Journal of Nursing Management, 2014

Professional behaviours and factors contributing to nursing professionalism among nurse managers MICHIKO TANAKA R N , P h D 1, KIKUKO TAKETOMI and RIEKO KAWAMOTO R N , M A , P h D 4

RN, MPH

2

, YOSHIKAZU YONEMITSU

MD, PhD, FAHA

3

1

Assistant Professor, 3Professor, R&D Laboratory for Innovative Biotherapeutics Science, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, 2Research Fellow, Center for Medical Education, Hokkaido University, Graduate School of Medicine, Sapporo and 4Executive Officer, Japan Nursing Association, Tokyo, Japan

Correspondence Michiko Tanaka R&D Laboratory for Innovative Biotherapeutics Science Graduate School of Pharmaceutical Sciences Kyushu University Room 601 Collaborative Research Station II 3-1-1 Maidashi Higashi-ku Fukuoka 812-8582 Japan E-mail: [email protected]

TANAKA M., TAKETOMI K., YONEMITSU Y.

&

KAWAMOTO R.

(2014) Journal of Nursing

Management Professional behaviours and factors contributing to nursing professionalism among nurse managers Aim To examine the perception of professional behaviours and factors contributing to nursing professionalism among nurse managers. Background Professional behaviours influence nursing professionalisation and managers’ behaviours strongly impact professional development. In Japan, few studies have examined professional nursing behaviours from the nurse managers’ perspective. Methods The Behavioural Inventory for Professionalism in Nursing was performed with 525 nurse managers representing 15 facilities in Japan. Results The highest professional behaviours score obtained was ‘competence and continuing education’ and the lowest behavioural score was ‘publication and communication’. The results demonstrate that higher nursing professionalism is related significantly to the increased length of nursing experience, a higher level of educational preparation and the current position as a nurse administrator. Conclusion This study demonstrated that nursing professionalism is influenced by years of experience and nursing management education. Implications for nursing management Awareness of extrinsic professional factors is important continually to maintain nursing professionalism. The findings of our study may help nurse managers to continue their self-development and to realise the potential of their nursing staff by developing professionalism. These findings also provide an understanding of international professionalism trends to achieve higher levels of nursing professionalism through the evaluation of professional nursing behaviours. Keywords: Japan, nurse manager, professional behaviour, professionalism Accepted for publication: 29 July 2014

Introduction The demand for nursing professionalisation has become greater than ever. Nurse managers are recognised to exhibit high levels of professionalism and to DOI: 10.1111/jonm.12264 ª 2014 John Wiley & Sons Ltd

act as role models to influence their nurses to improve their nursing professionalism (Adams & Miller 1994). Therefore, the recognition of the pivotal role of a nurse manager is important. The leadership of nurse managers is key to facilitating nursing professionalism 1

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(Locke et al. 2011). Nurse managers empower nurses to improve their performance and to propose interesting changes to their workplace. The practise of professional behaviours by the nurse manager is vital to facilitate an organisational culture that creates a beneficial workplace for nurses (Eneh et al. 2012). The purpose of this study was to examine the professional behaviours and factors contributing to nursing professionalism among nurse managers. In this study, we use the term ‘nurse manager’ to describe ward nurse managers and nurse administrators.

Background Nursing professionalism Nursing professionalism is often described as professional behaviours (Schwirian 1998). Hall (1968) demonstrated five components of attitudinal attributes of professionalism: using a professional organisation as a major referent, belief in public service, belief in selfregulation, a commitment to the profession beyond economic incentives and a sense of autonomy in practise. Over the year, nursing researchers used Hall’s model and its corresponding instrument, the Professionalism Inventory Scale, to measure professionalism in nursing (Wynd 2003, Kim-Godwin et al. 2010). Rutty (1998) showed that the characteristics of profession in nursing include a defined knowledge base, power and authority over training and education, registration, altruistic service, a code of ethics, lengthy socialisation and autonomy. Miller (1988) also developed a Wheel of Professionalism in Nursing model as a model of professionalism behaviours for nurses in 1984. Miller extracted nursing professional attributes from those previously identified by sociologists, nurse leaders, the American Nurses Association (ANA) policy statement, standards of practise and the ANA Code of Ethics for Nurses. Miller’s model noted that education in a university setting with a scientific background is critical for structuring professionalism in nursing. Miller’s model identifies eight characteristics other than education preparation, which are necessary for depicting the degree of professionalism in nursing: (1) publication and communication; (2) research development, use and evaluation; (3) participation in professional organisations; (4) community service; (5) competence and continuing education; (6) theory development, use and evaluation; (7) self-regulation and autonomy; and (8) adherence to the ANA Code of Ethics. Since nursing professionalism was identified as a fundamental factor in developing nursing, many 2

researchers have examined nursing professional behaviours (Yoder 1995, Hampton & Hampton 2000). The levels of professionalism in nursing have been assessed to improve nursing as a profession.

Professional development Nursing professional development is beneficial to patient care, organisations and individuals. It influences nurses to continue practising their profession, which improves the retention of staff (Pool et al. 2013). Nursing professional development is regarded as the knowledge and skills acquired during career advancement (Eneh et al. 2012). Adeniran et al. (2013) noted that mentorship is essential for professional growth. As nurse leaders, nurse managers are responsible for providing career advancement opportunities and professional development for their nurses. Empirical research has suggested that the working environment and job satisfaction positively impact professional practise and development (Lee & Cummings 2008, Sellgren et al. 2008, Pasaron 2013, Leach & McFarland 2014, Palmer 2014). Working environment and job satisfaction have often been described as the most important predictors for nurses’ intention to keep working at an institution and those are also associated with nurse managers’ behaviours (Abualrub & Alghamdi 2012, McSherry et al. 2012, Van Bogaert et al. 2013, Keys 2014, Palmer 2014). Nurse manager behaviours strongly impact professional development.

Nurse manager professionalism Leadership is one of the key factors identified in the nursing profession (Kean et al. 2011). Nurse managers are expected to provide professional leadership in nursing and contribute broadly to the senior leadership services in their organisation (Eneh et al. 2012). It is important that the organisation is committed to developing and maintaining supportive leadership development activities (Shekleton et al. 2010). How nurse managers show their leadership in nursing depends on the organisation culture and policies, but is often defined by their professional behaviours. Nurse leaders advocate changing the nursing profession by accepting the responsibility to acquire and maintain professional behaviours (Miller 1988). The nurse manager is accountable for ensuring and managing the resources needed to manage clinical nursing practise and patient care (Sullivan & Decker 2005). Several studies revealed higher professionalism in ª 2014 John Wiley & Sons Ltd Journal of Nursing Management

Professionalism

nurse managers compared with their nurses (Adams et al. 1996, Adams & Miller 2001, Kim-Godwin et al. 2010, Celik & Hisar 2012, Tanaka et al. 2014). Evaluating nurse managers’ professional behaviours indicates the level of professionalism among them. In Japan, however, there are no research studies that describe nurse manager perspectives on their professional behaviours and activities.

Methods Instrument We used the Behavioural Inventory for Professionalism in Nursing (BIPN), which was developed based on Miller’s Wheel of Professionalism in Nursing model. The BIPN measures the degree of nursing professionalism within the past 2 years through dichotomous responses to 48 items. The subscales are the same as Miller’s professional characteristics of ‘educational preparation’, ‘publication and communication’, ‘research development, use and evaluation’, ‘participation in professional organisations’, ‘community service’, ‘competence and continuing education’, ‘theory development, use and evaluation’, ‘self-regulation and autonomy’ and ‘adherence to the ANA Code of Ethics’. The BIPN weightings for specific behaviours within each of the nine BIPN categories equal 3, and therefore a total composite score of 27 is possible. Higher mean scores indicate that more professional behaviours were performed. The reliability and validity of the BIPN were established by the previous study (Miller et al. 1993). It is a unique tool that measures professionalism only in nurses and has been translated and used in more than 30 different countries. Previous studies using Miller’s BIPN included registered nurses, nurse executives, middle managers and nurse practitioners in several countries (Tanaka et al. 2013). It is very important to use reliable instruments to assess well-grounded or justifiable results. Permission to use this inventory was received from Dr. Adams at Arizona State University. The Japanese version of the BIPN was back-translated. The reliability and validity of the Japanese version of the BIPN were established by a pilot study previously conducted in three hospitals with 1014 Japanese nurses. The internal consistency measured by Cronbach’s alpha was 0.66–0.75, and a test–retest reliability showed a high consistency of r = 0.87 (P < 0.001). The construct validity evaluation also showed moderate levels of correlation of r = 0.41– 0.46 (P < 0.0001) (Tanaka et al. 2012). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management

Sample Using statistical software, 24 hospitals were chosen randomly from 353 facilities across the country, and consent to participate in this study was received from 15 hospitals (six national hospitals, six public hospitals, and three private hospitals) in Japan. A total of 2860 anonymous surveys were distributed to nurses by mail between May 2011 and November 2011. We received 1834 survey responses, a return rate of 64.1%. We excluded 122 surveys from the study because of incomplete information, and identified 525 nurse managers for analysis. A power analysis was conducted with G*Power 3.1.9.2 (Heinrich Hein University, Dusseldorf, Germany) to determine a sufficiently large sample size. When calculating the F-test value by a priori one-way ANOVA test with four groups, 280 subjects were needed based on a = 0.05, an effect size = 0.25 and power = 0.95.

Ethical consideration The study was approved by the Kyushu University Institutional Review Board for Clinical Research (permission number: 22–107). In addition, research permission was given by the chief nursing directors of all 15 hospitals. Participants were advised that their responses to the questionnaire were anonymous and entirely voluntary.

Data analysis The total and subscale scores of professionalism were described as the means and standard deviations (SDs). The arithmetic mean was computed as the sum of scores divided by the number of scores in the variables. The administrator and ward manager groups were compared at each subscale by the Wilcoxon rank-sum test. Spearman’s correlation coefficient was used to calculate the relationships between professionalism and years of experience as a nurse and current position, education preparation and years acquiring the highest nursing degree. Regression analysis (stepwise) was also performed to investigate the influencing factors on nursing professionalism using the same variables as the correlation analysis. A comparison of the total level of professionalism in education preparation and the years of experience was made by oneway analysis of variance (ANOVA) and the post-hoc Tukey–Kramer multiple comparisons test. Significance was inferred when P < 0.05. All analyses were carried 3

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out using the Statistical Package for the JMP software (v.9; SAS Institute Inc., Cary, NC, USA).

Results Demographic characteristics A total of 525 nurse managers (33 administrators and 492 ward managers) participated in this study. The majority were female nurse managers (96.4%). The mean years of experience as a nurse was 23.0 years (SD = 7.6), and the mean years of experience in the respondents’ current position as a manager was 8.9 years (SD = 8.3). All nurse managers in the sample were employed in a single workplace, with 291 (55.7%) managers working in a medical and surgical setting. With the historical background of nursing in Japan, it was not surprising to find that half of the respondents held a diploma degree as their highest nursing educational qualification. The mean years of acquiring their highest nursing degree was 19.2 years (SD = 9.5). A summary of the respondents’ characteristics is given in Table 1. Table 1 Demographic characteristics of samples (n = 525) Characteristic Sex Female Male Age 20–30 31–40 41–50 51+ Years of experience 0–10 11–20 21+ Current position Administrator Ward manager Current practice setting Medical and surgical Obstetrics/gynaecology Operation room Psychiatric/mental health Paediatric Critical care Others Education Diploma ADN BSN Graduate

n

%*

505 19

96.4 3.6

9 138 233 145

1.7 26.3 44.4 27.6

25 184 312

4.8 35.3 59.9

33 492

6.3 93.7

291 26 41 19 32 52 61

59.9 5.7 4.3 4.0 7.3 13.6 5.2

259 152 69 45

49.3 30.0 13.1 8.6

ADN, Associates Degree in Nursing; BSN, Bachelor of Science in Nursing. *Unknown answers were excluded from percentages.

4

Nursing professional scores A composite score of 27 is possible on the BIPN and its Japanese version. The mean composite score achieved by the 525 nurse managers was 9.19 (SD = 3.89). The highest category score was obtained in ‘competence and continuing education,’ and the lowest category score was in ‘publication and communication’ (Table 2). The total mean scores of nursing professionalism were increased by the years of nursing experience as a nurse (Table 3). Administrators had significantly higher total scores of nursing professionalism than nurse managers (mean 14.17 and 8.86, respectively, P < 0.0001) and all professional subscales were significantly high in administrators.

Correlation between nursing professionalism and characteristics Spearman’s correlation coefficient was calculated to determine the relationship between nursing professionalism and characteristic variables (Table 4). As a result, personal factors and the score of nursing professionalism showed a significant positive correlation with years of experience (r = 0.22, P < 0.0001) and educational preparation (r = 0.27, P < 0.0001).

Factors influencing nursing professionalism Multiple regression analysis (stepwise) was performed to observe the factors influencing nursing professionalism using variables that correlated with nursing professionalism as explanatory variables. The results showed that the influencing factors were years of experience as a nurse and education preparation (Table 5). Also, the results showed that education preparation had more influence on nursing professionalism than the years of experience (b = 0.467 and 0.269, respectively). The value of R2 was 0.295 in this regression analysis. A one-way ANOVA was performed to examine the influence of years of experience, current position and education preparation on nursing professionalism. The results showed a highly significant relationship (F = 48.69, P < 0.0001) between education preparation and the total score of professionalism. The Tukey–Kramer multiple comparisons test revealed that a higher education degree was significantly associated with high scores of professionalism (P < 0.0001), with the exception of a non-significant relationship between diploma and associate degree (P = 0.59). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management

Professionalism

Table 2 Professionalism subscales (n = 525) Manager (n = 525) Mean *(SD)

Subscale Education preparation Publication and communication Research development, use and evaluation Participation in professional organisations Community service Competence and continuing education Adherence to the ANA Code of Ethics Theory development, use and evaluation Self-development and autonomy Total score†

0.30 0.25 1.19 0.95 0.45 2.03 1.53 1.37 1.11 9.19

Administrator (n = 33) Mean *(SD)

(0.63) (0.62) (0.80) (0.48) (0.83) (0.60) (1.50) (0.74) (0.63) (3.89)

1.09 0.75 1.48 1.33 1.05 2.33 2.45 1.83 1.80 14.17

Ward manager (n = 492) Mean *(SD)

(0.95) (1.03) (0.95) (0.68) (1.09) (0.55) (1.18) (0.71) (0.79) (5.25)

0.25 0.22 1.18 0.93 0.41 2.00 1.47 1.33 1.06 8.86

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Professional behaviours and factors contributing to nursing professionalism among nurse managers.

To examine the perception of professional behaviours and factors contributing to nursing professionalism among nurse managers...
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