Professionalism and Its Predictors among Nurses Working in Jimma Zone Public Hospitals, South West Ethiopia

Professionalism is a conceptualization of obligations, attributes, interactions, attitudes, and role behaviors required for professionals in relationship to individual clients and to society as a whole or it is the conduct, aims or qualities that define a profession or a professional person [2-5]. The attributes of Professionalism include knowledge, spirit of inquiry, accountability, autonomy, advocacy, innovation and visionary, collaboration and collegiality, and ethics [6].


Introduction
The current definition of nursing, as defined by the ANA (2010c), is "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" [1].
As cited by Oweis AI "The definition of a profession consists of contributing characteristics. Nursing must achieve these characteristics in order to confirm its professional status. These characteristics include: a standard of education; professional organizations; commitment; autonomy; continuing education; body of knowledge and competencies; social value; and a code of ethics" [2].
Professionalism is a conceptualization of obligations, attributes, interactions, attitudes, and role behaviors required for professionals in relationship to individual clients and to society as a whole or it is the conduct, aims or qualities that define a profession or a professional person [2][3][4][5]. The attributes of Professionalism include knowledge, spirit of inquiry, accountability, autonomy, advocacy, innovation and visionary, collaboration and collegiality, and ethics [6].
Nursing professional practice is a commitment to compassion, caring and strong ethical values; continuous development of self and others; accountability and responsibility for insightful practice; demonstrating a spirit of collaboration and flexibility [7]. Nurses who value professionalism exhibited adherence to practice standards and technical (psychomotor) competence [8].
Historically, nurses have struggled to determine whether professionalism is present or absent in nursing. However, nursing has changed drastically in the past three decades, with the expansion of roles and autonomy in a variety of settings. Nurses have established credential and educational standards. The presence of nurses in healthcare settings has become now more significant than ever. In the healthcare system, nursing professionalization is in great demand [9].
The challenges in Nursing Professionalism are: Membership, Communication, Changes in Nursing practice, Diversity in the population, Lack of autonomy, Lack of leadership skills, Nature of the job: long hours, health care risks, emotional load and undervalue by society, Shortage of the nurses and Limited opportunities [10].
The RNAO BPG outlines the attributes of professionalism and discussion of the existing evidence and/or literature in the area, concluding with general statements that provide some strategies for success. The guideline was written to help the individual practitioner reflect on their own practice situation. It will assist educators to relay the concept of professionalism to students in a comprehensive and meaningful way. Finally, it will guide administrators in providing environmental supports that reinforce the attributes of professionalism [6].
The lack of nursing professionalism must be addressed from two perspectives: that of personal attributes and that of organizational influences on role development. This concept has not been addressed in previous studies in Ethiopia; therefore this study tries to identify the relationship between organizational culture and nursing professionalism in addition to socio demographic, personal and societal factor.

Method and Subjects
The study setting Institution based cross-sectional study design supplemented by qualitative data was conducted among Nurses who were working in Jimma zone public hospitals, Jimma, Ethiopia. In this zone there are four public hospitals namely, Jimma University specialized hospital (JUSH), Shenen Gibe, Agaro and Limu hospital. Except JUSH all are district hospital. JUSH had 518 nurses. The numbers of nursing staffs for the district hospitals [Shenen Gibe, Agaro and Limu hospital] were 32, 27 and 34 nurses, respectively. The data were collected over a period of 16 days from March 2 -March 18, 2015.

Population
All sampled Nurses who were on active duty in the study setting that fulfil inclusion criteria. Based on this all nurse who serve six month or more in the hospitals at the time of the study were included and those who were not available during data collection time due to annual leave, maternal leave and sick leave were excluded.

Sample size
Sample size is determined using single population proportion formula by considering the 54.8% proportion, 95% confidence level and 0.04 margin of error. Since the number of nurses is 611(<10000), finite population correction formula was used. Considering 10% nonresponse rate, finally=332 nurses were included in the study. Six interviewees were selected for conducting in-depth interviews.

Sampling techniques
Proportional to size allocation of sample was done for each hospital giving a result of 282 nurses for JUSH, 17 nurses for Shene gibe, 15 nurses for Agaro and 18 nurses for Limu genet hospital. The final study participants were selected through systematic sampling technique by calculating k after having a complete list of nurses. For qualitative study Purposive sampling technique was used to gather in-depth information from key informants.

Instrument
Data were collected from the study participants using pre-tested Likert scale type self-administered English version questionnaires which had 4 parts: Part -I: Participants characteristics (includes age, gender, marital status, qualification, salary, position at work, length of service, college, level of hospital).
Part -II: It had a 34-item scale used to measure a total score for professionalism and participants were asked to rate each item on a 5point scale which ranged from strongly disagree (1) to strongly agree (5). The questionnaire was adapted from RNAO guideline which was validated in our country and used by Atsede Fantahun et al. 2012, which contains 5 point likert scale Questions prepared in English with 34-item scale in 8 subscales. In this study one professionalism scale with 6-item emerged following Principal Component Analysis with inter-item reliability of α=0.869.
Part -III: Measures organizational cultures which were adopted from Nursing Assessment Survey (NAS) revised and used by Manojlovich M and Ketefian S and have 14 items in five subscales which contains five point likert scale ranged from strongly disagree (1) to strongly agree (5) α=0.838.
Part -IV: It had 5-items which measures professional self-image having five items measured with five point liker scales ranged from strongly disagree (1) to strongly agree (5). Self-image questionnaire were adapted from Dorothee L, Hampton and Gerald M Hampton, which contains 5 point likert scale Questions prepared in English with 5-item scale. In this study one scale with 3-item emerged following Principal Component Analysis with inter-item reliability of α=0.732.
To avoid halo effect, some questions were negatively worded and the scores of the negatively worded items were reversed so that a higher score always corresponds to a more positive value. The questionnaires were pretested on nurses in Bedele Hospital, making 5% of the study population, before the actual data collection. The clarity and understandability of each of the items was tested and minor revisions were required (few vague words were changed). The Cronbach's alpha result for professionalism score, organizational culture and self-image were 0.928, 0.838 and 0.739, respectively.
For in-depth interview open ended questions were adapted from Atsede F and adjusted contextually to meet the objectives and triangulate the quantitative data [17].

Data collection procedure
The data collection was facilitated by five diploma nurse, after one day of training to familiarize them on data collection procedure. Shift of the respondent were arranged in contact with shift leader of nurses. The completeness of the data was checked on site and the codes for the incomplete questionnaires were filled by revisiting the participant with respective codes.
In-depth interview were held with the key informants, that took from 30-40 minutes for each interview

Data processing and analysis procedures
Data were checked for completeness, edited and entered into EpiData version 3.1 and exported to SPSS version 21.00 for analysis. The data were explored using descriptive and frequencies to clean data. Scatter plots, skewness, and kurtosis were examined to determine the shape of the data distribution.
To understand the factors that were considered and to derive common factors that reflect level of professionalism score, principal components analysis (PCA) was implemented on the professionalism scale. Prior to performing PCA, the suitability of data for factor analysis was assessed. The results revealed the presence of many coefficients of 0.4 and above, Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.812, and a Barlett's test of Sphericity (P<0.001).This indicate that the sampling adequacy and the matrix were suitable to perform factor analysis. To assist in the decision concerning the number of factors to retain and create the index, the following criteria were used: 1) Fixed number of factors (only 1) with an Eigen value of one or more for each factor. 2) An item-to-factor loading of 0.4 or greater, 3) A minimum of three items loading on a factor; a factor with fewer than three items was considered weak and unstable. 3) Catell's scree plot test which recommends retaining all factors above the elbow, or break in the plot, as these factors contribute the most to the explanation of the variance in the professionalism data set.
When the 34 professionalism scale items were entered into principal component analysis one latent/proxy-variables were extracted, six items have contained in the component. Factor scores were created and were used in the subsequent analysis. Following that, one-way analysis of variance (ANOVA) and independent sample t-tests were used for comparing professionalism scores across the categories. Similar procedures were applied for extracting factor score for societal factor scales leaving only 3-items (KMO=0.882, Barlett's test of Sphericity P<0.001).
Bi variate analysis was done to see the independent effect of predictors on the dependent variables. Variables with p ≤ 0.25 in Bivariable analysis were entered in the final model. Multiple linear regression analysis was conducted with P ≤ 0.05 to determine the independent predictors of the dependent variable. The assumptions in linear regressions (linearity, normality and multi-collinearity) were checked.
The qualitative data were analyzed first by transcribing the recorded data from Amharic in to English verbatim, and then the transcript were coded and grouped in to thematic frameworks. Concepts extracted from themes were presented in narratives and triangulated with the quantitative results.

Data quality assurance
Five percent of the questionnaires were pre-tested in Bedelle Hospital to assess the reliability, clarity, sequence, consistency and understandability and the total time it takes to finish the questionnaire before the actual data collection. Then after, the necessary comments and feedbacks were incorporated in the final tool.

Ethical consideration
Ethical clearance and approval to conduct the research was obtained from Jimma University College of health science, Ethical Review Board. Then a letter was secured from the University to respective hospital management to gain support for the study. Prior to administering the questionnaires, the aims and objectives of the study were explained to the participants and personal consent was also being obtained from study participant after explaining the objective of study. They were also told that participation is voluntarily and confidentiality and anonymity will be ensured throughout the execution of the study as participants are not required to disclose personal information on the questionnaire.

Results
From the total 332 sample size 303 were involved in the final analysis giving the response rate of 91.26 %. From the study participants, 148 (51.0%) were male and 257 (88.6%) of the participants were from the specialized hospital. The mean (± SD) age of the study subjects was 26.54 ± 5.06 years. Approximately, equal proportions of males and females were involved in the study accounting 148 (51.0%) and 142 (142), respectively. Regarding educational qualification, 180 (62.1%) of nurses were diploma holders and only 3 (1.0%) were masters. They had work experience ranged from 6 months to 30 years with a mean of 4.56 ± 5.48 years. Their monthly salary ranges from 1516 EBR to 5583 EBR with a mean of 2499.82 ± 815.23 EBR.
Mean scores of professionalism has also shown variation against sex category. The male's mean 23.19 (SD 4.22) was significantly higher than the mean of female's (mean=21.32, SD=4.28) at t=-3.734 and p<0.001. But, there were no significant mean difference seen in working unit and college (  Also mean scores were compared using one way ANOVA among college, age category and salary groups of nurses. Professionalism mean score differed significantly among the three age groups, F=3.09, p=0.049. The LSD Post Hoc test shows that the age group's (20-29) mean score 22.47; SD 4.42 differed significantly from the age group's (30-39) mean score 20.09, SD 3.34 at p=0.049. But there was no mean difference among salary and college category of nurses (Table 3).

Associations of professionalism and independent factors
In the organizational culture assessment 151 (52.1%) of the respondent fail to share the organizations value ( Figure 3). The top three factors described strongly disagree from the organizational culture were "This hospital stresses excellence and doing right", "this hospital makes me feel like I am an important productive person" and "In this hospital, there is respect for each individual worker". The top three strongly agree were "Power and influence count a lot here", "Employees are afraid to make a mistake" and "I regularly receive information about the quality of my work" (Annex IF) (Figure 4). Annex-I F: Scores of predictors items. The assessment of self-image showed that 160 (55.2%) have positive self-image ( Figure 4). From those items "The dedication of people in Nursing is gratifying" was the top one to be described as a strongly disagree and "If ever an occupation is indispensable, it is Nursing" was described as strongly agree (Annex IF) (Figure 4). The mean score of organizational culture was 40.99 (SD=9.14) and the mean score of self-image was 9.71 (SD=2.93).

Initial model of predictors of professionalism among nurses
Thirteen predictors were entered independently to see their independent effect on level of professionalism and out of these selfimage, organizational culture, sex category, and experience in nursing profession, marital status and qualification of nurses were found to have a significant association with level of professionalism in nursing (

Predictors of professionalism among nurses
Variables with p-valve ≤ 0.25 in Bivariable analysis were entered in the final model. In the model self-image, organizational culture, sex, qualification, position, marital status, age, experience, current salary and college category were entered through enter method. Of these variables; self-image factors, organizational culture, sex, marital status and qualification were found to be significant predictors of level of professionalism among nurses.
Self-image was found to have a positive association with professionalism and it explains slightly over 6% of the variance in nursing professionalism in bivariate analysis. For a unit increase in self-image score professionalism score increases by .207 times at p<0.001; those nurses who have positive self-image have increased level of professionalism than those nurses with negative self-image. This result was supported by the qualitative study. A 54 years female staff nurse with an experience of 33 years stated that "…being a nurse is all about devotion, commitment and love…this is the main thing that differentiate between your generations and our generations…we choose to become a nurse but you didn't rather nursing chooses you… it is obvious that there are a lot of challenges in nursing but whatever it is we first need to accept and respect nursing…. " Organizational culture was also having a positive association with professionalism and it explains slightly over 4% of the variance in nursing professionalism in bivariate analysis. For a unit increase in organizational culture increases professionalism score by 0.013 times at p=0.030. Those nurses who work in a good organizational culture have increased level of professionalism than those nurses who works in poor organizational culture. This result was also supported by a qualitative finding. A 42 year old female nurse with a position of staff nurse and an experience of 19 years stated that "… I have seen many managers in my life and they all have a common problem they don't respect nurses…they keep telling us that our work is worth off bed making…" another nurse also stated "…we are not a worker here rather we are a laborer…we totally don't have a friendly relationship with our leaders…everything works with punishment. " Being male nurse was also positively associated with professionalism. Those male nurse have an increased professionalism score by 0.238 times than female nurses at p=0.019.
Being single was another variable which was found to have a positive association with professionalism; being single have shown to increase professionalism by 0.245 times than ever married nurses at p=0.018.
The last variable found to have a positive association was qualification. BSc and above degree holder nurses have an increased professionalism score by 0.443 times than those nurse with only diploma at p=0.012 (Table 5).
This result was also supported by findings from in-depth interview. 38 year old male nurse with a position of a head nurse and experience of 10 years which stated as "…I think education have a direct effect on professionalism because increasing your level of education means increasing your level of knowledge which in turn increases your confidence and the ability to deal with patients and different challenges that you face in your daily practices…. "

Discussion
This study was carried out with the aim of determining the level of professionalism and its predictors among nurses. The study findings point to low level of professionalism among the studied nurses which is similar as compared with findings in other studies [9]. Only about onethird 88 (30.3%) of the nurses had a high level of professionalism. A number of factors might explain this low level of professionalism in nursing. These are related to organizational culture, societal factors, personal factors and other socio-demographic factors and they are discussed in the following sections.
The result of the current study revealed low level of professionalism among nurses which was similar with studies done in Japan and Turkey using BIPN tool but it's inconsistent with the findings from Mekelle reporting high professionalism [9,12]. This discrepancy might be due to sample size in which there was only 210 study subjects and measurement tool they used in which the score ranges from 34-170 but in this study it ranges from 6-30.
It's known that low level of professionalism leads to negative outcomes including increased turnover and attrition and decreased productivity [22]. It can also erode the trust that exists between a profession and the public and loss of trust at this level can influence the profession's status as a reputable profession [3]. In the 21st century, where we are striving to deliver a quality of care, improve patient satisfaction, change the public image and as a whole achieving the health related indicators in post MDG's. But, we can't achieve all these goals by having nurses with low level of professionalism which takes the majority of health team in any health care settings.
With the development of professionalism, the roles of nurses will expand and as a result work environment will also change; the quality of nursing application in the hospital will increase, and patient care will be enhanced. So, both the MOH and ENA in addition to academicians may implement different strategies to foster professionalism in nursing.
Level of education is one of the basic criteria for professionalism. Today, many disciplines, including nursing, require a degree at BSN level in order for graduates to be considered as professionals in their field and this is supported by the results of this study showing qualification of nurses was a significant predictor of professionalism. Mean professionalism scores increase as the qualification level increases. Mean scores were highest for nurses who had completed their B.Sc. and M.Sc. in nursing, their scores being .443 times higher than those of nurses who had only completed diploma program (P=0.012). This finding was consistent with that of a previous study conducted in Turkey, china and Ethiopia and all stated that the nurses with higher educational levels showed a higher level of professionalism [7,12,17].
So it is critical to develop various educational programmes for nurses and to provide encouraging environment for obtaining higher degrees, in order to improve nursing professionalism.
The most substantial finding of this study is that of organizational culture as a significant predictor of nursing professionalism (p=0.030). The overall R2 of 0.044 indicated that slightly over 4% of the variance in nursing professionalism could be explained by organizational culture. But from the five subscales only power was significant predictor of professionalism (see annex-I D). The fact that organizational culture affects nursing professionalism has been empirically shown elsewhere. A study conducted in Canada showed that organizational culture were significant and substantial predictor of nursing professionalism explaining 16% of the variance in nursing professionalism [13].
If ever an occupation is indispensable, it is Nursing 0.763 The dedication of people in Nursing is gratifying 0.804 Annex-I D: Component matrixa for societal factor scale items, a 1 component extracted.
In the present study, there was no significant difference in professionalism score with nurse's experiences which was inconsistent with Wynd's finding revealing significant association between overall professionalism score and years of experience in nursing [23]. The results of a study conducted in Mekelle also showed positive association between years of experience and professionalism score [12]. The discrepancies might be due to small number of nurse with the experience of more than 10 years in the study population. Because of poor labour environment like mandatory night shifts, long working hours and low wages it is challenging for nurses to gain significant experience.
The other findings from this study were that marital status and sex category found to be significant predictors of professionalism. Those nurses who were male scores 0.238 times more on the overall professionalism score (p=0.019) and being single nurse increases the professionalism score by 0.245 times than ever married nurses (p=0.018). This could be because of the growing male dominance in the nursing profession. The average age of a nursing graduate in Ethiopia is estimated to be in the early 20's and most are unmarried at the time of graduation. As might be expected, most will marry by the age of 30 years and begin families shortly afterward. As a result, many young female nurses will have a concern to raise their families, although their counterparts, the male nurses, will not.
This study also showed that there was no significant change in the mean professionalism score between the age group 20-29 and those with >=40 years but there was a significant decrement in the mean score in the age group of 30-39 (p=0.049) leaving the younger nurses (20-29 years of age) to be the high mean scorer in professionalism scale. This finding was consistent with a study conducted in china showing an age in the thirties was negatively related to professionalism in Chinese nurses [7]. In our country it is common to find a younger nurse with a bachelor's degree in a managerial position, with more experienced, less educated older nurses as subordinates and diminished respect for older colleagues are situation that may contribute to this phenomenon.
Nurses derive their self-concept and professional identity from their public image, work environment, work values, education and traditional social and cultural values. A positive self-image is a reflection of the professional identity, and is regards as a prerequisite for nurse to achieve in work field [21]. Therefore, positive professional self-image is a key for nurses to develop their professional identity which promotes development of professionalism [20].
The findings of this study also demonstrated that self-image was a significant predictor of professionalism score (p<0.001). The overall R2 of 0.066 indicated that slightly over 6% of the variance in nursing professionalism could be explained by self-image. Those nurse who have positive self-image scores 0.207 times more on professionalism score than those with negative self-image (p<0.001). This result clearly showed that the way we think about ourselves, the way we see ourselves and the way we present ourselves to others can boost our professionalism level. So nurses should possess positive self-image for the sake of their professionalism.
The finding of this study is limited to hospitals; so that the generalization of the finding may not be for nurses working at health centers in Jimma Zone. There is also limitation of literature on this topic in our country so that comparison of study results was done with other countries where the health institutions setup, health policy and other factors are quite different.

Conclusion
This study, the first to examine the effects of organizational culture and societal factor on nursing professionalism in Ethiopia, found both factors to be a significant and substantial predictor of nursing professionalism in addition to the personal and socio demographic factors. It adds a small but essential piece to the puzzle of how to maintain professionalism in nursing practice.
In conclusion, the results of this study indicate that the professionalism levels of nurses are at a low level and factors associated with this were; age, marital status, sex, societal factor, organizational culture and educational level.

Recommendations
• Matron, human resource personnel and CEO's of respective hospitals should develop various educational programmes for nurses and provide encouraging environments for obtaining higher degrees. • MOH, ENA, leaders in Nursing schools and hospital administrators need to establish a culture that values all contributions will help to maintain feelings of pride and motivation in staff. • Jimma Zone Health Bureau, ENA, JUSH and respective hospitals should aim to support and reinforce individuals' commitment to lifelong learning and ensure the provision of ongoing CPD opportunities that focus on issues of conduct as well as knowledge, competence and skill to support their development. • Further studies are also suggested with larger samples and using qualitative methodology to focus on to what extent organizational culture and self-image are a source of promoting nursing professionalism. • In addition interventional studies are suggested to raise the level of nursing professionalism. Replication of this study should also be carried out with nurses in different regions.