Nurses' Attitude towards Professionalization and Factors Influencing It.

Introduction: Professionalism is one of the fundamental concepts in nursing and the result of the interaction with the environment and others. Nursing professionalism influences the quality of care and is affected by several factors. This study aimed to determine the attitude of nurses regarding professionalism and the factors affecting it.
Methods: In this descriptive study, the attitude among nurses to professionalism has been measured through the questionnaire Hall, in five dimensions "membership in professional organizations", "public service", "a sense of calling", "self-regulation"," autonomy" and a researcher-made questionnaire about effective factors. One hundred eighty five nurses working in teaching hospitals affiliated to Tabriz University of Medical Sciences, participated in the study through stratified random sampling. The data were analyzed, using SPSS software, descriptive and inferential statistics.
Results: The results showed that the nurses' attitude to professionalism is at the average level. Among the five dimensions, the scores from the highest to lowest belonged to "membership in professional organizations", "a sense of calling", "selfregulation", "autonomy" and "public service". The relationship between nurses' attitudes toward professionalism and variables of work experience and participation in training courses for individual empowerment was found to be statistically significant.
Conclusion: The professional attitude among nurses is at the average level. Given the importance of the professionalism in nursing and the influence of various factors, efforts are directed at achieving the desired level and reducing the barriers.

Introduction

Nowadays, due to rapid advances in science and the growth of new technologies in different fields, we can see considerable changes in all professions including those related to human health. Such changes have led to the presentation of novel viewpoints and the extension of knowledge boundaries regarding better care of people's health. Nursing is not an exception in field due to its status in the health care system and its professional contingencies‏.[1,2]

Nowadays, nursing has changed from a mere job into a profession through the recent increase in professional independence and development of definitions for roles and performances.[3,4] Nurses form the largest group of employees who offer health care, and whose professional capability has an important role in the realization of an effective health care system.[5,6]

Professionalization includes application of knowledge and skills, carrying out standard activities, leadership, self-discipline, professional commitment and social values.[1] Professionalization state in nursing is one of the topics debated in nursing communities in the world.[7] Numerous components play a role in the formation of a professionalization state including historical, cultural and social perspectives.[8] A review of state documents and papers in Iran show that nursing has been influenced by changes and advancements in a positive way.[9] Building the first nursing school in Tabriz in 1916 and the first academic course in nursing at BSc. level at Shiraz University in 1967,[10] can be considered as the most important steps taken towards professionalization of nursing in Iran. After the Islamic revolution, the development of academic centers to train nurses at BSc, MSc. and later at PhD levels[11] on the one hand, and the war between Iraq and Iran on the other (since it brought about the need for skilled and experienced male nurses in war zones), had great sociopolitical and sociocultural effects on nursing profession in Iran.[12] Eventually, by establishing the Nursing Association, another essential step was taken in order for the nursing profession to evolve, develop and get empowered.[13]

In fact, professionalization includes a series of attitudes which represent levels of individuals' identification with, recognition by and commitment to a particular occupation. Advances in professionalization take place through the process of socialization, formal education at different levels and the acquisition of knowledge and skills. More professional and occupational experience is often acquired through the adoption and reinforcement of professional role model attitudes and behavior.[14] As a factor that determines behaviors, attitude consists of a relatively constant manner of thinking, feeling and behaving towards different individuals, groups and social issues or at a broader level, to any event that takes place in an individual's environment.[15] It is a durable system that consists of cognitive and emotional elements, as well as the desire to take action.[16]

Professionalization attitudes in nurses are of utmost importance.[17] Thus, in the studies conducted so far, nurses' beliefs, motivation and attitudes have been referred to as the basic factors that affect their professionalization.[18]

Nurses' experiences indicate that for them, professionalization is an excellent concept that represents comprehensive, holistic and altruistic care of patients and it has been considered as "the ways in which nurses perform their care-taking roles for patients".[17]

From nurses' viewpoints, professionalization is synonymous with having sufficient knowledge about a particular field in care-taking accompanied by experience and autonomy. Variables such as official authority, self-confidence, nurses' support for each other, unity among members of this profession and individuals' actions and behavior are factors that affect the formation and development of professional and individual abilities in nurses.[5,6] Factors such as scientific and research development in nursing, ethics and spirituality in nursing, acquisition of power and development of relationships with the society[18] and criteria like improving abilities, professional ethics and commitment, resources, structure of social status and its improvement, frequent training in nursing science and skills,[19] all play their roles in the professionalization of nursing. In addition, factors such as academic level of nurses' education, years of service as a nurse, membership in professional organizations, serving as an organization manager, having technical nursing licenses, employment status and type of the working environment are all related to professionalization in nursing.

Besides, changes taking place in the nursing services provided, including the ability to instruct like a teacher, the ability to work at managerial positions, a willingness to improve one's self-confidence, job satisfaction and trying to improve care-taking quality have influenced nurses and the people’s attitudes towards nursing as a profession.[7,20]

Despite the recognition of factors that affect professionalization and in spite of all changes and efforts spent to develop a professional status for nursing, there is still a blurred social image of the nursing profession in people's minds in Iran.[8] More importantly, nurses' image of themselves and the image that their colleagues, particularly doctors have of them are even much more blurred and fuzzier than those of the ordinary people’s .[21]

Weakness in professionalization has resulted in repeated criticism of nurses' skills and ability in providing nursing care.[22] In some cases, this weakness is so severe that nurses have many problems in or are incompetent at offering clinical care.[23,24] Many centers that provide clinical care services are faced with the problems of insufficient professional nurses, increase in the number of resignations, inability to recruit young people into the profession due to lack of job satisfaction among working nurses, low quality of the working environments and non-professional clinical environments.[25-28] Besides, nurses feel that they have not become professionals in its true sense yet, and they see a lot of complicated problems and challenges on their way to professionalization.[5,8] All this is going on nowadays, while the society needs nurses who accept the profession wholeheartedly, improve their professional roles and qualities and gain the ability to perform those roles in different situations.[29]

Professionalization in nursing is faced with challenges that hinder the improvement of care-taking and lower the quality of nursing services provided. In fact, the process of professionalization is one that must be focused upon more seriously in an age where there is insufficiency of nurses.[8]

The nursing field has significant obstacles such as weakness in scientific knowledge and autonomy 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 which may impede the professional development of nurses and their professional behaviors.[7] With respect to the advances made towards professionalization of nursing and changes occurring in professions and communities, it seems necessary to investigate the present situation of nursing professionalization, introduce educational and care-giving standards and define policies in order for the occupation of nursing in Iran to reach a totally professional status. Obviously, being aware of professional characteristics and behaviors will help nurses become professionals[1] and indifference towards this important point would lead to deficiencies in the professionalization process and cause problems for the future of nursing as a profession. Besides being effective in solving problems of the community of nurses and providing appropriate care, reflection upon the professionalization process and the factors that affect it can be effective in assisting nurses to strengthen and consolidate their professional identity. Thus, this study was carried out with the aim of determining nurses' attitudes towards professionalization and the factors that affect it in teaching hospitals in the city of Tabriz.

Materials and methods

This descriptive cross-sectional study was conducted in Tabriz in 2014. The population of the study consisted of nurses working in training centers affiliated to Medical Sciences University in Tabriz. The sample included 185 individuals based on the preliminary pilot studies. Proportional classification and random sampling techniques were applied to determine sample size and the subjects included in it. Thus, the number of nurses participating in the study was estimated for each hospital. Then the proportion of nurses as subjects of the study to the total number of nurses in each hospital was kept constant. Inclusion criteria were possessing a BSc degree or higher in nursing, participant consent and exclusion criteria were being in-service nurses and newly transferred staff.

After getting permission from the respective research council at Tabriz University of Medical Sciences, the university's committee of research ethics and the related offices in clinical education centers, the researcher went to different hospitals, selected the participants randomly, explained the aims of the study to them and emphasized that their responses would be kept anonymous. When the researcher got the participants' consent, they filled out questionnaires regarding the nurses' attitudes towards professionalization and the factors that affect it at an appropriate time.

They could take the questionnaires home if they wanted to and were asked to return them on their next shift. After gathering all the questionnaires, data analysis was performed, applying descriptive and inferential statistics at the significance level of P<0.05 using version 13 of the SPSS software.

Data collection tools consisted of demographic information form which, in turn, consisted of variables like age, gender, level of education, employment status, type of employment, position, having experience of being a trainer, membership in the Association of Iranian Nurses and keeping one's knowledge and expertise up-to-date and the well-known Hall questionnaire to measure nurses' inclination to professionalization and its levels. The latter questionnaire has been used for more than 35 years in many professions, including nursing and its validity and reliability have both been confirmed.[7,20]

The Validity and reliability (Pearson coefficient of correlation was 0.86) of this questionnaire in Iran have also been confirmed after being translated into Persian.[30] This questionnaire has 25 statements for describing attitudes. Five dimensions of attitude have been taken into consideration: membership in a professional organization, belief in providing public services, belief in self-regulation in a group, sense of acceptance towards one's field of study and sense of autonomy. The questionnaire was prepared, using the Likert scale with such phrases as "completely disagree", "disagree", "no idea", "agree" and "completely agree". Each aspect consists of five positive and negative questions which are distributed in the questionnaire. To respond with the "completely disagree" option number 1 was assigned. Numbers 2, 3, 4 and 5 were assigned to "disagree", "no idea", "agree" and "completely agree", respectively. For negative statements, the scoring took a reverse form.

The range of scores for each aspect varied from 5 to 25 and the professional attitude, as a whole, and the total of different aspects range was within 25-125 scores. The minimum and the maximum possible scores for each person filling out the questionnaire were 25 (completely unprofessional) and 125 (completely professional) and the high scores indicated professionalization. To classify the levels of the nurses' professional attitudes, the method used in Zamanzadeh et al.,[30] study was applied and the total scores obtained were put into three categories of "undesirable", "average" and "desirable". Using the confidence interval of 95%, the difference among each of the five dimensions was taken into account.

Tool validity and reliability for this study was estimated again. To confirm the validity, the questionnaire was given to 10 faculty members at the faculty of nursing and midwifery at Tabriz University of Medical Sciences. After some revisions, the questionnaire's internal consistency was ensured with alpha Cronbach coefficient of 96%. The reliability was estimated to be 89%, using test-retest method with an interval of 10 days.

Results

185 nurses working in hospitals affiliated to of Tabriz University of Medical Sciences participated in this study. Most of the participants, i.e. 134 individuals (72.4% of the nurses) were female and the others were male. On average, they were 33.4 (7.11) years old.

Most of them held a BSc degree (165 nurses who made up 89.2% of the population), were full-time (147 nurses who made up 79.5% of the population), worked under contract (101 nurses who made up 54.6% of the population), were busy in a hospital ward (165 nurses who made up 89.2% of the population) and had less than four years of working experience (51 nurses who made up 27.6% of the population). 55 nurses (29.7%) stated that they had passed three to 17 months as nursing trainers who instructed BSc students of nursing. Fifty four of them (29.2%) were members of the Iranian Association of nurses and 65 of them (35.1%) had taken part in the training courses offered by the Association in order to update their technical knowledge and skills (Table 1).

Table 1

Demographic characteristics of participants in the study and their relationship with attitude towards professionalization

Variable	N (%)	P-value
Age (years)
≤ 27	44‏) 23.8)	P>0.05
28-30	39 (21.1)
31-34	31 (17.3)
35-40	36 (19.5)
‏≤41	34 (18.4)
Minimum: 22 years, Maximum: 54 years
Mean(SD): 33.4 (7.11)
Gender
Male	51 (27.6)	P>0.05
Female	134 (72.4)
Academic degree
BSc	165 (89.2)	P>0.05
MSc	20 (10.8)
Employment status
Part-time	38 (24.3)	P>0.05
Full-time	148 (75.7)
Type of employment
Permanent employment	45 (24.3)	P>0.05
Trial employment	2 (1.1)
Contract employment	101 (54.6)
Internship and service commitment	31 (17)
Other	6 (3.2)
Post
Matron	1 (0.5)	P>0.05
Educational supervisor	2 (1.1)
Clinical supervisor	2 (1.1)
Head nurse	6 (3.2)
Staff	9 (4.2)
Nurse	165 (89.2)
Work experience (years)
Less than four years	51 (27.6)	P=0.04
5-9 years	49 (26.5)
10-14 years	42 (22.7)
More than 14 years	43 (23.2)
Educational background as a trainer
Yes	55 (29.7)	P>0.05
No	123 (66.5)
Participation in Continuing education program for personal empowerment
Yes	65 (35.1)	P=0.044
No	120 (64.9)
Membership in Iranian nursing association
Yes	54 (29.2)	P>0.05
No	31 (70.8)
Updating one's skills and expertise
Frequent training offered by the institute	53 (28.6)	P>0.05
Frequent training offered by the conferences outside the institute	35 (18.9)
Unofficial in-service training to review particular techniques and procedures	41 (22.2)
Participation in conferences	28 (15.1)
Reading nursing journals	21 (11.4)
Studying the modern medicines and therapies in brochures and notes	2 (1.1)
I do not make any efforts in this regard	5 (2.7)

Regarding the first purpose of the study which was about the nurses' attitude towards professionalization, the results obtained from the Hall professional attitude questionnaire indicate that most nurses could be placed at an average level of professional attitude. So, in the classification of the professionalization level, one nurse (0.5%) was at an undesirable level, 171 nurses (92.4%) were at an average level and 13 nurses (7%) were at a desirable level. All the nurses who participated in the study were at an average level in all the aspects of professional attitude. Their highest scores belonged to the dimensions of "membership in a professional organization" and "sense of acceptance towards one's major" and the lowest scores related to the aspects of "belief in public service" and "sense of autonomy" (Table 2).

Table 2

Nurses' mean scores with respect to the dimensions of Hall's professional attitudes' questionnaire

Dimensions of professional attitude	Range	Mean (SD)
Total professional attitudes	25-125	13.3 (2.3)
Different dimensions
Membership in a professional organization	5-25	14.31(2.21)
Belief in the provision of public services	5-25	12.09 (2.20)
Belief in self-regulation in a group	5-25	13.14 (2.12)
Sense of accepting one's major	5-25	14.08 (2.07)
Sense of autonomy	5-25	12.9 (2.22)

With regard to the second aim of the study, the relationship between the factors of demographic features, attitude towards professionalization and other parameters under investigation, and the variables of age, gender, level of education, employment status, type of employment, position, experience as a trainer, membership in the Nursing Association, the results of X2 test at the significance level of P<0.05 showed that there was not a significant relationship. However, the results indicated that there was a significant statistical relationship (P<0.05) between the variables of length of service and the attitude towards professionalization. Thus, with increase in the length of giving service as a nurse, attitude to professionalization also increased. Moreover, there was a significant statistical relationship between participation in training courses for self-empowerment and attitude towards professionalization (P<0.05).

Taking part in such courses had increased the rate of favorable attitudes towards professionalization (Table 1).

Discussion

Although several studies have been conducted about professionalization of nursing such as professional capabilities of nurses, their experiences of professionalization, professionalization parameters, designing patterns and trainers' attitudes before,[18,19,21,30] clinical nurses' attitudes have not been investigated as the largest group of individuals who provide healthcare services in Iran. Thus, the major emphasis in this study was on the levels of nurses' professional attitude.

The demographic characteristics indicate that the majority of nurses who work in clinical education centers are women who hold BSc degrees. One reason can be the fact that most people associate nursing with women. This is while men's entrance into the job has been considered as an influential factor in the professionalization of nursing.

Despite significant developments and efforts taken to allow men to get into the profession, there are still serious challenges during the training period and during clinical work life, such as pressure role, professional assignment to women, their clinical performance and nursing image which make it difficult for men to become nurses and remain in the profession after entrance.[31] For the same reason, it is more difficult to keep men in the profession compared to women and male nurses are less willing than their female counterparts to stay on the job.[32]

The nurses who participated in this study were between 22 to 54 years of age with an average age of 33.4 (7.11) and most of them (23.8%) were young.[27] These facts show that the population of nurses who participated in the study was young. In this respect, this study is similar to the previous studies conducted in Iran[19,33] and different from the studies performed in other countries. For example, nurses who participated in a study carried out by Wynd[7] were within the age range of 22-74 with an average of 45 and in Kim-Godwin's study,[20] the average age was 54.9. This indicates that the average age of nurses in Iran is much younger than that of nurses in other countries. The need to have an income or become self-sufficient can be a common reason for the presence of young nurses in Iranian clinics. Young age might in turn lead to quitting one's job when it is accompanied by other factors such as hard work, disinterest in working in stressful conditions and insufficient income.

The findings show that there is a shortage of nurses with higher university degrees and the ones who are trained in different technical and professional areas in clinical centers. Perhaps, lack of awareness about the goal of establishing technical training courses, disinterest in remaining in clinical centers and having this assumption that higher education is a way to get out of the stressful and difficult clinical conditions and enter the arena of education are reasons for the fact that nurses with high educational degrees seem reluctant to work in such environments. The goal of establishing and developing higher education courses is in fact to improve managerial, educational and research skills in nurses, reinforce ethical conduct and professional behavior in them and train specialist clinical nurses.[34]

However, there are challenges such as cultural challenges, challenges regarding professional identity and work environment, and the issue of imbalance among education, research and clinics.[35] It has been reported that willingness to quit the job is more intense among nurses who hold MSc degrees.[33] This is while in leading countries in the field of professional nursing education, nurses who hold higher educational degrees (particularly the ones who have passed postgraduate courses) work in clinical environments.[7,20]

According to the findings, the total score which showed all aspects of professional attitude in nurses was 13.3 (2.3). The score could be categorized as average and the majority of the nurses who participated in this study (92.4%) were at this stage. The only study carried out in Iran about nursing trainers' attitudes towards professionalization also indicates that the trainers' attitudes towards professionalization can be placed at an average level.[30] The rate of nurses' professional attitudes in the United States is at a higher level according to the studies carried out in that country. This rate was reported to be 83.37 in the year 2003 in a study performed by Wynd.[7] However, in a study conducted by Kim-Godwin et al., in 2010, the mean obtained score was 89.3,[20] a score that indicates a high level of professionalization. The findings of these studies show that the mean obtained score in 2010 was higher than that of 2003. This difference can be due to the difference in demographic characteristics of the nurses who participated in the studies. Nurses who participated in Kim-Godwin's[20] study were Korean-American nurses, 70% of whom had more than 10 years of clinical work experience in the United States and 60% of whom had worked in clinical environments for more than a total of 20 years. The authors state that work experience in the United States has resulted in the nurses' acquisition of clinical skills and helped them overcome linguistic and cultural barriers. In addition, holding higher academic degrees and passing educational and training courses in the United States can be mentioned as other reasons for getting higher scores.

With regard to the five aspects of professional attitude, in this study the scores can be ranked from the highest to the lowest in this manner: membership in a professional organization, sense of accepting one's major, belief in self-regulation, sense of autonomy and belief in providing public services. The highest scores were allocated to the dimensions of membership in a professional organization and sense of accepting one's major. In the study of Iranian nursing trainers' professional attitudes,[30] the highest to the lowest scores were given to belief in public services, sense of accepting one's discipline, membership in professional organizations, sense of autonomy and belief in self-regulation. Kim-Godwin et al.,[20] study showed this order: self-regulation, autonomy, sense of accepting one's field of study, belief in providing public services and membership in professional organizations and in Wynd[7] the highest scores were associated with a belief in providing public services, sense of commitment and sense of accepting one's discipline.

The results of the studies indicate difference in nurses' attitudes in different aspects and at different times. Formerly, nurses were inclined to give higher scores to belief in providing public services and sense of commitment to and acceptance of one's field of study or work while today they tend to move towards the aspects of autonomy and membership in professional organizations.[7] It might be safe to say that the concept of professionalization has been changed over time due to different political, economic and social changes.

Focus on professionalization would lead to the acquisition of such a power through which professions can find the path towards improving support for clients, creating better working conditions, having a better professional status, gaining autonomy and being influential and effective. The major part of this professional power can be achieved by working in professional organizations.[7] Membership in professional organizations has been recognized as an important predicting factor in professionalization. In this study, the maximum score is given to this aspect 14.31 (2.21). Despite the high score allotted to this dimension, the results indicate that only 29.2% of the Iranian nurses are members of the Iranian Nursing Association. This proportion is not significant regarding the age of this association and the role it plays in professionalization. In Wynd, few nurses were members of professional organizations such as ANA but the same number of individuals had higher scores of professionalization.[7]

Sense of acceptance means being committed to one's profession and goes beyond economic motifs. Professional people are committed to carrying out specific tasks and serving their clients with in the best possible manner. This aspect of professional conduct also got a high score in this study which shows that the nurses who participated in the study are committed to their jobs and their clients. These results are consistent with the results of other studies.[7,20]

The findings indicate the score obtained for self-regulation is at the average level compared to the other aspects. This is so while in previous studies, this aspect was placed at a low level regarding its score.[30] Self-regulation is a kind of "self-control" in the people of a group; i.e. only the individuals who belong to a profession have the right and specialty to judge their colleague's work and this is a sort of belief that does not commonly exist among Iranian nurses.[1] This interpretation of self-regulation is very close to the concept of "autonomy."

Autonomy allows professions to decide about themselves and judge the services provided with the minimum pressure from outside sources such as employees, janitors, law-makers and other professions.[36] It can be concluded that these two dimensions of professional behavior are very closely related and lack of autonomy results in weakness to self-regulate.

Low scores given to the aspect of autonomy in this study is consistent with the results of other studies.[7,30] Autonomy is interpreted as the right to decide for oneself and take action according to the decisions made[37] and autonomy in making decisions is considered as a professional characteristic.[38] Most researchers agree on the fact that autonomy is necessary in achieving a professional status in nursing.[39,40] In a study carried out by Adams and Miller, nurses who had more autonomy in making clinical decisions and were directly responsive to patients, acquired higher scores in professionalization.[41]

Hall refers to professional autonomy as one of the most important structural aspects in professionalization[1] and believes that low professional autonomy is a relatively common issue among nurses and might be related to their working conditions in hospitals and having to obey doctors.[30]

Failure in achieving autonomy in nursing can be related to different challenges including an ambiguous definition of autonomy, using inappropriate tools to measure autonomy, lack of a theory that is relevant to nurses' autonomy, inappropriate education of nursing students and trainers' emphasis on traditional training methods, lack of success in cooperation and teamwork, lack of support on the part of managers and inappropriate managerial structure, size of the hospital and its effect on organizational structure and nurses' capability and power.[42]

The lowest score was given to the aspect of belief in providing public services while in other studies,[20,30] this dimension of professional behavior is given higher scores. Belief in providing public services means that an individual's profession is essential, necessary and useful for the society. Belief in public service provision requires a kind of altruism and a perspective where members look at professionalism as a desirable characteristic and do not adopt a negative outlook on it, viewing it as something that is solely mechanical, inflexible and routine which is practiced with emotionless knowledge and unquestionable obedience against pre-determined rules and policies.[30] Perhaps, working in the stressful clinical environment and lack of satisfaction are the reasons for the low scores given to this aspect.

Numerous internal and external factors are related to levels of professionalization among nurses. According to the findings of this study regarding the demographic variables under investigation, only the variables of work experience and participation in training courses for personal empowerment have affected nurses attitudes towards professionalization.

In Kim-Godwin et al., study age, membership in professional organizations, nurses' present job status, working environments, work experience as a nurse in the United States, the education center where the latest academic degree was achieved and the length of nursing training in the United States were the factors that affected the rate of professionalization in the Korean nurses who worked in the United States.[20]

Wynd studied 774 nurses who had been selected through random sampling and found that higher degree in nursing, work experience as a nurse, membership in professional organizations, working as a manager in an organization and having technical nursing licenses are related to professionalization in nursing.[7]

In a study conducted by Yoder, the variables of age, work background and work experience had significant relationships with professionalization.[43]

What is common in the results of all studies is work background and experience. Gaining experience would lead to the acquisition of a better outlook towards one's job and helps an individual become more sophisticated. Nurses with the highest work experience (31 years and more) got significantly higher scores in professionalization, membership in professional organizations and sense of acceptance. Other studies also show that work experience affects the formation of attitudes towards professionalization.[44]

Another important and influential variable is education and its level. In a study conducted by Hampton & Hampton, it was shown that higher levels of education in midwife nurses were associated with higher professionalization scores.[45] Kim-Godwin et al.,[20] asserted that levels of professionalization among Korean American nurses were influenced by nursing education in the United States and nurses who had received their last academic degree in the United States had higher scores of professionalization. In addition, nurses who had passed some types of official nursing training courses in the United States scored higher in professionalization, as well. This shows the importance of education and its effect on nurses' professionalization.

As mentioned before, among the various factors that affect nursing professionalization, the role of nursing trainers is of utmost importance.[2] The results of a study performed by Elahi et al.,[46] indicate that nurses' weakness in scientific knowledge and practical expertise are two of major obstacles in front of students to become qualified as professional nurses who step into the clinical environment well-prepared. Education does not simply consist of passing courses or getting high degrees. It also involves in-service training. This study indicates that participation in in-service training sessions and getting technical licenses affects nurses' rate of professionalization. Similar conclusions have been reached by other studies as well.[7,20] According to a study carried out by cary, receiving valid certificates has benefits such as gaining experience, getting financial rewards like having an increase in one's salary, getting a raise and acquiring job security, and an increase in an individual's professional credibility through the improvement of his/her knowledge and expertise.[47]

Lack of relationship between professionalization and other variables under investigation might be due to the differences that exist in the number and characteristics of the participants in the study and differences in political, social and economic conditions, types of education received, work environments and conditions that govern them and some other criteria.

The findings of this study and those of the others indicate that although all aspects of Hall's professional attitude are highly important, a change in the trend can be seen over the past 35 years since different aspects have been emphasized at different times during this period. For instance, attitudes have turned from the aspects of belief in providing public services in the past to the acquisition of autonomy and membership in professional organizations in the present times.

Conclusion

The findings give us an insight into the values, features and characteristics involved in the professionalization of Iranian nurses.

Professionalization would lead to professional satisfaction with one's job, provision of better services and higher quality of caregiving to clients. The results show that the rate of Iranian nurses' professional attitudes falls at an average level. It can be stated that with respect to professional conduct, nurses are far from the desirable state. Although steps have been taken towards professionalization, the point that must be mentioned here is that nurses make the least efforts in becoming true professionals. The results also show that the number of nurses who hold MSc. degrees is quite low in clinical centers, nurses do not frequently take part in technical training courses and where they do, it is for the sake of getting good marks on the annual assessments through the certifications they receive. Few nurses are members of the Iranian Nursing Association while membership in professional organizations is considered as a criterion for determining one's professional identity.

Professionalization is a process that needs to be strengthened and supported by managers at different levels. Besides, nurses' efforts and cooperation are of special importance and in fact it is they who must pay particular attention to the topic.

Although the results of this study which investigates the level of Iranian nurses' professional attitude in clinical environments have very important practical implications, there are limitations in the study some of which are self-report nature of data collection tools, nurses' fatigue and perhaps lack of questions' comprehendsibility, and research plan's being descriptive and cross-sectional. Conducting research studies with greater sample sizes or using other research plans can be helpful.

Acknowledgments

All the participants in this study who helped us with data collection and Tabriz University of Medical Sciences which assisted us with its financial support are appreciated and acknowledged.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.