The Level of Professionalism of Nurses Working in a Hospital in Turkey.

INTRODUCTION: Professionalism is characterized by the degree of dedication displayed by individuals regarding the values and behavioral attributes of a specific career identity. Professionalism indicates attitudes that represent high levels of identification with and commitment to a specific profession. In the process of the professional development of nursing, various factors affect these obstacles which may impede the professional development of nurses and their professional behaviors. This study was carried out with the aim of determining the professional behavior of nurses in a hospital in Turkey.
METHODS: In this descriptive exploratory study a total of 89 nurses working in a public hospital in northwestern of Turkey were participated. Data were collected using a demographic questionnaire and Behavioral Inventory Form for Professionalism in Nursing (BIPN).
RESULTS: The result showed that mean scores on the BIPN were 5.07 (3.47). The areas with the highest levels of professional behavior were competence and continuing education 1.88 (0.34). The professionalism levels for nurses were the lowest in the areas of autonomy 0.06 (0.34), publication 0.10 (0.25), and research 0.25 (0.60). There was a statistically significant difference between the total BIPN scores and the education levels of the nurses and the working of nurses.
CONCLUSION: The professional behavior of nurses is at a low level. Since the arrangement of the nurses' working conditions affects their professional behaviors; therefore, development in the field of professional behaviors in nursing must be assessed and supported to increase the quality of patient care.

Introduction

Professionalism is characterized by the degree of dedication displayed by individuals regarding the values and behavioral attributes of a specific career identity.[1] Professionals are generally defined in terms of a particular body of knowledge obtained through formal education, an expanded level of skills, some type of certification to prove entry to profession, and a set of behavioral norms known as professionalism.[2] Moreover, professionalism indicates attitudes that represent high levels of identification with and commitment to a specific profession.[3] Healthcare practice today is changing and advancing rapidly and demands highly professional nurses rather than just those with experience.[4]

The criteria of professionalism in nursing were first identified by Miller et al. The basic attributes of professionalism include educational preparation, research and scholarship participation in professional organizations, community service, competence and continuing education, the code of nurses, theory, and autonomy. Based on these characteristics of professionalism, professionals can be distinguished from other workers. Professionalism in nursing has focused on the role of the expansion of nursing in the rapidly changing healthcare environment. Nursing professionalism reflects the manner in which nurses view their work and is a guide for the behaviors of nurses in practice to ensure patient safety and quality care.[5] However, social, cultural, scientific, and technological elements have shaped the development of nursing as a profession.[5]

The foundations of nursing were established in Turkey through the system offered by Florence Nightingale and her colleagues to wounded British soldiers in the Selimiye Barracks during the Crimean War, which took place between 1854 and 1856.[6] In Turkey, professionalization in nursing is still one of the most important issues for nurse leaders. During the assessment of the evolution of nursing in Turkey, significant developments and changes have been observed; however, not all of them are regarded as satisfactory. The healthcare system in Turkey is constantly undergoing major changes (nursing management about legal changes, health-care system about legal changes) due to social, consumer-related, governmental, technological, and economic pressures. These changes will naturally influence the nature of healthcare organizations. The level of professionalism demonstrated by nurses, and the resulting image created, is increasingly crucial in attracting clients.

Few studies have been carried out in metropolitan hospitals in different regions of Turkey to identify the professional level of nursing, professional behavior of nurses in different contexts, and the factors affecting professionalism.[6-8] A significant development in the process of professionalism occurred in Turkey after the 1980s. However, there are still weak fields in nursing, such as scientific knowledge and autonomy, which need to be strengthened. Additionally, the nursing field has significant obstacles that hinder the adoption of professional identity, and hence the performance of professional roles related to it. In the process of the professional development of nursing, various social, political, cultural, scientific, and technological factors affect these obstacles,[9] which may impede the professional development of nurses and their professional behaviors. Therefore, the purpose of this study was to examine the professional behavior of nurses working in a public hospital in Turkey. Also, we aimed to identify factors which affect the professional behavior of nurses.

Materials and methods

Data for this descriptive exploratory study were collected from September 2012 to December 2012 during face-to-face meetings with nurses. The important criteria for accepting nurses into this study were that all of the nurses must have been employed full time for at least 6 months and they must have had direct patient care experience during those six months. The study was conducted at a public hospital (Bolu Izzet Baysal Public Hospital) in northwestern Turkey. The institution had a 200 bed capacity, with 120 nurses in various clinical areas. However, there were no pediatric, obstetrics /gynecology, and psychiatry departments in the hospital where this study was conducted. A total of 89 nurses (response rate: 74%) were included in the final sample.

The data of the study were collected by using personal information form which was prepared by researcher’s involved sociodemographic and job characteristics, as well as Behavioral Inventory for Professionalism in Nursing.[1] The Behavioral Inventory for Professionalism in Nursing (BIPN) includes questions about the professional behaviors of nurses. The reliability and validity of the BIPN in Turkey was assessed by Karadag et al.[5] Permission to use the Turkish version of the BIPN was granted from these researchers. In an adaptation study, the Cronbach alpha coefficient was 0.78–0.87 and the test-retest coefficient was 0.86. The BIPN includes 46 questions. The BIPN consists of 9 subgroups: educational preparation, publication, research, participation in a professional organization, community service, competence and continuing education, code for nurses, theory, and autonomy. In this study, the total Cronbach alpha coefficient was 0.76. The BIPN was evaluated with the original evaluation criteria. In the BIPN, each behavior received 0–3 points. The overall score of each group was 3 and the total possible weighted score was 27. A high score means display more professional behavior. The instrument was initially administered to 20 nurses who were asked to provide written or verbal comments regarding the clarity of the items in the instrument. The instrument was then administered to a pilot sample of 16 nurses and was reviewed for completeness and clarity on their presentation for testing.

All of the data were analyzed using SPSS version 17 (SPSS, Chicago, Illinois, USA). All variables were initially analyzed descriptively. The Mann-Whitney U test and the Kruskal-Wallis tests, as nonparametric tests, were used to detect whether 2 or more samples come from the same distribution or to test whether medians between comparison groups are different, under the assumption that the shapes of the underlying distributions are the same. A significance level of 0.05 was used for all of the statistical tests.

This study was conducted according to the principles expressed in the Declaration of Helsinki. Before starting the study, an ethical approval was received from Ethics Committee of the Abant Izzet Baysal University and written permissions were obtained from the institutions involved. The participants were informed that their participation was voluntary and that all responses would be held in confidence. Written consent was obtained from all participants.

Results

All of the nurses (100%) in the study were female, 52.8% (n=47) of the participants were between the ages of 39 and 45, 27% (n=24) had a Bachelor’s degree, and 55.1% (n=49) had been working in their present position for between 6 and 14 years. The majority of the participants were working as clinical nurses. All of the nurses had a minimum of a bachelor’s degree in nursing.

The distribution of the mean scores of the nurses obtained from the BIPN subscales are shown in table 1. The mean score of the nurses was 5.07±3.47 and the areas with low mean scores were in the areas of autonomy (mean scores= 0.06±0.34), publication (mean scores= 0.10±0.25), research (mean scores= 0.25±0.60), and participation in a professional organization (mean scores= 0.32 ± 0.76). The areas with the highest scores were competence and continuing education (mean scores= 1.88±0.34). (Table 1)

Table 1

Distribution of total and subscale mean scores of BIPN (n=89)

Subscale score of BIPN	Mean (SD)	Minimum-Maximum
Educational preparation	0.96 (0.34)	0.00-3.00
Publication	0.10 (0.25)	0.00-2.00
Research	0.25 (0.60)	0.00-2.00
Participation in a professional organization	0.32 (0.76)	0.00-3.00
Community service	0.92 (0.63)	0.00-3.00
Competence and continuing education	1.88 (0.34)	0.00-3.00
Code for nurses	0.52 (1.38)	0.00-3.00
Theory	1.05 (1.09)	0.00-3.00
Autonomy	0.06 (0.34)	0.00-2.00
Total score of BIPN	5.07 (3.47)	1-19.50

The mean BIPN score was highest in the group who had been working as nurses for 1 to 5 years (mean scores=7.01±3.32) and was the lowest in the group that had been working for 6 or more years (mean scores= 6.89±3.12 and mean scores= 5.03±2.98). The difference between the groups was found to be statistically significant (KW=6.342; P<0.05). There was a statistically significant difference between the total BIPN scores and the education levels of the nurses (KW=7.112; P<0.05) (Table 2).

Table 2

BIPN mean scores of nurse executives according to educational preparation and time worked as nurse (n=89)

Variables	N	Mean (SD)	Kruskal Wallis test	p
Time worked as nurse (in years)
1-5 years	11	7.01 (3.32)
6-14 years	49	6.89 (3.12)	6.342	0.032
15 years and over	29	5.03 (2.98)
Educational level
Associate degree in nursing	65	5.76 (2.12)	7.112	0.012
Baccalaureate in nursing	24	6.08 (2.58)

The mean scores of professionalism of the nurses were 5.45 ± 5.10 (n = 1019), 5.97 ± 3.80 (n=225), and 7.16 ± 3.48 (n=531) in the studies of Karadag et al., Cerit &amp; Dinc, and Celik &amp; Hisar, respectively. However, the mean scores on the BIPN were higher for nurse executives (Manny Whitney U= 2.375; P<0.05).

Discussion

The present study revealed that the professional behavior of the nurses’ was quite low compared to findings in other studies.[2,3,10,11] Professionalism studies on nursing were first carried out by Miller et al., based on the “Model for Professionalism in Nursing”. This model aimed to determine the extent of the professional behavior of nurses with the BIPN that she had developed using this model.[1]

The professional levels of nurses have been found to be low in professionalism studies conducted in Turkey,[6,7] and these results also support our study.

The underlying reasons of these results, which inhibit the development of professional behaviors, may be excessive workload, long work hours, and an inadequacy of the sources provided.

Professionalism in nursing is delayed due to many negative factors, such as the differences between educational levels in nursing in Turkey, perception in the community about nursing as a profession, the hierarchic structures of hospitals, intense workloads, the focus of nursing on tasks, a lack of personnel and equipment, insufficient job security, low salaries, and weakness in organized labor.

Education level is one of the basic criteria for professionalism.[6] In our study, educational preparation was found to be one of the areas where the lowest scores were obtained (Table 1). This is a reflection of the status of nursing education levels in Turkey, as approximately one-third of the nurses participating in our study finished their education with only associate degree level. Insufficiency of educational preparation has also been stated by nurses in other studies.[7] Changes implemented in Turkish Nursing Law in 2007 resulted in a development in nursing education.[12] With this new regulation, requirements for basic nursing education were increased to that of a baccalaureate degree in nursing (BSN). It is thought that this favorable development will have a positive impact on nursing in future.

It has been established that BIPN mean scores increase as the education level increases. This finding was consistent with those of previous studies.[3,7] Hwang et al.,[4] also reported that Korean and Chinese nurses with higher education levels demonstrated higher levels of professionalism. However, the nurses working in the hospital in the present study have lower education levels. Some nurses working in Turkey graduated from a 2-year associate degree and some graduated from a 4-year Bachelor program. The number of nurses who graduated from a 4-year Bachelor program in university and private hospitals was greater than that in the rural state hospitals in Turkey.

In present study, level of nurses related to research and publication were low in terms of professional behavior [publication (0.10±0.25) and research (0.25± 0.60)] (Table 2) compared to previous studies.[6,7] The Society for Research and development in Nursing, founded in Turkey in 1996, provided an organized structure for research activities in nursing.[8,13]

Although the number of research studies in nursing has increased since the 1950s, it is still insufficient.[14] Kocaman et al., stated perceived barriers as the reason for restricting research activities and the most frequently (84,5%) perceived barrier for Turkish nurses was found to be the lack of time to implement new ideas.[15] Moreover, in another study in Turkey, it was found that most of the participants had not published a research article (90,5%), and 23,4% reported that they had never read research articles.[16] Therefore, generally undertaken in metropolitan training hospitals with nurses with higher levels of education in Turkey. Higher levels of research and publication scores in previous studies may be due to better facilities for research activities among nurses with masters’ and PhD degrees.[6]

Autonomy is the important criteria in gaining a professional status, in the determination or assessment of professionalism, responsibility for one’s behavior, and the ability to take risks.[17,18] In our study, the autonomy levels of the nurses were scored as low for professional behavior.

A study conducted by Karadag,[9] in Turkey reported low levels of autonomy in nursing, resulting from laws and regulations in nursing. It is low when compared with those obtained in similar studies carried out in other countries.[10] In the current Turkish health-care system, there are many challenges that influence a nurses’ autonomy, such as the rules and regulations of the hospitals and health-care organizations. Furthermore, the low education level of nurses who do not carry out research and do not have regular access to publications contributes to the problem.[6] In Turkey today, the majority of nurses work without an undergraduate degree, including nurses in administrative positions.

Professional organizations are established to solve problems that the members of a profession cannot individually deal with.[17] A sense of unity among the members of a profession shows the power of that profession, but this seems to be rather low among nurses in Turkey.[19] The first nursing organization in Turkey, founded in 1933, was the Turkish Nurses Association (TNA); a member of the International Council of Nursing (ICN) since 1949. Today, there are 23 nursing associations.[20] In the present study, participation in a professional organization of nurses was scored as low for professional behavior. In a study by Miller et al., concerning the membership of nurses in professional organizations, 15,9% of nurses were found to have a membership to the American Nurses Association and 35% were members in other specialty organizations; whereas in Turkey, this percentage is 11%–38% since last 30 years.[21-23] Although awareness of nursing associations and the percentage of nurses believing that an association membership is important were very high, the low rate of participation in professional organizations is a very important problem in nursing.

Nurses are obliged to have a code of ethics in order to meet the criteria of professionalism.[24] However, only a small number of nurses had copies of these codes (n= 10) in this study. At present, ethic codes specific to Turkey are being prepared,[12] and the translations of ethics codes developed by both the American Nurses Association and the International Council of Nurses are available, and their use is recommended. Our findings are consistent with those of similar studies, including that by Miller et al., of nurses in the Western USA and that of Hisar and Karadag with nurse executives in Turkey, which established that the majority of respondents did not have a copy of the code.[1,6]

In this study, increased working hours in professional life was found to cause decreases in displaying professional behaviors (P<0.05). Results showed that a decrease in professionalism was parallel to increases in burnout, depending on the number of years spent working in the profession. However, our findings were not consistent with the findings of previous studies,[25,26] which confirmed that nurses with longer professional experience have also high professional scores. It was found in a study in Turkey that the burnout of healthcare staff composed of female nurses (n= 89) was directly related to conditions of the work place and to increased work overload.[27] Since the profession of nursing is mainly regarded as a female profession, stress factors became more dominant due to the addition of other gender related roles and responsibilities.[28]

In our study, nurses with executive roles had high BIPN scores (P<0.05) in total when compared to the results of other studies.[7] The professional standards of behavior required from nurse executives are crucial to the development of professional nursing. As leaders, nurse executives must become actively involved in the ongoing development and improvement of professional standards of behavior and conduct in their field.

Conclusion

The results of our study indicate that the professional behavior of nurses is at a low level. The areas with the highest levels for professional behavior were “competence” and “continuing education”. The professionalism levels for nurses were the lowest in the areas of “autonomy”, “publication”, and “research”.

Another noticeable problem in the field of nursing was the low number of publications related to nursing and participation in professional organizations. Regarding autonomy, it is believed that the current law on nursing in Turkey prevents nurses from making decisions and acting independently.

Finally, despite few rights gained by the 2007 and 2011 laws, nurses still have some problems, which are more pronounced in rural areas than in urban parts of Turkey. The arrangement of the nurses’ working conditions affects their professional behaviors; therefore, development in the field of professional behaviors in nursing must be assessed and supported to increase the quality of patient care. Moreover, the involvement of nurses in scientific research and in educational programs and the importance of membership in professional associations must be supported by nursing leaders. Nurses have to learn to view their roles in the healthcare field as decision-making positions as opposed to passive and submissive behaviors from their past experiences. Additionally, nurses have to accept the characteristics that make up the concept of professionalism by taking responsibility for common problems, emphasizing both their own values and those of the community.

This study was conducted in a public hospital in northwestern Turkey and may not be representative of the entire population of nurses. Generalization is limited since only those nurses who voluntarily chose to answer the BIPN were included in the study. The sample was not randomized, and the items on the BIPN were self-reported in nature.

Generalization of these findings is therefore limited to the sample in the study. One of the variables that may have influenced the professional behavior of the nurses was “the type of patient care unit that the nurses worked on”, but this was not examined in this study.

Acknowledgments

This study did not receive grant from any institution or organization. We would like to thank all the participants.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.