Professionalism Characteristics of Nurses Working in Internal Medicine Clinics

Although there has long been a focus on professionalism in nursing in many countries, it is just now gaining importance in Turkey. In fact, few studies on this topic have been conducted in our country, and this is the first study carried out in the Eastern Black Sea region of Turkey. The aim of the current study was to determine professionalism characteristics of nurses working in the internal medicine clinics of a university hospital located in Trabzon Province. This descriptive study was done with 103 nurses between Feb.1 and Feb. 28, 2015. The data were gathered using a “Personal Information Form” and a “Professionalism Information Form” through face-to-face interviews. To assess the data, numbers, percentages and arithmetical means were employed. In the current study, 95.1% of the participating nurses were female. Their mean age was 31.54+7.42 years, 66.0% of them had an undergraduate degree, 85.4% were clinic nurses, and their average work duration was 8+6.2 years. This current study determined that nurses thought the most important professionalism characteristics were “taking individual responsibility in nursing practices (92.2%)” and “paying attention to using a simple and clear language by establishing a good communication with patients and team members (90.3%)”. The characteristics of “becoming a member of a nursing association (24.3%)” and “feeling the necessity to use the titles of specialist nurse, doctorate nurse (19.4%)” were less meaningful to our study participants.


Introduction
According to the Webster's dictionary, professionalism is "the conduct, aims, or qualities that characterize or mark a profession or a professional person". It is also the recognition and acceptance of the knowledge, skills, and values required of those who have been trained in that profession [1]. Individuals with professionalism characteristics choose a field as a profession, become experts in the field by specialization, become competent in the field, follow developments in the field, contribute to problem-solving efforts and work efficiently with their team members [2,3,4].
Achieving professional status is an important goal in nursing as in all disciplines. The International Council of Nurses (ICN) defines nursing as a profession that helps to protect the health of individuals, families and communities and participates in rehabilitation and treatment protocols in case of illness. Nurses are members of the nursing profession which plays an active role in the development and implementation of treatment and training protocols of the health care team [5]. Professionalism is important in the establishment of nursing care standards and provision of quality services [2]. However, professionalism in nursing is a complex concept [6]. Throughout the world and in our country the nursing profession has been evolving from a traditional nursing model to a professional nursing model. Scientific studies have reported that members of most professions are required throughout their careers to continue in their professional improvement and education. This requires being open to advancements and possessing both intellectual and investigative backgrounds and interests which manifest through responsible leadership and effective communication. In this way, nurses can advance in the career of professional nursing [3].
The basic objective in the provision and management of nursing services is to offer quality health care. To achieve this goal, nurses will be required to conduct studies, establish theories and participate in professional organizations and political activities [2]. However, the studies conducted thus far have reported that the mean professionalism scores of nurses' autonomy, membership in professional associations, and written scientific articles are low [7,8].
It is very important for nurses to project the characteristics and values of professionalism in the nursing profession. These include educational preparation, conducting research, reading publications, providing community trainings, participating in professional organizations, adhering to nursing codes, exhibiting autonomy, and showing competence with sufficient theoretical knowledge and continuing education [3,9,10].
Patients who receive treatment and care at internal medicine clinics are those with very serious health issues, long-term care needs, or treatment challenges. Nurses working at these clinics often witness the physical and psychological pain of patients and their families in life-threatening situations [11]. Therefore, internal medicine nurses serve individuals with high stress health crises, and they themselves suffer intense stress as well. Indeed, in addition to the demands of their professional lives, most of the internal medicine nurses are female who already are struggling to combine the responsibilities of womanhood, motherhood, and the social pressures associated with those roles [5]. In the Zakari, Al Khamis and Hamadi study on how nurses perceived the concepts of professionalism and conflict, most of the nurses perceived their professionalism at low levels [12]. This should cause great concern within the nursing field. When professionalism is not practiced by the internal medicine nurses the consequences can lead to compromised care services, reduced quality of care, and dissatisfaction among those offering services and receiving services. Organizational problems may be the result, which can negatively impact the professionalism of internal medicine nurses [5].
The efficacy of nursing care provided to patients hospitalized at internal medicine clinics depends on nurses' ability to display professional characteristics such as professional knowledge, autonomy, and discipline [13,14,15]. The importance of professionalism and the ability of internal medicine nurses to offer care and services at a satisfactory level are an absolute necessity. Furthermore, should difficulties in providing services arise, the need to maintain professionalism as problems are solved is equally important [9,10]. Acquisition of professionalism characteristics by internal medicine nurses enhances quality of nursing services and reduces errors. It also provides a path to professional advancement and specialization and boosts performances and satisfaction with the job and nursing services [11,16]. Other advantages are that the hospital stays of patients and costs in health services decrease [2,17]. A study on the effect of job satisfaction upon professional behaviors found a significant and positive correlation between them [18].
We believe that more studies are needed which explore the professional characteristics of internal medicine nurses. More research on this topic will contribute to the ongoing need for nurses to remain cognizant of the importance of continual professional growth and development. The current study was undertaken to determine the professionalism characteristics of internal medicine nurses employed at internal medicine clinics.

Type and Place of the Study
The current study, in descriptive design, was undertaken at Internal Medicine Clinics of a university hospital located in Trabzon Province, Turkey.

Population and Sample of the Study
The population of the study consisted of 153 nurses working at the Internal Medicine Clinics of a university hospital located in Trabzon Province. No sampling was made and the whole population was targeted. However, for various reasons the study was completed with 103 nurses. Twenty-three nurses were off duty or on sick leave, seven nurses were out of Trabzon Province due to educational commitments, sixteen nurses declined to participate in the study and four nurses transferred to another clinic between Feb. 1 and Feb. 28, 2015. Nurses who worked at internal medicine clinics and volunteered to participate in the study were recruited for the study.

Data Collection Tools
The data were collected using the "Personal Information Form" and the "Professionalism Information Form".

Personal Information Form
The "Personal Information Form" was designed by the researchers after a literature review. The form included seven questions addressing nurses' "sex, age, marital status, educational level, clinic where nurses worked, work-position and work-duration".

Professionalism Information Form
The "Professionalism Information Form" was designed by the researchers after a literature review. There were 24 questions to determine professionalism characteristics of nurses working in internal medicine clinics. The questions were as follows: "do you take individual responsibility in nursing practices?"; "do you pay attention to division of labor in team work?"; "do you demonstrate positive attitudes while offering nursing services?"; "do you make efforts to produce different and customized nursing services for each patient?"; "do you perform your nursing duties in a professional manner?"; "do you support association/society related activities?"; "do you use evidence-based study results in nursing practices?"; "do you follow scientific and technological developments and advancements in nursing?"; "do you promote constructive and positive conditions and actions in nursing practices?";"do you feel the necessity to use titles of specialty nurse, doctorate nurse?" etc.). The questions were answered as "yes", "no" and "partly".
The "Personal Information Form" and "Professionalism Information Form" were administered to nurses who worked at internal medicine clinics and who had volunteered to participate in the study through face-to face-interviews. The study took place Feb. 1 to Feb. 28,2015, and participants needed about 20 minutes to complete the forms.

Assessment of the Data
The Statistical Package for the Social Sciences (SPSS 18.0) was employed for the assessment of the data obtained from the study, and number, percentages and average scores were used.

Ethical Suitability of the Study
Before the study, the ethical suitability of the research was approved by the Office of the Head Physician of Farabi Hospital of Medicine Faculty of Karadeniz Technical University. In addition, all patients were informed of the purpose of the study and gave their informed consent to take part in the study.

Results
For this current study, 95.1% of the participants were female. Their average age was 31.54+7.42 years and 58.3% of them were married. Sixty-six percent of them had an undergraduate degree, all of them worked at internal medicine clinics (100.0%), 85.4% of them were clinic nurses and their average work-duration was 8+6.2 years (Table 1).  When the current study examined the professionalism characteristics of the internal medicine nurses, findings showed that 92.2% of them took individual responsibility in nursing practices; 90.3% of nurses used simple and clear language to communicate effectively with patients; 84.5% of them used simple and clear language in their communication with members of the health care team; 84.5% of them paid attention to division of labor in working with their team, and 81.5% of the nurses demonstrated positive attitudes while offering nursing services. Other findings revealed that they wanted nursing services to be specifically customized for each patient (78.6%). They also designed a work plan for themselves while working (77.6%), and they thought nursing should have specialization (77.6%). Nurses emphasized correct nursing practices even though other members of the health care team did not (76.7%). In addition, 73.8% of internal medicine nurses made efforts to work with patients and members of the health care team to solve the problems at the clinics. The study results also showed that 70.8% of them thought there were circumstances that would limit professionalism in the nursing profession. These included a stressful work load, responsibility for too many patients and institutional nursing care policies.
In our study, 67.9% of the nurses felt the need to obey the work rules in nursing practices. They also had the necessary knowledge and skills to be a professional in the nursing profession, and they made efforts to produce different and customized nursing services for each patient. The study results showed that 61.2% of the participating nurses made efforts in nursing practices to increase patients' trust in them, and 60.2% of the nurses tried to consistently carry out their nursing duties in a most professional manner. Nurses wanted nursing practices to be evaluated by their nursing colleagues (58.3%), supported association/society related activities (57.3%), used evidence-based study results in nursing practices (50.5%), and they could detect problems of patients in advance (50.5%).
The current study results also showed that 42.7% of the internal medicine nurses followed scientific and technological developments and advancements in nursing; 30.1% of them found ways to improve nursing practices and to initiate needed changes; 24.3% of them became a member of an association/society in nursing; and 19.4% of them felt the need to use titles of specialist nurse, doctorate nurse ( Table 2).

Discussion
Internal medicine nursing is a specialty field in the nursing profession. Among the individual characteristics that nurses should have are the competence and ability to help individuals and the desire to find solutions to their problems. It is important to be professional and to demonstrate these characteristics in internal medicine nursing which serves different patient groups. Determining and developing professionalism characteristics of internal medicine nurses are important in terms of enhancing quality of nursing care [13]. In the current study, it was found that nearly all of the internal medicine nurses took individual responsibility for their nursing practices. This quality ranks first among professionalism characteristics of internal medicine nurses (92.2%). The American Nurses' Association defines taking individual responsibility as "questioning individuals about their actions". Individual responsibility includes "accountability for colleagues, oneself, those treated, and the institution where they work". Therefore, responsibility does not refer only to fulfilling a duty in line with instructions. It is being willing to carry out the duty and having a certain amount of knowledge and implementing one's own decisions [19]. The study of Jang et al. on oncology nurses found that nurses received the highest score in self-control beliefs as related to their professionalism [11].
A significant number of the study participants reported that they paid attention to using simple and clear language to ensure good communications with their patients (90.3%) and team members (84.5%). One study identified that nurses who established good communication with patients and members of the health care team demonstrated higher professionalism [5]. The study of Karakoc Kaya et al. reported that nurses who established a good relationship with superiors felt more independent in their profession [20].
It was determined that 84.5% of the internal medicine nurses paid attention to division of labor in teamwork, and 77.6% of them designed a work plan for themselves. In order to increase the level of professionalism in the nursing profession, nurses must feel a commitment to and responsibility for their profession and professional identity [11]. Professionalism requires that nurses take responsibility for their own role as part of the team. In addition, they need to be committed to the individual team members' success as well as to the entire team as a unit [6]. This current study found that most of the nurse participants assumed this responsibility.
The first step in establishing a high degree of professionalism begins by considering oneself a professional and demonstrating a professional work ethic [3]. Within the work environment one's colleagues will always evaluate how a person speaks, presents themselves, and performs their job tasks [3,5]. In keeping with these principles, the goal of nursing professionals is to protect and respect the dignity of patients in their care. The current study results determined that the participating nurses demonstrated positive behaviors while offering nursing services (81.5%).
In the current study, the nurses wanted nursing services to be customized for each patient (78.6%) and made efforts to implement this (67.9%). With access to the internet and other sources of information, most individuals know more about nursing services, question these services, and they also expect more when it comes to their health care. Therefore, patient-centered care has now become the focus of an emphasis on quality nursing services [21]. An important part of professionalism includes respecting each patient's individual choices, needs and values. In the current study, we found that many of the nurses achieved these goals successfully.
Another topic of focus for the study participants was their belief that nurses should have an area of specialty within the field of nursing (77.6%). The study of Wade found that being a certified nurse increased the quality of patient care given by nurses. They also had greater job satisfaction, professional sensitivity, and a greater sense of responsibility role to their team. The study of Wynd also confirmed that being a certified nurse increased professionalism [8,22].
Hutchings et al. pointed out that a very important professionalism characteristic for many nurses was the consistent modeling of correct practices, thus ensuring continuity of patient care [23]. Indeed, the current study supports this finding which showed that a significant number of the nurses (76.7%) reported that even when their health care team members no longer practiced correct nursing protocols, they were determined to follow through on their tasks in the most professional manner possible.
Nurses bear the responsibilities of developing positive relations, solving conflicts and increasing the quality of nursing care. In addition, the nursing profession requires critical thinking, problem solving, and analyzing skills. In the current study 73.8% of the nurses made efforts to contribute to the well-being of patients and members of the health care team regarding any problems that arose. These study participants understand the importance of demonstrating their professional characteristics by exercising their autonomy, independence, and respect for others in problem-solving strategies [11]. Furthermore, they also know that the most effective way to attain professionalism characteristics in nursing is to employ critical thinking and scientific problem solving skills [2].
Our study found that 70.8% of the participating nurses thought there were circumstances that would hinder professionalism in the nursing profession. Factors such as irregular work conditions, a high number of patients per nurse, negative or uncooperative behaviors on the part of health team members or patients, too many responsibilities outside of nursing services and working under intense stress impede a nurse's capacity to practice professionalism in nursing [5]. Nonetheless, such negative circumstances highlight the importance of always retaining one's professionalism in nursing.
One of the criteria of professionalism is to abide by work rules and instructions. In our study, 67.9% of nurses reported that they obey the work rules in their nursing practice. The basic values of professionalism in nursing also require an awareness of professional duties, advocacy, dignity, honesty, autonomy and perfectionism. [6]. In the current study, the fact that most of the nurses felt the necessity to obey the work rules in nursing practices made us conclude that they demonstrated their professionalism and commitment to the duties and tasks of their chosen profession.
A profession encompasses the activities done through knowledge and skills gained with a certain education and training [5]. In the current study, more than half of the internal medicine nurses (68.0%) reported that they had the necessary knowledge and skills to be a professional in nursing. This finding made us conclude that more emphasis needs to be put on improving internal medicine nurses' professionalism. Although scientific knowledge and using theory in practice are important characteristics of nursing, Tan et al. reported that the duties and care that nurses provided to patients were dependent on nurses' professional knowledge and skills [13].
Being reliable and trustworthy are particularly important qualities with respect to professionalism characteristics. Bimray and Jooste suggested that nursing care is based on a trust relationship between patient and nurse [6]. Our study results found that the internal medicine nurses (61.2%) made efforts in nursing practices to earn the trust of their patients. To earn patients' trust, nurses must exhibit many professional attributes. These include treating patients with dignity and providing fair, defensive and patient-centered nursing services. Nurses must also follow the rules of confidentiality, provide understandable and clear information, and update their knowledge and skills [23].
To achieve professionalism in nursing, the values of this profession must first be named and defined. Thereafter the objectives, tasks, and activities required in the profession of nursing should also be identified. In nursing professionalism, beliefs, opinions, ideas and values (prestige, autonomy, knowledge accumulation, etc.) are integrated [11]. These values enhance safety, ethics and competence in nursing care [6]. In our study, 60.2% of nurses were always careful to perform their nursing duties in the most professional manner possible. This finding made us conclude that more internal medicine nurses need to work towards this goal. Professionalism is strongly reflected in behaviors and actions demonstrated by nurses. This means that the professional message conveyed by the nurses' practices must coincide with the professional values of being a nurse [6].
Assessment and evaluation of nursing practices by other nursing colleagues are crucial to providing successful health care. In the current study, more than half of the internal medicine nurses (58.3%) wanted nursing practices to be evaluated by their colleagues. It is argued that remarks of nursing colleagues help nurses review patient care and shed light on policies and practices that affect the standards and quality of nursing care [21].
One of the significant criteria of professionalism and being a professional is membership in professional societies or associations. This study found that 57.3% of nurses supported association or society-related activities but only 24.3% of them were members of such organizations. The purpose of professional societies or associations, which are usually established by members of a certain profession, is to define professional roles, establish professional ethics and policies, strive for professional rights, increase media publicity, help members build group consciousness and pride, empower the profession and motivate professional members [24]. In a study done with nurses, 76.2% of nurses did not belong to any professional societies or associations [24]. Similarly, the study of Karadağ et al. indicated that the rate of nurses' participation in professional organizations, societies or associations was low [25]. In our country, as well, participation in professional organizations, societies or associations was not at a desired level.
Nurses who are devoted to their profession are interested in improving patient care quality and the development of professional characteristics. This requires that nurses incorporate the results of studies and the use of evidence-based practices into their nursing responsibilities. Organizations such as the ICN and the American Association of Colleges of Nursing emphasize that professional nursing should be developed through evidence-based practices. We found that only 50.5% of study participants used evidence-based study results in their nursing practices. This indicates that more studies should be supported and conducted. Opportunities should also be made available so nurses may attend congresses and symposiums so they may assess and evaluate studies from a critical perspective [26,27].
Professionalism includes the ability to make an early diagnosis and medical intervention of a patient's needs. This ability has been found to be associated with nurses' motivation, decision-making, happiness and level of burnout [11]. In the current study, 50.5% of the study participants stated that they were able to diagnose patients' problems in advance. The efficacy of nursing care given to patients depends on nurses' professional knowledge and skills as well as the ability to use these in assessing patient needs [13]. The study of Tan et al., conducted with internal medicine nurses, reported that 54.7% of nurses had difficulty implementing a care plan and determining a diagnosis [13]. Therefore, to deliver the best care possible, nurses should strive to prioritize a patient's most urgent needs [19]. This current study determined that only half of the nurses had enough knowledge and skills to detect patient difficulties in advance.
In today's world, medical advancements and practices change quickly. Our study found that less than half of the internal medicine nurses (42.7%) kept abreast of the latest 52 Professionalism Characteristics of Nurses Working in Internal Medicine Clinics scientific and technological developments and advancements in nursing. A study on nurses' participation in scientific activities and events reported that 78.9% of the nurses had attended professional scientific meetings (congress, symposium, etc.) at least once [28]. The study of Karamanoglu et al. indicated that the rate of nurses who did not join any professional scientific meeting was 50.5% [5].
Although nurses play an active role in demonstrating their knowledge, abilities, and experience in their nursing practices, only 30.1% of the nurses in this current study made efforts to create and implement constructive/positive conditions and actions in their nursing practices [23]. One way to make positive change in this regard is to encourage professional nurses to communicate and share information with their colleagues, patients, families and others [6]. Regarding the current study, we believe that internal medicine nurses should receive strong encouragement and support to develop constructive/positive conditions and actions that will improve their nursing practices.
Education is an important feature of professionalism. For this reason, a graduate and/or doctorate degree should be required to work as a professional internal medicine nurse. In the current study, only 19.4% of the nurses felt that it was necessary for nurses to have a specialty in nursing (requiring graduate studies) or to possess a doctorate degree. The study of Tanaka et al. done with Japanese nurses reported that the professionalism level of nurses was low, and they linked professionalism to possessing a higher education [29]. The same study also found that nurses with higher education degrees scored higher in their professionalism characteristics. However, in the current study 73.8% of the internal medicine nurses did not believe in the need to use titles of specialist nurse or doctorate nurse in the work environment even if they had achieved these levels of higher education.

Conclusions
The current study produced the first data to research professionalism characteristics of the nurses who worked at internal medicine clinics in Turkey. Results showed that nurses' willingness to accept individual responsibility for their nursing practices was at a high level, however, their need to use titles of specialist nurse or doctorate nurse was at a low level. Our study results confirmed the need and importance of supporting the growth and development of nurses' professionalism characteristics. We recommend that internal medicine clinic nurses receive support and encouragement to achieve this goal. We also suggest that nurses be encouraged to become members of professional associations, and we emphasize the importance of increasing their expertise and experience by participating in scientific activities and educational programs.