to the same protocol.
Description of the research sample Kumar (2011) states that the selection of the sample in a group interview is the researcher's responsibility and that they should follow the purpose, which is addressing strategic themes.It is important that the professionals who are involved know the field and cover a wide spectrum of content that is related to the field of the discussion.In order to satisfy the conditions, we used a systematic purposeful sample of professionals (n = 48) that Green and Thorogood (2004) define as a prerequisite for obtaining representative data.The systematic feature of the sample was understood to mean ensuring an appropriate involvement of various sectors and other participants in the development of professionalization of nursing care.We included professionals from the following fields: secondary education (n = 8) and higher education in nursing (n = 15), healthcare institutions on all three levels of healthcare and other institutions (n = 17), students of master's and doctoral studies programmes that work in nursing (n = 3), and members of various professional bodies on the national level (n = 5).Those invited had operated at various levels of responsibility, from a professional leader of a certain area to a leader on the highest level of organisational management.42 women and 6 men participated and all the participants had at least a higher education professional study degree; 9 (19 %) participants cooperated in both rounds of the study.

Description of the research procedure and data analysis
In data analysis we followed the thematic text analysis approach according to Gomm (2008), and Green and Thorogood (2004), which means that the researcher searches for common characteristics in the entire set of interview data and forms themes based on a comparison between similarities and differences in the respondents' responses in the interviews.A researcher decides what will count as evidence in order to design themes.The final themes may also be inspired by the ideas of the researcher; most often originating from the previous research of the research problem in question.In doing so, a researcher should be capable of reflection.
Based on the described guidelines we excluded the content that was unclear and could not be understood.We put all the forms in the female grammatical gender form as there were more women in both groups.We deleted all place names, names of institutions, bodies and communication fillers.In this way we secured anonymity of the respondent.The unit of coding was an uttered thought or opinion of a respondent about a specific topic.If a speaker talked about several themes, the uttered items were coded in several individual themes.In coding, the Thematic coding technique was used (Gomm, 2008), so we formed the codes with several words in order to describe the gist of what was said, which is called open descriptive coding.This enabled us to design categories such as hypernyms of the codes also in terms of content and to therefore come up with key findings based on the interviews that we presented in the form of themes.We conducted a secondary analysis of results and added some content and terminology in accordance with the research report by Skela-Savič and colleagues (2017b).In the data analysis we followed the processing guidelines according to Green (2004), as we wished to understand the connections between the attitude, behaviour and experience of the respondents in the field of the discussed themes.We also wished to understand the phenomenon of some elements of professionalization which the respondents used in their descriptions and, as a result of the study, we aimed at forming new ideas and a theoretical construct of findings for future research.The synthesis of findings from both rounds gave us the opportunity to better define the responsibility for the development of professionalism in nursing on a strategic level, which is also the purpose of the group interview technique.

Round 1: Development of the competence model for all levels of education in healthcare
As part of the analysis we formed 49 codes that were supported by 150 quotations by the respondents.Each quotation was used only once.From 47 codes we developed 14 hypernymic categories that form 3 final themes (Table 1), while two codes were not listed under any category.A few examples of the development of codes are presented below.The development of all codes is shown in the research report with reference to the project Nursing as a scientific discipline (Skela-Savič, et al., 2017b).
As an example, the code "It is necessary to define the competencies depending on the level of education" was developed with three quotations: As part of text analysis we designed 20 codes that are justified with 101 quotations by respondents.Every quotation is used only once.We developed 7 hypernym categories that form 4 completed themes (Table 2).Below we present a few examples of code development, which is shown in great detail in the research report of the project Nursing as a scientific discipline (Skela-Savič, et al., 2017b).
As a further example, we developed the code "The interest in research skills is questionable" in reference to four quotations: Quotation 25: There is 30 min allocated to nurses with a higher education degree intended for reading just like doctors.

Codes/Kode
Categories/Kategorije Themes/Teme The title of healthcare assistant is not acceptable.
It is expected that a healthcare assistant works independently.
Systemic responsibility of the nursing management and national professional association to stop exceeding the competencies of healthcare assistants and to ensure placement of the required levels of competences in nursing into the healthcare system.
Healthcare assistant is an independent worker in health care, and is more than an assistant.Nurses with a higher education degree have to do too much administrative work.
A nurse with a higher education degree is not accepted as a responsible healthcare worker.Delegation and management performed by a nurse is not accepted.Awareness exists that the competencies of healthcare assistants are often exceeded.
All the involved parties are aware of the fact that competencies of healthcare assistants are being exceeded in clinical environments.
There is no exceeding of competencies in secondary schools.Clinical environments the competencies of healthcare assistants to be exceeded.Exceeding of competencies is a professional selfapproval for healthcare assistants.Exceeding the competencies of healthcare assistants is a complex problem.The informing of employees is insufficient.
Nursing management has a significant responsibility for classifying the levels of competencies and stop exceeding the competencies of healthcare assistants.
Competencies should be determined based on the level of education.Changes of the collective agreement, systematisation and levels of competence are needed.A uniform understanding of the role of a master of healthcare is necessary.Interests of the profession should be balanced with the interests of employers.Exceeding the competencies of healthcare assistants is a serious problem.Responsibility of the management for exceeding the competencies of healthcare assistants.Vertical terms caregiver.
The professional term 'caregiver' does not have good social standing.
Defining a healthcare assistant as a co-worker on the team of nursing care on all levels of healthcare system and as a key performer in healthcare and social care in the community and long-term care.Assistive workers should be part of the vertical system.
There is a danger of overlapping competencies of a healthcare assistant and an assistive healthcare worker.There is a danger of overlapping the competencies of an assistive healthcare worker and healthcare assistant.
Quotation 26: It is up to an individual how much they will then educate themselves about a certain topic and whether they will look out for additional knowledge.
Quotation 29: I think the main problem is that we do not know about the opportunity or wish for additional knowledge.
Quotation 79: The management will decide, but she also has to venerate and be aware of the knowledge that she needs.
The code "Nurses are not prepared to conduct research" was developed with five quotations: Quotation 3: A lot of knowledge, experience, but they don't know how to put this into words and write it down, which is a problem.
Quotation 8: Because of all that, the majority of those who enrol in nursing are people who are practical and who like working with people etc.
Quotation 30: And if you come with that idea to a clinical environment you get beaten.
Quotation 119: The problem lies in us as a professional group in the first place and then in our colleagues, especially doctors who won't allow us to develop.But, my personal opinion is that the problem is in our professional group, in our heads and our way of thinking.We say: "We are independent, we are autonomous," but if we take a look around at what goes on....subordination of nursing is... Quotation 120: I strongly agree with my colleague and I think that the key problem is in us and in the fact that we underestimate intellectual work.That we should really identify what is necessary.
Table 3, which shows a synthesis of content of the seven themes obtained in both rounds, points Table 2: Results of the discussion on the development and consolidation of healthcare as a scientific discipline (round 2) Tabela 2: Rezultati razprave o razvoju in krepitvi zdravstvene nege kot znanstvene discipline (sekvenca 2)

Codes/Kode
Categories/Kategorije Themes/Teme The management must be considerate of the employees' professional qualifications.
Management of healthcare institutions is responsible for the development of nursing as a scientific discipline.

The responsibility of nursing management and management of faculties for the development of a scientific discipline at the level of each institution.
Research and development must be supported by a systemization of job positions.With institutionalised organisation of research and development there are several issues.Movement of employees between a higher education and healthcare institution as part of 100 % employment is necessary.Management does not take on sufficient responsibility for research and development.Cooperation between the higher education and healthcare institutions is necessary.
Research groups should be organised between healthcare and higher education institutions.A research entity should be established between the higher education and healthcare institutions.Professional work and research must be connected.
The point of research is the development of the occupation and benefits for the patient.

Research and development of the field as a work commitment of nurses with higher education qualifications.
The centre of the research and development work should be the patient.
Interest in knowledge of research is questionable.
Research is seen as optional and not as a priority of nurses.
Understanding of research and development as leisure time activities conducted by nurses.
Nurses are not willing to do research.
To build a scientific discipline, knowledge is necessary.
Disagree on the scope and type of knowledge for development of occupation and science.

Implementation of Europian comparable knowledge and competencies for the development of the occupation and scientific discipline in Slovenia.
There An influence on the policy makers should be exerted through a National Research Institute.
The National Research Institute should influence the policy makers.
at factors that have, in the study, been found as important in constructing a national approach to the development of nursing as a scientific discipline in Slovenia.We have found two main themes that refer to national responsibility.The first one focuses on those responsible for the implementation of a competence model in practice and for the implementation of the development of nursing as a scientific discipline, while the second one refers to the indicators which we will use to follow the development of nursing as a scientific discipline.

Discussion
The results of group interviews conducted in two rounds bring our attention to the seven themes and two umbrella themes.The responsibility of healthcare management and higher education institutions and the professional association that is the Nurses and Midwives Association of Slovenia is of major importance for the development of nursing as a scientific discipline.These responsibilities have been defined on the level of national responsibility for the development of professionalization of nursing in Slovenia.We have also defined three national indicators of the implementation of this national responsibility: systematization of job positions on four levels of competencies in nursing, research and development as a tool for working in nursing and the establishment of the national institute for research in nursing.
The study has shown that we will only be able to talk about the real development of nursing care as a profession and scientific discipline when the key holders of responsibility, especially the nursing management in healthcare institutions, begin with systematization of job positions for four levels of competencies in nursing care and follow the internationally comparable conditions of qualifications for implementing competencies at a certain level.Two previous studies conducted by Skela-Savič andcolleagues (2016b, 2016c) have shown that experts agree on the achieved adjustments of competencies as recommended by the European Federation of Nurses Associations -EFN, however, realistically speaking, there is no model outlining the competencies and activities of nursing care for the four levels of providers of nursing care despite the fact that a professional master's degree has been offered for ten years.
This study has shown that content and terminological implementation of the categories of providers of nursing care according to the EFN model (EFN Workforce Committee, 2014) into our education system, the system of national competencies and activities of nursing care is sensible, and its transfer into descriptions and systematization of job positions.Under the auspices of the project Nursing as a scientific discipline, matrix of the levels of competencies in nursing according to the model EFN (Skela-Savič, et al., 2017b) with the use of a quantitative and qualitative approach was verified.For the purposes of the article this matrix has been terminologically upgraded and conditions of qualifications were set and comparisons with the frameworks of qualifications have been made.The proposed model for Slovenia will be explained in detail in the future publications relating to this project.
The proposed competence model of the level of providers of nursing care in Slovenia: Level 1: an employee on the nursing team and the − healthcare team -healthcare assistant ('tehnik/ tehnica zdravstvene nege'), education -secondary vocational school for nursing (5th level of the Slovenian framework of qualifications or 4th level of the European framework of qualifications); Table 3: Synthesis of rounds 1 and 2 Tabela 3: Sinteza tem sekvenc 1 in 2 Themes/Teme Themes synthesis/Sinteza tem The responsibility of the nursing management and the management of faculties for the development of a scientific discipline on the level of each institution.
NATIONAL RESPONSIBILITY -responsible for the implementation of a competence model in practice and for the development of nursing as a scientific discipline: (1) nursing management, (2) management of higher education and (3) the national association of nursing Social responsibility of higher education for organisation of education on all levels and for argumentation of the development of nursing as a scientific discipline.
Implementation of European comparable knowledge and competencies for the development of the occupation and scientific discipline in Slovenia.
Research and development of the occupation as a work commitment of nurses with a higher education degree.

INDICATORS OF IMPLEMENTATION OF NATIONAL RESPONSIBILITY: (1) systematization of job position on four levels of competences in nursing, (2) research and development as a tool for working in nursing, (3) establishment of a national institute for research in nursing
Systemic responsibility of the nursing management and the national professional association to end the exceeding competencies of healthcare assistants and introduction of levels of competences in nursing into the healthcare system.Defining a healthcare assistant as a co-worker on the team of nursing care on all levels of healthcare system and as a key performer in healthcare and social care in the community and long-term care.In reference to the proposal of the presented competence model it should be emphasised that Level 3 and 4 cannot be reached if Level 2 has not been reached, while Level 1 is not a pre-condition to achieve Level 2, which is in accordance with the conditions to enter the education programme for a regulated profession (Directive 2013/55/EU of the European Parliament and of the Council, 2013).
The next significant step is to include all levels of competence into national human resource norms and into appropriate salary brackets.The study brings attention to the fact that developmental and research work in nursing is a tool for reaching evidence-based work.The respondents think that the implementation of research work in nursing may only eventuate through a national institute for research in nursing care whose founder is the Nurses and Midwives Association of Slovenia.The institute should be funded from membership fees and applications to tenders.The author of the article believes that waiting for other institutions to support nursing care considering the general current state of the healthcare policies in Slovenia is not sensible, but that rather the Nurses and Midwives Association of Slovenia should invest.Namely, the study has shown that a national research institute should implement an effect on healthcare policies.The following finding is that studies conducted by the new institute should be directed especially towards the needs of the patients.In this way, researchers of nursing care would contribute to forming new policies on the state level and broader, and would be more successful in obtaining research funding, which was mentioned by Büscher and colleagues (2009) in one of the studies.
A thorough analysis of the research results shows an important emphasis on higher education management from the perspective of social responsibility for the argumentation of the development of nursing as a scientific discipline and organisation of education on all levels.This is a logical expectation as accumulation of knowledge from research is the highest at faculties since research work must be conducted in order for the faculty to offer and further develop high quality programmes, which is possible only if there is research on the occupation for which the faculty educates and, if it is connected with the occupation, also in direct contact work with the patients.It is highly significant to also involve the clinical setting into research work, which the study has confirmed by the obtained codes such as "Higher education and healthcare institutions must cooperate", "There should exist a common research entity between the higher education and healthcare institution" and "Professional and research work must be connected".More emphasis on these themes is recommended in nursing study programmes to provide better integration of research culture and paradigms of conducting research in clinical settings (Kelly, et al., 2013;Loke, et al., 2014).Our study has brought attention to the above-mentioned, especially from the perspective that in Slovenia building a research culture is challenging, as the respondents are indecisive about the type and scope of knowledge for the development of the professional field and science.There is also an issue referring to the fact that research does not belong to standard work commitments of nurses and that nurses themselves do not see it as a big enough priority.
The present state that has been found in this study will improve when the nursing management support the development of knowledge of research and knowledge of evidence-based work with their employees (Skela-Savič, et al., 2016a).In this way, despite the present belief that research and development are not compulsory nor are they a priority; motivation for developmental work will increase -the study has shown a low awareness of the needs of developmental work; interest in obtaining knowledge to conduct research and development will increase and awareness on the relevance of research for high quality work will increase.Kelly and colleagues (2013) and Loke and colleagues (2014) state that research is simply not yet a part of the professional identity of nurses, so it often happens that nurses do not apply research findings in their everyday practical work, which has also been shown by this and other studies conducted in Slovenia (Skela-Savič, et al., 2016a;Skela-Savič, et al. 2017a).The established present situation also supports the established concept of values and competencies that would support the development of nursing as the value system of the nurses' work in Slovenian hospitals is directed especially at completing daily professional tasks rather than developmental tasks (Skela-Savič, et al., 2017).The latter can also be confirmed with an existing study when we define the issue of exceeding the level of professional competence by healthcare assistants and thus bring attention to the lack of systematised job positions for nurses with a higher education study degree who are the only ones to carry the responsibility for development tasks in nursing and that are listed as competence level 4. The International Council of Nurses (2008) states that to perform development tasks a master's degree in nursing is a requirement, however, in Slovenia these job positions have not yet been systematized.That is why the defined responsibility of nursing management in this and previous research is justified.
A review of competencies written in the European Directive (Directive 2013/EU of the European Parliament and of the Council, 2013) clearly shows that the competence ability to analyse the quality of nursing care and consequently improvement of the professional work of nurses for general healthcare (listed under group H in the Directive) cannot be realised if the provider does not possess the basic knowledge on research and development and if they do not work according to the evidence-based concept.The fact that research and development should be included in the regular workload of nurses with a higher education study programme degree is logically a condition for realising the listed competences and consolidates the topic "implementation of knowledge and competencies for the development of the profession and science in Slovenia comparable to the European Union".Here it should be continuously explained that levels of competence should be implemented as our research has shown that there is indecisiveness present among the participants regarding the scope and levels of education, which means that the professional public does not yet understand the levels of education well and has difficulties trying to transfer them to a real clinical setting.It is also important to be aware of the fact that in developmental work in nursing we can come across many problems such as the time intended for research, a lack of research skills, insufficient support from the management and doctors, work processes and organisational culture that do not support research (Kelly, et al., 2013;Loke, et al., 2014;Yoder, et al., 2014).As regards nurses with a higher education study programme degree in Slovenian hospitals, it can be unfortunately said that there is a lack of knowledge and education and poor accessibility to professional and scientific literature (Skela-Savič, et al., 2016a, 2017a).All these findings make us consider the compulsory training courses to obtain a licence for work and whether this content is up to date in terms of knowledge necessary for the development of nursing in Slovenia and the qualifications of the nursing management, whose research has shown to be one of the key factors of the development of professionalization.
The research also draws attention to the discrepancies between secondary and higher education, as the expectations of secondary education, in the sense of uninterrupted vertical promotion for pupils of secondary schools for healthcare without the general schoolleaving exam 'Matura', hinder ambitions of faculties to develop university study programmes of nursing.In this way the expected vertical schooling system in nursing in secondary school might be an obstacle for university education of nursing, which is also the starting point of the academic studies of nursing as this is how the majority of the providers for the professionalization of nursing obtain their professionalization.
The finding that competencies of healthcare assistants in clinical settingss are regularly being exceeded on a conscious level, which formally means that clinical setting disregards the fact that education for the occupation of a healthcare assistant in the education system does not compare with the competencies of nurses with a higher education degree.Namely, on a conscious level, healthcare assistants are expected to exceed their level of competencies.Similarly, participants of the secondary sector are bothered by a nurse who delegates and controls the work of a healthcare assistant because healthcare assistants are expected to be independent, which is the next obstacle in the professionalization of nursing in Slovenia.The established exceeding of competencies draws attention to the fact that employment of nurses should increase and that those healthcare assistants whose work interferes with the competencies of nurses with a higher education degree should be given an opportunity to train further.The nursing management is responsible for exceeding the levels of competencies of healthcare assistants because they fail to employ enough staff with a higher education degree.This is irresponsible towards patients and the occupation of nursing as it was also established by a study completed this year in Belgium, England, Spain and Finland by Linde Aiken (2017).The findings of this research state very clearly that if, in the nursing team who looks after 25 surgery patients and is composed of four nurses with a higher education degree and two caregivers with lower qualifications, we replace one nurse with a caregiver with lower qualifications, the probability for a patients' death increase by as much as 21 %.Melnyk and colleagues (2012) state that research studies enable practice which is evidence-based.These studies increase the quality and reliability of healthcare treatment, improve the outcomes of the treatment and decrease the variations in the treatment and costs.That is why in Slovenia systematic research in relation to the connections between the level of education and the number of healthcare employees and the outcomes of the treatment of patients is needed on a national level.
We can conclude that in nursing professionalization there are issues also in naming the occupation in Slovenia, as the research has shown that "Professional name of a caregiver" is generally not very respected in the society and is considered as less valued or an inappropriate name for providers of nursing care.In addition, recognising new areas of operation of healthcare assistants such as social and care competencies by the representatives of the secondary school sector has not been accepted, which puts forward challenges for nursing as an occupation and scientific discipline.
The limitations of the research relate to the selection of the paradigm as high quality research in the field of validity and reliability has several restrictions.Validity and reliability was ensured with the method of a hermeneutic circle (Mesec, 1998), as the data was obtained based on broadening the findings of previous research and sequential research was conducted.The respondents of the study were always informed with previous findings on which our questions for the group interviews were based.Therefore, in the first round the respondents were sent a report on the conducted quantitative research among secondary school students, students, healthcare employees, secondary and higher education on the competence model in nursing and the attitude towards research and development in nursing (Skela-Savič, et al., 2016b, 2016d).These results were presented orally before the beginning of the first round.In the second round the respondents were sent and orally presented the results of the first round (Skela-Savič, et al., 2016c).Our research and the developed open questions are based on a research project that was previously conducted in Slovenian hospitals on a large sample (Skela-Savič, et al., 2016a;Skela-Savič, et al., 2017b), which might be understood as legitimising the research, that is evidenced by long-term observation, triangulation of various research methods for researching nursing professionalization in Slovenia and by informing the respondents about previous findings of our research on this topic.As a final step in legitimising the validity of the conducted research we conducted a "scientific café" in 2017 to which we invited experts in nursing, higher education and research.At the meeting we presented the obtained themes of the research and discussed them with the invited guests from a strategic point of view and also from the point of view of planning the necessary changes.Green and Thorogood (2004) name this a consensual conference.It should also be noted that the author of this article is an advocate for the need for accelerated development of nursing professionalization in Slovenia and that she is also a higher education lecturer of research methods, evidence-based work and healthcare management, which may be reflected in the interpretation of the results that the author managed with a reflective stance and by informing the participants of the research with previous findings of research (Mesec, 1998) that formed the course of the group interview.For the purposes of the article, the author reviewed the obtained results for the second time with the secondary analysis technique with an aim to achieve clarity, transparency and precision.
An inductive approach to research was used to identify some responsibilities for the development of the elements of nursing professionalization in Slovenia, which could be a challenge for researchers to verify the findings using a deductive approach to research.The research offers the basis for planning strategic guidelines for the development of nursing professionalization in the future, which was also the purpose of this study.

Conclusion
Research with a qualitative approach brings attention to the factors that will play an important role in the development of nursing professionalization in Slovenia and its breakthrough in scientific research and placement of the level of competencies in clinical work.An occupation becomes a profession once it creates its own knowledge with a systematic approach and transfers it directly into professional work and when experts generate research problems that they resolve together with those who have the competencies for thorough scientific work.The tools of operation include systematic research, professional judgement, development of critical thinking and decision-making on the basis of evidence.That is why nurses with a higher education degree in Slovenia must be given access to knowledge for the development of values of activism and development, research skills and evidencebased work, as in this way they will have a significant influence on the development of professionalization and nursing as a scientific discipline.Healthcare managers in key positions in various sectors must be trained to understand professionalization and for their responsibility in this area.A clear and ambitious vision is needed, as well as a development strategy for nursing that should include national guidelines for life-long professional training for healthcare institutions, professional sections, regional professional associations and management at all levels of nursing.The national professional association should assume the responsibility for the presentation of the new paradigm of the development of nursing that will be a response to the needs of the society, occupation and science, and to conduct a precise allocation of financial means in order to realise it.

Table 1 :
Quotation 14: I think that it is time that we agree on things, that this applies to the whole of Slovenia; that we do not ask ourselves who does what and what they should not be doing; that it is clear what the competencies of those with completed secondary school education are and of those who have completed the higher education programme.Results of the discussion on education and competencies in nursing care (Round 1) Tabela 1: Rezultati razprave o izobraževanju in kompetencah v zdravstveni negi (sekvenca 1) The National Research Institute as a formal connection for the development and research of nursing care in Slovenia.

Table 1 :
Results of the discussion on education and competencies in nursing care(Round 1)

Table 2 :
Rezultati razprave o razvoju in krepitvi zdravstvene nege kot znanstvene discipline (sekvenca 2) Results of the discussion on the development and consolidation of healthcare as a scientific discipline (round 2)