Considerations for professionalism of nursing students in clinical practices

This is a descriptive study that aims to determine the factors affecting the professional behaviour of nursing students in clinical applications. The survey was conducted between 20 September and 20 December 2017 with the participation of 274 students studying in the Nursing Department of Health Sciences Faculty of a University. The data were collected using a questionnaire consisting of 18 questions and Nursing Students Professional Behaviours Scale (NSPBS). The mean age of the nursing students participated in the study was 20.67 ± 1.88 years and 81.8% of the students were female while 18.2% were male. Of them, 78.5% loved their profession, 60.9% chose their profession willingly, 67.5% did not want to change their profession and 9.5% of them were members of professional associations and followed professional publications. The mean score of NSPBS was determined to be 122 (29–135). Hence, the nursing students’ ability to perform professional behaviours was found to be high.


Introduction
Nursing, which emerges in line with the need for healthcare in order to protect, improve and raise the individual's health, to offer care and treatment and to facilitate adaptation to the disease, is a professional health discipline composed of science and art (Ay, 2011;Oztunc, 2016;Zaybak, Ismailoglu & Efesli, 2014).As in all occupational groups, developing also a professional attitude in the nursing profession is among the most basic features of the ability to be productive and effective (Dikmen et al., 2014;Goris, Kilic, Ceyhan & Senturk, 2014;Oztunc, 2016;Tarhan, Kilic & Yildiz, 2016).In the literature, the concept of being professional can be described as 'promising to the population that s/he, as a member of that profession, will do the best of his/her profession or to give a service with a high standard' (Kahramanoglu, Ozer & Tugcu, 2009;Mete, 2016).At the same time, professionalism can be explained in terms of knowledge, skills, attitudes, behaviours and perspectives required for being competent in a certain field (Dikmen et al., 2014;Goris et al., 2014;Oztunc, 2016;Tarhan et al., 2016).
During the historical process, the professionalisation in nursing started with Florence Nightingale and later on, nursing education entered into a scientific identity development process (Goz & Geckil, 2010).Nurses, who are important members of the health team, take important responsibilities in giving healthcare services (Goris et al., 2014).Professionalism in the nursing profession has a quite important role in providing a quality care and in developing standards for the profession (Cevik & Khorshid, 2012;Demir & Yildirim, 2014;Ozdelikara, Alkan & Boga, 2016).The ability of a profession to reach a professional status and provide a qualified service to population depends on the strong professional identities of professional members (Sabanciogullari & Dogan, 2012) as well as perceiving the concept of professionalism by academicians, clinicians and nursing student in the same way (Altiok & Ustun, 2014;Karadag, Hisar, Celik & Baykara, 2016).As reported by Dikmen et al. (2014), Arthur described the qualities of a professional nurse as 'communication, satisfaction with profession, leadership, responsibility, flexibility, creativity and professional practice'.In this regard, the development of professional identity in nursing starts with nursing education and continues to improve and develop throughout her/his working life (Sabanciogullari & Dogan, 2012).
For the development of professional behaviour in nursing, understanding the science and scientific method adequately and using it effectively play an important role.In the professional sense, nurses are expected to protect the ethical values in nursing, have a high level of autonomy, follow scientific developments, use intellectual knowledge, skills, attitudes and behaviours in preventive and therapeutic health services by integrating them with practice in line with theoretical knowledge (Cevik & Khorshid, 2012;Karadagli, 2016).
Nursing education is a process which integrates theoretical and practical education and training, which should bring in knowledge, skills and attitude and which is based on observation, practice and interpretation (Bayraktar, Yilmaz & Khorshid, 2016;Vicdan, 2010).Practice constitutes one of the most important components of nursing education and in this respect, nursing students need clinical settings where they can apply, consolidate and improve the knowledge and skills they acquire during their education.From this aspect, clinical practices giving the opportunity to learn by practicing play a role in adapting nursing role effectively by students (Sari, 2001).As reported by Sabanciogullari and Dogan (2012), Spouse reported that the support provided by knowledgeable and experienced practitioners contributed substantially to the professional development of nursing students.On the other hand, the changes occurring in recent years have affected the healthcare system, healthcare professionals, nursing education and have increased the need for the labour force of nurses with a high level of professional qualifications (Adiguzel, Tanriverdi & Ozkan, 2011).
Examining the literature of our country on this subject, the number of the studies for identifying the factors affecting the professional behaviours of nursing students is quite a few (Cevik & Khorshid, 2012;Ozdelikara et al., 2016;Sezgin, Ozguder & Coskun, 2015).In line with the data to be obtained from the present study, the factors affecting the professional behaviours of nursing students during clinical practices will be identified and appropriate strategies for improving the professional attitudes of nursing students will be developed.

Objective of the study
Answers were sought for the following questions in the present study that was conducted for identifying the factors affecting the professional behaviours of the nursing students in their clinical practices: • What are the socio-demographic and occupational characteristics of nursing students?
• What is the level of professional behaviours of nursing students?• What are the factors affecting the professional behaviours of nursing students during their clinical practices?

Place and time of the research
The present study that was conducted between 20 September and 20 December 2017 is a descriptive and cross-sectional study aiming to identify the factors affecting the professional behaviours of nursing students during their clinical practices.

Population and sample of the research
In this study, the students were selected using the simple random sampling method and a probabilistic sampling method, in which individuals can be selected from the population with an equal probability.For the study, the sample number to represent the target population of the survey was calculated to be 194 with a margin error of 5% at 95% confidence interval out of 389 students studying in the second, third, and fourth grades of the nursing department in the Health Sciences Faculty where the study would be conducted.Given that data may be lost, the data collection process was completed when 274 students were accessed.The first-grade students who were on leave or on sick leave, who refused to participate in the survey, who did not fill the questionnaire form completely and who had not been to clinical practice yet were excluded from the study.The response rate of the questionnaire form was 70.4% in this study.

Tools of data collection
In this study, the data were collected using the 'nursing students' information form' and 'Nursing Students Professional Behaviours Scale (NSPBS)'.The nursing students' information form was composed of 18 questions including the socio-demographic and professional characteristics of nursing students.

Data collection
The questionnaire was tested by administering a pilot study on a group of 10 people and the students participated in the pilot study were not included in the study sample.The students participated in the study were informed about the study and the data were started to be collected by the researchers after obtaining their informed consents.The data collection period lasted approximately 10-15 minutes.It was said to the students that the decision whether to participate or not in the survey was completely their own decision, that their names would not be written in the questionnaire form and that the data to be collected from this study would only be used within the scope of this survey.The questionnaire form and scale were administered after receiving the written approval from the relevant institution and informed consents from the participating students.

Data assessment
The statistical analysis of the data related to the practice levels of professional behaviours by the nursing students included in the study was carried out using the SPSS 21 package program in the computer environment.Median, percentage, chi-square, minimum, maximum, Kolmogorov-Smirnov test, Mann-Whitney U test and Kruskal-Wallis test were used for the analysis of the data.

Results of nursing students' sociodemographic and professional characteristics
Of the nursing students participated in the study, 81.8% were female, 18.2% were male, 33.6% were studying in the second and third grades, 98.9% were single and the mothers of 48.2% and fathers of 27% were primary school graduates.The mothers of 77.7% were housewives, fathers of 24.1% were retired.The families of 44.5% lived in the district, 80.3% of them had a nuclear family type, 95.3% of them had social security and the family income of 73% was equal to their expense and the mean age of nursing students was found to be 20.67 ± 1.88 years.78.5% of the nursing students who were enrolled in the study were determined to love their profession, 60.9% of them chose their occupation willingly, 67.5% of them did not want to change their profession, 9.5% of them were members of professional associations and 9.9% of them followed professional publications (Table 1).

Results related to nursing students professional behaviours scale
In this study, the total mean score of NSPBS was 119.37 ± 14.55 and the median score was found to be 122.0.The mean scores of NSPBS subdimensions including Healthcare Practices, Activity Practices and Reporting were determined to be 81.06 ± 9.85, 30.14 ± 4.28 and 8.17 ± 1.96, respectively.However, the median scores of Healthcare Practices, Activity Practices and Reporting subdimensions of NSPBS were 84.0, 31.0 and 8.0, respectively (Table 2).The total median score of NSPBS was determined to differ depending on choosing profession willingly (p = 0.012), loving profession (p = 0.001), thinking about changing profession (p = 0.030) and following professional publications (p = 0.031) by the nursing students.The median score of NSPBS was found to be higher in the students who chose their profession willingly, who loved their profession, who did not want to change their profession and who followed professional publications.The total median score of NSPBS was found not to differ depending on the nursing students' age, gender, grade, marital status, graduated high schools, mother's education level, mother's profession, father's education level, father's profession, family type, family's accommodation unit, family's social security status, family's income status and being a member of professional associations (p > 0.05) (Table 3).The median score of Healthcare Practices subdimension of NSPBS was determined to differ depending on choosing profession willingly (p = 0.007), loving profession (p = 0.001) and following professional publications (p = 0.032) by the nursing students.The median score of Healthcare Practices subdimension of NSPBS was observed to be higher in the students who chose profession willingly, who loved their profession and who followed professional publications.The median score of Healthcare Practices subdimension of NSPBS was determined not to differ depending on the nursing students' age, gender, grade, marital status, graduated high schools, mother's education level, mother's profession, father's education level, father's profession, family type, family's accommodation unit, family's social security status, family's income status, thinking about changing profession and being a member of professional associations (p > 0.05) (Table 4).

Discussion
Professionalism in nursing has a very important role in establishing standards for the profession and in providing a quality service for the healthy/sick individual (Bayraktar et al., 2016;Dikmen et al., 2014).The present study is a study in which the factors affecting the professional behaviours of the students studying in the nursing department of Health Sciences Faculty of a University located in the middle Black Sea region of Turkey during their clinical practices were identified.
The mean and median scores of NSPBS that was used to measure the professional behaviours of the nursing students were found to be 119.37 ± 14.55 and 122.0, respectively.Considering that the score that can be obtained from the scale may vary between 27 and 135 and that as the scale score increases, the level of performing professional behaviours by students increases, the professionalism levels of the nursing students were determined to be very high in this study.Supporting the results of this survey, the mean score of NSPBS was 116.73 ± 13.62 in the study conducted by Cevik and Khorshid (2012) and it was found to be 119.96± 11.30 in the study by Sezgin et al. (2015).
In this study, the total median score of NSPBS was determined to differ depending on choosing profession willingly, loving profession, thinking about changing profession and following professional publications by the nursing students.The median score of NSPBS was found to be higher in the students who chose their profession willingly, who loved their profession, who did not want to change their profession and who followed professional publications.
Supporting the results of this survey, the score of the scale assessing the ability to perform professional behaviours by the nursing students who chose their profession willingly (Cevik & Khorshid, 2012;Sezgin et al., 2015), who loved their profession (Cevik & Khorshid, 2012;Ozdelikara et al., 2016;Sezgin et al., 2015) and who did not think about changing their profession (Cevik & Khorshid, 2012) was also reported to be higher in the other studies conducted on this subject.
Choosing a profession willingly and loving a profession are important criteria in choosing a profession and practicing it professionally.Choosing nursing profession willingly has a quite important place in practicing the profession gladly by nurses as well as in the emergence of their specific skills and in exhibiting a professional attitude by activating individuals (Beydag, Gunduz & Ozer, 2008).In this respect, practicing nursing profession gladly by nursing students makes them more successful as well as renders the care given to healthy/sick individuals more qualified.It demonstrates that it will contribute to the improvement of the nursing profession by representing it more respectful to the individual and population (Andsoy, Gungor & Bayburtluoglu, 2012).
Hence, some studies on nurses after graduation, supporting this survey results, also reported that the professionalism levels of nurses who loved their profession were found to be higher (Celik, Unal & Saruhan, 2012;Karamanoglu et al., 2009).
In line with the results obtained from the present study, the total median score of NSPBS was determined not to differ depending on the nursing students' age, gender, grade, marital status, graduated high school, mother's education level, mother's profession, father's education level, father's profession, family type, family's accommodation unit, family's social security status, family's income status and being a member of professional associations.Despite the study results, in a study conducted by Ozdelikara et al. (2016) for determining the professionalism levels of the last grade students, it was reported that there was a relationship between gender and professional attitude in the profession and that the professionalism levels of the girls were found to be higher than the boys.
In accordance with the results of this survey, Sezgin et al. (2015) stated that the score of the Scale for determining the ability to perform professional behaviours did not differ depending on the grades they were studying.Whereas in the study conducted by Cevik and Khorshid (2012), despite the results of this study, the professionalism levels of the last-grade students were determined to be higher than the third-grade students.Another study conducted on this subject reported that the gender variable did not affect the professionalism values and levels of nursing students (Parvan, Zamanzadeh & Hosseini, 2012).
In another study conducted by Bang et al. (2011) for identifying the professionalism values of nursing students, professionalism was perceived as 'helping' by the nurses who were at the beginning of nursing education whereas in the study by Lui et al. (2008), the students who recently started nursing education were observed to perceive professionalism as 'being competent in nursing care' compared to the students in the senior grades.
Professional nursing education focuses on the value systems of individuals along with cultural and professional knowledge, clinical and conceptual skills (Adiguzel et al., 2011).Although the concept of professionalism in nursing students differs depending on the grades they are studying, it is considered that this situation may arise from the lack of knowledge about the profession and clinical practice of the students who have just started nursing education and that the professional identity development of nursing students shows a positive development as their level of education increases.
The concept of professionalism in nursing keeps renewing itself in line with today's conditions.In this respect, nursing care is a process which is composed of some values that are produced for competence, autonomy, theory-based knowledge specific to nursing, volunteerism for serving the society, conducting scientific studies and professional identity development and which is transformed into behaviour.In this respect, both nurse trainers and clinician nurses play an important role in the development of nursing students' professional attitudes (Altiok & Ustun, 2014).

Conclusion
It was determined that 78.5% of the nursing students participated in the survey loved their profession, 60.9% of them chose their profession willingly, 67.5% of them did not want to change their profession, 9.5% of them were the members of professional associations and followed professional publications.The total mean score and the median score of NSPBS were found to be 119.37 ± 14.55 and 122.0, respectively.However, the total median score of NSPBS was determined to differ depending on choosing profession willingly, loving profession, thinking about changing a profession and following professional publications by the nursing students.The scale score of the students who chose their profession willingly, who loved their profession, who did not think about changing their profession and who followed professional publications was found to be higher.

Limitations of the research
In the present study, the data were collected using the questionnaire form based on the selfassessment of the nursing students.The fact that the results obtained were not based on simultaneous interviews with the nursing students and not making observations in order to determine their professional behaviours during clinical practice are the limitations of this study.