Funda Erol  ( Nursing Department, Sakarya University, Faculty of Health )
Gulengun Turk  ( Adnan Menderes University, Faculty of Nursing, Turkey )

Objective: To determine nurses' caring attributes and professionalism.
Methods: The descriptive study was conducted between January and July 2015 in two university hospitals in two Turkish cities and located in two state hospitals belonging to the Ministry of Health of the Republic of Turkey. Data was gathered using nurse introduction form, caring behaviours inventory-24 and the inventory of professionalattitude at occupation. Data was analysed using SPSS 16.0
Results: Of the 360 subjects, 316(87.8%) were female and 177(49.2%) worked in intensive care units. The overall mean age was 30.83}8.02 years. The mean CBI-24 score was 5.20}0.6, and the mean IPAO score 137.39}16.29. A statistically significant difference was found among caring behaviours point average and the institution, age, workexperience, clinic where they worked and their working position  (p<0.05 each). Institutional work environmentaffected professional attitude of nurses (p<0.05).
Conclusions: Nurses' caring attributes and professional levels were high.
Keywords: Nurse, Nursing care, Quality, Professionalism, Professional attitude. (JPMA 69: 783; 2019)

Introduction

Care is a concept that is often used in nursing literature, and it is regarded as the basis of the discipline. 1 Providing care is one of the basic missions of a nurse in which professional knowledge, skills and abilities are used, and autonomous decisions are made. Nursing care is a service that every individual member of society will require or has required at some point of their lives. While the quality of the care services reflects the general health services, caring is the primary responsibility of nurses before everyone else. Therefore, to provide high-quality care, nurses require the necessary knowledge and skills, and they must be sensitive to the humane and moral aspects of caring. They continuously need to improve their professional competence, and they must provide services in compliance with professional ethics. 2,3 It is apparent that professional and competent nurses are essential for the providing implementation of higher quality nursing care. 4  Therefore, for the professionalization of nursing, it is very important that members of the nursing profession fulfil the necessities of their profession knowing their professional values of educational preparation, research, publication, providing social services, participating in professional organisations, nursing codes, autonomy, theory, competence and continuing education. 5  Establishing a professional attitude among members of the profession also contributes to facilitating professional unity and improving the professional status besides improving the quality of care. 6  
It is becoming mandatory to measure, improve and develop the quality of care, which is such an essential aspect of the nursing profession. There are studies conducted in Turkey that have investigated the levels of professionalism among nurses. However, we did not come across any study that evaluated the relationship of nurses' perceptions of caring behaviours and their occupational professionalism with their caring behaviours in Turkey. Therefore, the current study was planned to determine the perceptions regarding the caring behaviours and occupational professional attitudes of the nurses in Turkey.

Subjects and Method

The descriptive study was conducted between January and July 2015 in two university hospitals in two Turkish cities and in two state hospitals belonging to the Turkish Ministry of Health. The universe of this study consisted of the 1933 nurses working in two university hospitals (hospital I: 507 - hospital II: 541) in two metropolises and in two state hospitals (hospital III: 340 - hospital IV: 545) belonging to the Ministry of Health of the Republic of Turkey. In the study, 321 were planned to be reached within the 95% confidence level using the stratified sampling method. After the number of samples was determined, thehospitals were accepted as a layer and the number of nurses (1. hospital: 94 - 2. hospital: 97 - 3.hospital: 74 - 4. hospital: 95) to represent each cluster has been determined. Voluntarily participation was ensured in each case. Nurses working in the outpatientclinics and those who did not agree to participate were excluded. Written permission was obtained from the institutions in which the study was carried out and from the ethical board for non-interventional clinical research of one of the universities. Subsequently, data was collected using the nurse introduction form (NIF), the caring behaviours inventory-24 (CBI-24) and the inventory of professional attitude at occupation (IPAO) prepared by the researchers through literature scanning.1,4,6,7 The NIF consisted of 11 demographic questions. The validity and reliability trial of CBI-24 was carried out earlier. 7  This is a Likert-type scale and consists of 24 items in 4 subgroups, namely assurance (8 items=16, 17, 18, 20, 21, 22, 23, 24), knowledge and skills (5 items = 9, 10, 11, 12, 15), being respectful (6 items = 1, 3, 5, 6, 13, 19) and connectedness (5 items= 2, 4, 7, 8, 14). After scores of all articles are summed, the total scale score between 1 and 6 is obtained through dividing that sum by 24. And the sub-dimension scale scores between 1 and 6 are obtained through dividing the sum of the scores of the articles which fall within the sub-dimensions by the number of articles. As the sub-dimension and total scale scores increase, so do the levels of perception of care quality of both nurses and patients. It was identified that the Cronbach's alpha value of the scale was higher than 0.80. Cronbach's alpha value of our study was 0.95. The IPAO was developed by Erbil and Bakir8 to provide an instrument specific to Turkish culture to determine the occupational professional attitudes of nurses and midwives. The scale is a 5-point Likert-type selfassessment scale with 32 items. The total IPAO score gives the score of professional attitude in occupation. It is evaluated that as the score increases, the professionalism level also increases. The Cronbach's alpha value of the IPAO was identified as 0.89. 8  The Cronbach's alpha value of our study was 0.93. Data was analysed using SPSS. Kolmogorov-Smirnov test was used to determine whether the data was normally distributed or not. Spearman-Brown Correlation technique was used to identify the relationship between the caring behaviour of the nurses and their professional attitudes. To determine the differences between the caring behaviours and professional attitudes of the nurses, Mann-Whitney U test was used for the criteria of gender and institution worked in, and the Kruskal Wallis test was used for the criteria of age, education, years worked, work position, and the clinic worked in Statistical significance was set at p<0.05.

Results

Of the 360 subjects, 316(87.8%) were female; 174(48.3%) were aged 18-29 years with average of 30.83}8.02 years; 180(50%) had graduate degrees; 191(53.1%) worked in a university hospital; and 177(49.2%) worked in intensive care units (ICUs). Overall, 118(32.8%) nurses had been working for 1 to 5 years. Caring behaviour was assessed for each demographic characteristic (Table-1).



(Page-785) The organisation worked in, age group, education level, years worked, clinic worked in, and work position affected CBI-24 scores (p<0.05), while gender and education did not have any influence (p>0.05). The institution worked in affected the occupational professional attitudes of nurses (p<0.05). The overall mean CBI-24 score was 5.20 } 0.6 and the mean IPAO score was 137.39}16.29 (Table-2).



A positive relationship of moderate degree was identified between IPAO and CBI-24 and the subscales of the CBI-24 assurance, knowledge and skills, being respectful and connectedness (p<0.00) (Table-3).



Discussion

Nursing care is essential in the maintenance of human life, as well as improvement and preservation of life quality. The advances in health-related knowledge and technology, the shift in individuals' expectations and opinions about health, individuals participating in their care more actively, and the increase in costs and competition in the health industry have brought providing care of higher quality to the agenda. 7  Establishing a professional attitude among members of the profession also contributes to facilitating professional unity and improving the professional status of nurses besides improving the quality of care. 6  In our study, it was identified that the levels of perception of care quality among nurses were high. InUzelli's9  study that determined the caring behaviours perceived by nurses, it was identified that the perceptions of caring behaviour among nurses were high (5.44 } 0.33). In their study, which determined the work environment and caring behaviours of nurses, Burtson and Stichler10 identified that the perception levels regarding caring were high among nurses. Another study conducted has shown that the caring behaviour scores of both clinical nurses and nurses in training are high. 11  The findings of our study are similar to the findings of other studies in literature. It is pleasing that the levels of perception regarding caring behaviours was high among the nurses in our study. However, the fact that more than half of the nurses in our study worked in ICUs may have affected this result, because the number of patients appointed to one nurse is lower and the time allocated to the patients' care is longer in ICUs. In our study, nurses registered took high scores in every subscale of the CBI-24. The highest scores in the subscales were in the knowledge and skill subscale, and the lowest was in the commitment subscale. In various studies, it has been identified that the highest scores was reached in the knowledge and skill subscale while the lowest scores were recorded in the connectedness subscale.9,12,13 As such, the findings of our study regarding CBI-24 subscales are parallel to similar studies in literature. Occupational professionalism is rather important in establishing the standards of the profession and providing quality care. A professional attitude is a desired characteristic. In the current study, the nurses' professional attitudes were high (137.39}16.29). In other studies, it has also been identified that the professional attitudes were high.8,14,15 Dikmen et al.6 identified the average total IPAO score as 140.28.01}11.99. The study conducted among 156 nurses by Tarhan et al.16 established that the levels of professionalism among nurses were high. In another study conducted by Goris, 17  the level of professionalism among nurses was above average and was identified as 90.7}14.7.Establishing a professional attitude among members of a profession contributes to improving the quality of care and the professional status. Caring is one of the important indicators of professionalism. In our study, a positive relationship of moderate degree was detected between the occupational professional attitudes and caring behaviours of nurses. It is believed that the occupational professionalism of nurses will increase as the perception levels of nurses regarding caring behaviours increases. A statistically significant difference was noted between the nurses' years of work and their perceptions of caring behaviours. The caring behaviour scores of the first five years were high and the scores decreased after the fifth year in the current study. It is thought that the decrease in scores may be due to excessive workload. A statistically significant difference was identified among the clinics the nurses worked in regarding their perceptions of caring behaviour. Scores of ICU nurses were high and they were lower in nurses working in emergency clinics. It is thought that this is due to the fast patient circulation and the shorter duration of stay in emergency clinics, and because nurses only get to spend a short time with patients because they are then either admitted to the relevant clinic or discharged. There was a statistically significant difference between the nurses' work positions and the perceptions of caring behaviours. It was observed that the perceptions of caring levels among ICU nurses were higher than those of clinical nurses. The number of patients per nurse working in clinics is high in Turkey. This reduces the time nurses spend with patients. The number of patients per nurse is lower in ICUs than it is in other clinics, and the time spent with the patients is longer. It is considered that this condition may have affected this result.No statistically significant difference was present between the nurses' caring behaviours and the occupational professional attitudes with respect to their gender and education levels. While it is expected that the perception levels of nurses regarding caring behaviours and their occupational professional attitudes would increase as their education levels increase, it is a surprising fact that education had not demonstrated any effect in our study. In a study, 18  it was determined that there was no significant relationship between the education levels of the nurses and their perceptions ofcaring behaviours. Similar to the current study, others have also reported that the nurses' gender did not influence their perceptions of caring behaviours. 9,19  In one study, 14  it was stated that there was no significant relationship between the education levels of nurses and their IPAO scores. The fact that the research area encompassed only two Turkish cities limits the possibility of generalising theresults. Besides, male nurses in the study were far fewer than the females. In the light of the results, clinical nurses should be provided with opportunities for recognising and improving their own care behaviours. It is recommended that new studies should be conducted to identify the other factors that influence the caring behaviours and occupational professional attitudes of nurses and to determine the care provided by nurses by means of instruments tested for validity and reliability at certain intervals.

Conclusion

The perception levels of caring behaviours and the occupational professional attitudes of the nurses werehigh. The perception among ICU nurses was higher than that of clinical nurses.

Disclaimer: The study is part of a thesis project and was presented at the 4th Basic Nursing Care Conference in Turkey.
Conflict of Interests: None.
Source of Funding: The Adnan Menderes University Scientific Research Projects Unit.

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