Students’ professional attitudes and behaviours during the courses is important in nursing education and must be taken into consideration during their training [1,4,5]. It is evident that the first and most critical stage in professionalism is when an individual enters the educational or apprenticeship environment as a nursing student [6].
Various factors affect professionalism in nursing and the role of nurse educators is particularly important [7]. The results of a study by Elahi N et al., indicated that the weakness of nurse educators in academic and clinical education is one of the factors that hinders a nursing student’s ability to acquire the competencies and higher levels of professionalism [8]. Nikbakht Nasrabadi A et al., also showed that unpreparedness of nurses to enter clinical environments is the main reason for the delay in the process of professionalism [7]. In fact, in all educational fields, influential variables such as behaviours, beliefs, emotions, feelings, interests, experiences, motivation and development of positive attitudes play significant roles in achieving educational goals [9]. Therefore, nursing education in all educational institutes must be planned and applied in a way that would lead to the creation of a positive professional attitude in nurses and nursing students [10].
Despite recognition of the factors that affect professionalism and the modifications, changes and efforts made to develop the professional status of nursing, there is still a poor social image of the nursing profession in Iran [7]. The lack of professionalism has led to the criticism of nurses’ skills and abilities in providing nursing care [11] and they have often been considered impaired or incompetent in fulfilling their clinical tasks [12]. In addition, nurses have usually felt that they have not become fully professional yet and see numerous complex challenges in front of them on the way to professionalism [7,13]. Nevertheless, now-a-days the society needs nurses who can accept their profession, develop attitudes and characteristics related to professional roles in themselves and succeed in playing those roles in different conditions [14].
One of the important reasons to study the nurses’ attitudes before employment is to gain information about the attitudes and behaviours that exist among nursing students before employment. These attitudes can be identified before the nursing student start their professional life so that they would be able to recognise potential challenges and try to overcome those challenges through more positive attitudes. Therefore, the present study was aimed to investigate the professional attitude in Iranian Nursing Students.
Materials and Methods
Design and Sample of the Study
The present descriptive cross-sectional study was conducted from October 2015 to October 2016 at Ilam University of Medical Sciences. The population of the study comprised all undergraduate nursing students (280 students) in the fourth to eighth semesters. Sample size was determined to be 117 students based on a pilot study and a 95% confidence interval, while 114 questionnaires were filled completely and three questionnaires were omitted due to incomplete information. The sample size is given in details according to the following formula:
d=10% δ=.58 α=.05 z1-α/2=1.96 N=117
The subjects were randomly selected through proportionate stratified random sampling. The inclusion criteria were being a nursing undergraduate, consent to participate in the study and the exclusion criteria were being guest and transfer students. The participants were selected randomly and after being informed about the research goals and being ensured about the anonymity of the questionnaires, they gave their consent to take part in the study. Thus, they were asked to fill out the questionnaires on the same day. Fourth to sixth semester students with clinical education experience completed the questionnaire on the university campus after the end of one of their classes and seventh and eighth semester students were invited to the faculty office to fill out the questionnaire, since they attended different courses.
Research Instruments
One of the data collection tools was a demographic information form to be filled out by nursing undergraduates. The form comprised the variables of age, gender, semester and items related of interest in the profession, membership in the Iranian Nursing Organization and the individuals who would affect the professionalism of nurses.
Another tool used to gather data was the Inventory to Measure Professional Attitudes in Student Nurses (IPASN). This scale measured nursing undergraduates’ attitudes towards professionalism and its levels. It is the only tool that is available to measure nursing undergraduates’ attitudes towards professionalism and was first devised by Hisar F et al., [4] and developed by Çelik B et al., [10]. This scale consists of 28 items grouped according to eight different factors based on the five-point Likert scale. Eight different factors of professional attitude included in this inventory are contribution to the increase in scientific information load (6 items), autonomy (3 items), collaboration (5 items), competence and continuous education (3 items), participation in professional organisations and professional development (3 items), working in committees (2 items), community service (3 items), and ethical codes and theory (3 items). The questions were answered based on a five-point Likert scale (1=completely disagree, 2=disagree, 3=no idea, 4=agree, 5=completely agree). The scale was translated into Persian after getting permission from the authors. Then, its validity was tested with the participation of 10 nursing lecturers. After some revisions, the internal consistency of the inventory was measured to be 0.96 using Cronbach’s Alpha. The reliability was calculated using test-retest with an interval of ten days and the Pearson’s coefficient of correlation was 0.81.
Data Analysis
Data analysis was carried out using descriptive and inferential statistics through SPSS 18, while p<0.05 was considered significant.
Research Ethics
The present study was conducted after getting permission from the Committee of Research at Ilam University of Medical Sciences in accordance with the ir.medilam.rec.1394.85 ethical code. The affiliated departments in the faculty of nursing and midwifery also agreed with the performance of the project.
Results
The nursing students were within the age range of 19-45 with the mean and standard deviation of 22.71±3.13. The majority of the participants (60.5%) were female, 88.6% were single, 65.8% said they were interested in the nursing profession, the majority of them (69.3%) lived in the dormitory, 60.52% said that the nursing educators had been effective in their Professionalism and 15.8% considered the nursing personnel as the most influential factor in their professionalism. Only 13.16% of the subjects were members of the Iranian Nursing Organization [Table/Fig-1].
Demographic variables for the nursing students participating in the study.
| Variable | Status | Number | Percentage |
|---|
| Age (years) | Minimum: 19 | Mean: 22.71 | Standard deviation: 3.13 |
| Maximum: 45 | | |
| Gender | Male | 45 | 39.5 |
| Female | 69 | 60.5 |
| Marital status | Married | 13 | 11.4 |
| Single | 101 | 88.6 |
| Semester | Fourth to sixth | 78 | 68.4 |
| seventh and eighth | 36 | 31.6 |
| Interest in the nursing profession | Yes | 75 | 65.8 |
| No | 39 | 34.2 |
| Place of residence | Dormitory | 79 | 69.3 |
| With the family | 30 | 26.32 |
| Friend’s home | 3 | 2.63 |
| Other | 2 | 1.75 |
| Membership in the Iranian Nursing Organization | Yes | 15 | 13.16 |
| No | 99 | 86.84 |
| Individuals and factors that affect professionalism | Nursing educators | 69 | 60.52 |
| Nursing personnel | 18 | 15.80 |
| Hospital clinical environment | 27 | 23.68 |
Mean and standard deviation for the total professional attitude score was 91.01±15.7. Mean scores on different factors are given in [Table/Fig-2].
Mean scores for different factors of the professional attitude among the nursing students.
| Professional attitude | Range | Mean±Standard deviation |
|---|
| Total professional attitude | 28-140 | 91.01±15.7 |
| Factors | | |
| Contribution to the increase of scientific information load | 6-30 | 15.97±3.35 |
| Autonomy | 3-15 | 9.51±2.00 |
| Collaboration | 5-25 | 15.97±3.35 |
| Competence and continuous education | 3-15 | 9.76±2.51 |
| Participation in professional organizations and professional development | 3-15 | 9.61±2.17 |
| Working in committees | 2-10 | 6.85±1.82 |
| Community service | 3-15 | 10.93±2.74 |
| ethical codes and theory | 3-15 | 10.73±2.55 |
There is a significant relationship between the total professional attitude score and the semester (p<0.01) and gender (p<0.003). However, there is no statistically significant relationship between the variables of interest in the nursing profession and age and the total professional attitude score (p>0.05) [Table/Fig-3].
The relationship between Professional Attitude Score and demographic characteristics.
| Variables | | Professional Attitude Score Mean (SD) | p-value |
|---|
| Gender | Male | 96.4 (16.3) | 0.003 |
| Female | 87.5 (14.4) |
| Age (years) | - | 22.7 (3.2) | 0.31 |
| Semester | ≤4 | 93.3 (15.6) | 0.01 |
| 5-6 | 92.1 (14.7) |
| ≤7 | 80.1 (19.7) |
| Interest in the nursing profession | Yes | 92.4 (14.8) | 0.4 |
| No | 89 (20.5) |
Discussion
This study was conducted to determine the professional attitude in Iranian Nursing Students. The results of the study showed the 39.5% and 60.5% of students were male and female, respectively. The results also showed that 65.8% of the students were interested in the nursing profession.
Nursing students stated that nursing educators and the nursing personnel had the highest effects on their professionalism, respectively. The role of nursing educators seems to be particularly important in this regard [7], and it can be said that any kind of shortcoming or negligence on the part of the educators might have detrimental effects on the process of professionalism. Elahi N et al., consider scientific and practical weaknesses of nursing educators as obstacles in front of the nursing students to gain competency and become professional [8].
In addition to educators, nurses with clinical experiences also play an important role in the professionalism of the nursing students. Undoubtedly, a nurse’s positive or negative attitude can also affect the attitudes of nursing students. The results of the previous studies [2,15] show that the years of working experience acquired as a nurse are significantly related to professionalism. Altiok HO et al., carried out a qualitative study about the meaning of professionalism for the nursing students and concluded that the awareness of educators, nurses and other team members regarding the importance of their roles, their relationships with the nursing students, the status of the role model and the clinical environment were the factors related to the development of a professional identity in nursing students [16].
Professionalism has some particular aspects. One of the important aspects of professional attitude in nursing students is the academic load of the students. This aspect got the mean score of 15.97±3.35 in this study. When the students are encouraged in the process of learning and participate in this process actively, they can develop a professional identity in a much more efficient manner [17]. A factor that can contribute the academic load of the students is giving them feedback on their performance. In this regard, Anderson EE et al., stated that educators and trainers’ provision of feedback can lead to an increase in the nursing students’ self-confidence, autonomy and professionalism [18].
Another important aspect of professionalism in nursing is professional autonomy. The evidence indicates that the level of autonomy among nurses and nursing students is low. A study conducted about professional autonomy among students of medical sciences who were in their fourth year of education showed that the students of midwifery, medicine and nursing got the highest scores regarding professional autonomy, respectively [19].
In gaining professional autonomy, nurses face challenges such as a vague definition of autonomy, use of inappropriate tools to measure autonomy, lack of a theory related to nursing autonomy, improper education for the nursing students and emphasis on traditional training on the part of the educators, failure in cooperation and teamwork, lack of support on the part of the administrators and inappropriate management structure [20]. Doing autonomous professional activities is an important criterion that must be paid attention to by nurses and nursing students [21]. Howkins EJ et al., focused on the importance of political awareness and teamwork in the definition of professionalism [21].
Nursing students are also willing to perform autonomous activities. One of the these in the study of Altiok HO et al., was taking care of a patient by the nursing students only, particularly when they gave that care without an educator’s supervision [16]. This was exactly what gave them a sense of competence and professionalism. Anderson EE et al., also stated that when nursing students operate independently of their educators, they feel they are real nurses and have better relationship with their patients [18].
Collaboration has also been recognised as an aspect of professionalism. Collaboration and teamwork are essential elements in nursing [22] and increase in collaboration among nurses is a critical factor and a key strategy that helps maintain a safe and effective clinical environment [23]. However, there are several challenges in the area of collaboration among nurses and nursing students [24]. The results of this study showed a high mean score of 15.97±3.35 from the viewpoint of students, indicating that they are willing to collaborate and participate in teamwork. However, collaboration is something that must be taught to the nursing students [24]. Collaboration is in fact a two-way process, and all clinical teams should provide nursing students with their full support and assistance. The clinical staff should trust the nursing students and collaborate with them. From the view of nursing students and nursing educators, low collaboration on the part of the clinical staff is one of the internship problems [25].
Providing patients with knowledge-based care is an important and influential aspect of nursing students’ professionalism. Kapborg I et al., stated that when nursing students give clinical care with awareness, they create a sense of being useful [26]. Andersson EP also argued that power of knowledge is very valuable in nursing students’ understanding of professionalism [27]. In fact, assuming responsibility for their actions enables nursing students to feel competent and strong [28].
Yet another important aspect of professionalism is membership in professional organizations [29]. In this study, few students of nursing (13.16%) were members of the Iranian Nursing Organization. Considering the age of the Iranian Nursing Organization and the role it plays in the professionalism of nurses, a small number of nurses are members of this organization. In a study carried out by Wynd CA, few nurses were members of professional organizations such as ANA, but the same small number got higher scores in regard with professionalism [2].
One other significant aspect of professionalism is participation in teamwork. Team membership, participation in the processes of care-giving and working like a nurse are important concepts in the experience of professionalism among nursing students [16]. Team membership contributes to the increase in self-confidence and autonomy and improves relationships with others, i.e., develops abilities necessary to participate in teamwork. The results of a study by Bradbury-Jones C et al., also showed that students’ collaboration with nurses and their participation in teamwork help them feel empowered [28].
According to the definition of nursing, one major role of the nurses in a society is the provision of social value. Although the social value aspect of professionalism was only measured through three items in this study, the higher-than-average score on this aspect showed that the participants in the study were willing to provide social value. As a matter of fact, not only do nurses have a responsibility to take care of patients, but also they play an important role in the rehabilitation of the sick people and well-being of the healthy individuals.
An important and valuable aspect of professionalism is observance of the code of ethics; a topic taken into account by previous studies. Wade GH refers to defending the patients’ rights as one of the responsibilities of a professional nurse [30]. In fact, a very important dimension of professional nursing is the nurse’s awareness of ethical and legal responsibilities [26]. Nurse’s awareness of these rules is required and helps them give better and more appropriate care based on a set of principles. It also prevents them from having to get involved in the legal cases related to the patients’ rights or issues of forensic medicine.
Limitation
A limitation of the study is that the sample was selected from only one university. Conducting research projects with larger sample size at a national level can lead to better results regarding the problems of professionalism.
Conclusion
In this study, nursing students were at an average level of professionalism. Professionalism requires more focused attention and taking firmer steps. Undoubtedly, the first stage of professionalism for nurses is their course of education as university undergraduates. Being aware of the nursing students’ attitudes and behaviours can contribute to the recognition of their potential problems in professionalism.