Determination of Professional Behaviours among Nurses Working at a Selected Teaching Hospital in India

Nursing is an essential component of all healthcare services, with the potential to have a significant and long-term impact on health outcomes for the world's ageing population. As their professional behaviour plays a major role in improving the quality of patient care, this study was conducted to determine the professional behaviour of nurses. A descriptive and cross-sectional study design was selected with fifty nurses working in a selected teaching hospital who were selected using convenient sampling technique. The Behavioural Inventory for Professionalism in Nursing (BIPN) was used to determine the professional behaviour of nurses. The inventory has a total possible composite score of 27. All of the items were dichotomous and questioned about the nurse's actions in the last two years. The autonomy and research were the areas where nurses receive the lowest Original Research Article Alshahrani et al.; JPRI, 33(43B): 361-367, 2021; Article no.JPRI.73090 362 mean ratings from the BIPN subscales. The nurse's mean scores in the areas of competence and continuous education (mean = 1.97), educational preparedness (mean = 1.87) and application of theory (mean = 1.73) were the highest with the mean total score from BIPN was 10.44± 3.55. The results showed that age, gender, nurses' role, their years of experience and educational status had a statistically significant association with professional behaviour. Hence, the ways to improve the professional behaviour among nurses to be investigated and must be supported to uplift the image of nursing and the quality of patient care.

mean ratings from the BIPN subscales. The nurse's mean scores in the areas of competence and continuous education (mean = 1.97), educational preparedness (mean = 1.87) and application of theory (mean = 1.73) were the highest with the mean total score from BIPN was 10.44± 3.55. The results showed that age, gender, nurses' role, their years of experience and educational status had a statistically significant association with professional behaviour. Hence, the ways to improve the professional behaviour among nurses to be investigated and must be supported to uplift the image of nursing and the quality of patient care.

INTRODUCTION
Professionalism is defined as an individual's level of commitment to the ideals and behavioural characteristics of a given career identity [1]. Professionalism also refers to attitudes that show a strong identification with and devotion to a certain profession [2]. Professionalism in nursing has centred on the role of nursing expansion in the continually changing healthcare environment. Nursing as a profession, however, has been shaped by social, cultural, scientific, and technical factors [1].
In today's contemporary health and social care practice, patients' expectations of being cared for by a nurse who is caring, competent, and professional are particularly significant. Nursing professionalism shows how nurses perceive their work and serves as a guide for nurses' inpractice behaviours in order to maintain patient safety and quality care [3].
Nurses are the largest professional healthcare workforce, and maximizing their contribution to health is critical that when a worldwide ageing population is to be served [4]. Nurses often serve as first-line caregivers, ensuring that patients have access to safe care while also improving the lives of vulnerable communities through education. Now, more than ever in this pandemic, the world needs them working to the full extent of their education and training [5].
Nursing professionalism entails providing highquality care to patients while adhering to the values of accountability, respect, and integrity [6]. Patients receive better care, team communication improves, all professionals are held more accountable, and the overall clinical milieu strengthens when nurses display professionalism. Patients, other members of the healthcare team, and support workers will be the beneficiaries which lead to highest-quality care to patients [7].
Nursing is an essential component of all healthcare services; it has the potential to have a significant and long-term impact on health outcomes for the world's population. Nurses have taken on new tasks and responsibilities such as nurse practitioners, clinical nurse specialists, and consultant nurses, as time has passed. The conventional definitions and qualities of professionalism no longer fit the needs of the nursing discipline, with expanding nursing duties in a variety of settings, rising numbers of nurses with graduate degrees, and modified curriculum requirements in nursing schools [7].
To support the rationale for far more investment and expansion of nursing services around the world, it is becoming increasingly vital to demonstrate the safety and overall benefit of nurses' practice through research. According to the Behavioural Inventory for Professionalism model (BIPN) [1], educational preparation, application of theory, adherence to a code of ethics, engagement in a professional organization, continuing education and competence, communication and publication, autonomy, community service, and research are the essential components of professional behaviour among nurses.
Nurses' professional behaviours are critical in achieving and developing quality and safety in practices and patient care, as well as maintaining the profession's standards. The level of professionalism displayed by nurses, as well as the image established as a result, is becoming increasingly important in attracting clients too. The International Nursing Council (ICN) defines nursing as a profession that works to safeguard and promote the health of individuals, families, and communities, as well as participate in rehabilitative activities. Nurses' motivation, job satisfaction, morale, and use of evidence-based strategies will all contribute to their ability to provide professional nursing care. As a result, the aim of this study is to determine the professional behaviour of nurses working at a selected teaching hospital in India. The findings of the study will enlighten the current professional behaviours of the nurses, so that, interventions to improve their professional status can be deliberated and executed.
The research question of the study is, "what is the level of professional behaviour exhibited by the nurses working in a selected teaching hospital in India?" which could be a guide for improving the nursing professionalism.

Design
A descriptive and cross-sectional study was adopted to determine the professional behaviours of nurses working in the chosen teaching hospital in India.

Sample
The target population of the study was the nurses working in the teaching hospitals. Fifty Nurses working in a selected teaching hospital were selected using convenient sampling technique.

Tools/instruments
The self administered tool consisted of 2 sections; Section A: The socio-demographic characteristics of the Participants and Section B: The Behavioural Inventory for Professionalism in Nursing (BIPN) which was used to determine the professional behaviour of nurses. This inventory was developed by Miller et al.,(1993) 1 with 46 questions about professional behaviours in 9 subheadings which was designed to assist nurses assess their own professionalism and provide guidance for professional development. The subheading includes educational preparation(8 items), the application of theory(4 items), adherence to a code of ethics(1 item), membership in a professional organization(5 items), continuing education and competence( 9 items), communication and publication(3 items), autonomy( 9 items), community service(2 items), and research(4 items). Each behaviour was given a score of 0 to 3 points in the BIPN. Each group received a 3 overall score, with a total weighted score of 27. There was no determination made as to whether nursing has a high or low level of professionalism. All of the items were dichotomous and questioned about the nurse's actions in the last two years. The conduct was either present or absent in the respondent. Though it is a standardised tool, Content validity of the tool was obtained from five experts from Nursing specialised in medicalsurgical nursing, pediatric nursing, OBG , mental health and community health nursing . The reliability of the tool was assessed after the pilot study by internal consistency with Cronbach Alpha test. The 'r' value of the tool was 0.871.

Procedures of Data Collection
The tool was self-administered questionnaire which took approximately 45 minutes to complete. It was distributed to the nurses through electronic media as Google docs such as email, what's app etc. The nurses were reminded about the tool twice and it was ensured to complete all the questions. The study was conducted between Feb.2021 to Apr.2021.

Ethical Consideration
Official Permission from the Medical Director was obtained as well as ethical permission was obtained from the Institutional ethical committee. Consent from the participant nurses were collected before starting the study by explaining the purpose of the study, the role of the participants, confidentiality of the information and their right to withdraw from the study.

Statistical Analysis
The data was split into two sections for analysis.
1) The use of descriptive statistics: The socio demographic and Professional Behaviour of the participants were analyzed using frequencies and percentages distribution. The level of professionalism was assessed using the mean and standard deviation. 2) Inferential statistics: The relationship of level of professional behaviour with chosen sociodemographic characteristics was determined using a Chi-square test. The reliability of the tool was assessed after the pilot study by internal consistency with Cronbach Alpha test

RESULTS
According to table 1, there were 78% of female nurses, 48 % were between the ages of 20 -25 and 58 % of the participants were married. Forty two percent had bachelor's degree, 64% had work experience of more than 5 years while 32% worked in surgery units. Regarding their role in the clinical setting, 70% of them were clinical nurses, 20% were in supervisory role and 10% were handling the teaching responsibilities of the hospital. Table 2 shows the statistical analysis of the distribution of the nurses' mean scores obtained from the BIPN subscales. The autonomy and research were the areas where nurses receive the lowest mean ratings from the BIPN subscales. The nurse's mean scores in the areas  of competence and continuous education (mean = 1.97), educational preparedness (mean = 1.87) and application of theory (mean = 1.73) were the highest with the mean total score from BIPN was 10.44± 3.55.
In terms of gender, there is a statistically significant difference between the professionalism inventory of male and female nurses at p=0.045. There is, nevertheless, a statistically significant difference between the nurses' role and their years of experience with professionalism behaviour at p=0.01. In terms of professionalism inventory with age and educational status, there is a statistically significant difference at p=0.01 level (Table 3).

DISCUSSION
The aim of this study is to determine the professional behaviour of nurses working at a selected teaching hospital in India. The results of this study shows that the autonomy and research were the areas where nurses receive the lowest mean sores where as competence and continuous education (mean = 1.97), educational preparedness (mean = 1.87) and application of theory (mean = 1.73) were the highest with the mean total score from BIPN was 10.44± 3.55. Similar study findings were reported in a study by Hui Yang et al., [8] on the investigation and analysis of nurses professionalism using BIPN. The results of the study revealed that continuing education was rated as the best professional behaviour while autonomy and research had the lowest scores.
Education level and autonomy are the basic criteria for professionalism. Various social, political, cultural, scientific, and technological factors influence development of nursing profession, which may hamper nurses' professional development and behaviours. Nurses' growing importance has led to a significant increase in demand for their services in a range of roles and settings [9]. The professional behaviours and autonomy among nurses can be improved by encouraging them for higher degrees and motivating to participate in continuing education, research activities as well as taking active part in professional organizations and community services.
Also, nurses' low involvement rate in occupational organizations is a serious and ongoing issue. In a study of 473 nurses working in two university hospitals, Kocak discovered that 347 (73.3%) of the nurses were not members of occupational associations, and the majority of non-member nurses had the dominant belief that the organizations "takes no action on behalf of the profession [10].
According to the present study findings, age, gender, educational status, years and area of experience as well as the nurses' role in the health care settings have significant association with their professional behaviours. Similar study findings were reported in various studies also [11][12][13] which show that the qualification and years of experience of the nurses plays a major role in their professional behaviour.
Also, in a study among nurse constituency of Korean Americans, conclude that the duration of nursing education, current location of nursing, present employment status, total years of experience and membership in professional organisations, are all related to the level of professionalism [14]. Hence, the nurses should be encouraged to pursue higher studies, participate in professional organizations, continuing education as well as research and publication activities to improve their professionalism and quality of patient care.

CONCLUSION
The findings of our survey show that nurses' professional behaviour scores is low. Professional behavior was rated highest in the areas of "competence and continuous education", "educational preparedness" and "application of theory". Nurses had the lowest degrees of professionalism in the categories of "autonomy," and "research." Though the nurses' scores on the professional behaviour inventory components of this study were found to be low and insufficient to make conclusions, they must be motivated and given opportunities to involve in scientific endeavours, educational programs, and professional organization participation as well as community services.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.

DECLARATION OF CONFLICTING INTERESTS
The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.