Professionalism is a multifaceted concept, lacking a consensus on its definition in literature, although certain characteristics are commonly identified.1 Some research findings show that nurses who invest more time in self-preparation are perceived as more professional.2 According to Akhtar-Danesh et al., professionalism can be defined as possessing knowledge, specialization, intellectual abilities, and a sense of responsibility.1 In fact, professionalism is a process in which people acquire and internalize knowledge, skills, culture, attitudes, and values, as well as the standards of nursing ethics as a behavior and mental image of the profession.3 To achieve professional status in nursing, the nursing code of ethics was approved by the American Nurses Association in 1950, with interpretative statements added in 1976 and revision in 1985. Also, Miller described the model of the "wheel of professionalism in nursing" in 9 categories.4 The professional standards were amended in 2002 and developed by the Ontario College of Nursing (CNO).5 Reducing the number of professional nurses and employing untrained nurses or other medical staff instead of a nursing expert has had adverse effects on the quality of patient care.6 A study of non-standard care and distrust of Mead Staffordshire National Health Services in the United Kingdom led to significant reports of nursing failure.7 Therefore, ensuring the quality of care and the professionalism of nurses alarmed the nursing managers and the health care provider system to guarantee the quality of services provided to inpatients.8 In recent years, nursing in Iran and some other countries has been criticized for the quality of care due to poor growth; however, the factors leading to the health system response are diverse.9 Nevertheless, most of the nurses believe that the main reason for the loss of quality of nursing care is the lack of a well-developed and specific professional framework for nursing, nurses' negligence in defining and developing indicators of nursing professionalism and delays in meeting the necessary needs. Paying inadequate attention leads to a reduction in the quality of nursing care services, which in turn has led to failures in health care programs.10

The process of professional socialization is one of the important processes that occur for the nurses in order to become professionals during education. The purpose of professional socialization is to develop professional behavior, which means that a series of learning and socialization experiences are needed to transform an individual from a student to a professional nurse. The process of professional socialization requires students to internalize or learn knowledge, skills, attitudes, behaviors, values, and ethical standards, and this process forms part of their professional identity and behaviors which are expected to develop during college and during patient care.11

Despite the emphasis on the importance of professionalism in nursing and its role in providing services to society and patients, at the same time considering that part of a nurse's professional behavior is formed during the year of study and through practice and education, few research studies have been conducted on professionalism in internship nursing students. To solve the problem, the first step is identifying the current situation, and the study of professional behaviors of students before graduation can clarify part of the process of creating and developing professional behaviors during formal and informal nursing education. The aim of this study was assessing the level of professionalism in internship nursing student. In addition, this study could pave the way for developing interventions in the educational curriculum of nursing students and taking effective measures for the professionalism of these students and their proper preparation to enter the field.

This cross-sectional study was done in Namazi Hospital of Shiraz University of Medical Sciences among final year or internship nursing students from October to December 2021. Shiraz University of Medical Sciences and Health Services is a public university located in Shiraz, Iran. It is one of the largest and best universities for medical sciences in the country, with 17 faculties, over 10 000 students, and 782 faculty members. The university offers 91 fields of study and has 56 research centers, 53 hospitals, and 33 health networks that offer treatment and healthcare services to more than 4 million people in Fars province.12,13

This study used non-probability convenience sampling. Azemian et al (16) reported that σ = 18.8 and desire accuracy range d = 0.15 σ and the test error level is α = 0.05, N = 90 and 10% attrition sample size were 70 using the following formula:

Two instructors who were the head nurse of ward of high-risk mothers and neonatal intensive care units rated each nursing students using professionalism in nursing questionnaire (PNQ) individually. Both the raters, the participant trainer was female and 49- and 45 years old, who volunteered for this study. Finally, 70 questionnaires were completed for nursing internships in clinical units including high-risk mothers and neonatal intensive care units in Namazi Hospital.

The PNQ was used as the study instrument.14 PNQ includes 7 dimensions, 37-item scale to measure a total score for professionalism including individual competencies (11 questions), professional responsibility (6 questions), respect for human dignity (3 questions), behavior based on professional values and norms (5 questions), professional development (5 questions), professional and organizational interactions (peers and other members of the health team) (3 questions), and interaction with clients (patient and companion) (4 questions). The responses were on a Likert scale and all items of the questionnaires are positively answered. Response was based on a 5-point Likert scale as follows: “I totally disagree” with the score of 0, “I disagree” with the score of 1, “I neither disagree nor disagree” with the score of 2, “I agree” with the score of 3 and “I completely agree” with the score of 4. Linear conversion method was used to score and compare the scores of different components of the questionnaire. The following linear formula was used to convert the scores of the subscales and the whole questionnaire to a score of 0–100: a score of 0 means unprofessionalism, and higher the score towards a maximum (100), the higher and more desirable the professionalism. Questions were asked to elicit socio-demographic characteristics instructors included age, gender, degree, work experience, and year of instructor’s nursing experience. The students’ demographic questions included gender and regular attendance in internship.

The overall reliability of PNQ was 0.97 by Cronbach’s alpha and intra-cluster correlations were also used for individual domains, i.e., individual competencies (0.91), professional responsibility (0.87), respect for human dignity (0.88), behavior based on professional values and norms (0.99), professional development (0.97), professional and organizational interactions (Peers and other members of the health team) (0.98), and interaction with clients (0.89). To determine the content validity, this study used the opinions of 31 experts in the field of nursing, medical ethics, and medical education; based on the collected opinions mean for whole scale (S-CVI/Ave) was equal to 0.91 and the content validity ratio (CVR) was 0.8.15,16

The data were analyzed using SPSS, version 16, for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics (mean and percentage) were used to describe demographic characteristics and mean scores of professionalisms and its dimensions. Histograms and the bias-kurtosis and Shapiro–Wilk test were used to evaluate the normality. Comparisons between the 2 groups were made by independent samples t-test. To compare more groups, the Kruskal–Wallis test was used.

Professionals who have a high level of commitment work harder to promote the values of the profession and have a high level of responsibility.17

Based on the findings of this study the mean score of professionalism is 75.26, which shows that nursing internship students have achieved the necessary professionalism to enter the workplace as a nurse. Among the dimensions, the highest mean is equal to 80.36 and is related to the dimension of behavior based on professional values and norms. Nursing is not only just gathering special knowledge or skills, but also it changes the ethical and professional values and attitude towards nursing and improves the professional performance to gain people's trust in nurses. Professional values, before it manifests itself in behavior, is an inner desire and feeling that is reinforced by conscientiousness, and self-sacrifice. In the fields of medical sciences, especially nursing, compassion, empathy, patient support, etc., in addition to being a moral virtue, are also considered as the essence of care and therefore the essence of nursing and nurses are expected to show compassionate behavior.18

In addition, the second dimension that had the highest mean among nursing students was interaction with clients (80.30). Perhaps one of the main reasons why students earn this score is that they do not yet have full responsibility for the patients and as a third party away from job stress, communicate effectively with patients and other clients. Accordingly, Mazhari-Azad et al. argued that the most important challenges for the nurses in communicating with the patients were classified into 4 areas: individual and social factors, job characteristics, patient's clinical condition, and environmental factors.19

The period of education of nurses is very important to establish proper communication with clients.

Another finding shows that the dimension of professional interactions was the lowest mean (75.00). Probably the low score of this dimension can be due to the conditions of being a student and his/her limited communication with other professions. Nurses rarely work alone, so the role of proper communication within organizations in establishing appropriate relationships between nurses, patients, and other medical professionals and nurses' awareness of the rules and regulations related to responsibility and accountability for services provided cannot be ignored.20 Therefore, proper communication and knowledge of the rules are effective factors in facilitating and developing professionalism in nursing.

Nursing students will enter their professional activity immediately after the internship, and the professionalism and its components in nursing students should be strengthened before graduation.

The results of this study showed that the mean score of students’ responsibilities was 78.50. Nurses are accountable for their performance and must act in accordance with their professional responsibilities and standards of professional performance. The Australian Registered Nurse Standards for Practice, developed by the Nursing and Midwifery Board of Australia (NMBA) in 2016, encompasses the importance of responsibility and accountability by highlighting critical thinking, reflective practice, and lifelong learning in its framework for continuing educational development.21

In addition, the results of this study show that, the mean of dimension of professional competencies among internship students was 75.80, which includes cognitive, emotional, and psychological characteristics. Adams and Miller believe that developing cognitive skills and intellectual ability causes nursing professionals improve their position by following the orders of others to make independent decisions.4 Tajwidi et al. believe that critical thinking, ability to analyze the patient's condition, and ability to use the evidence properly are positively related to clinical competence.22

The nurse had emotional and psychological characteristics and the ability to control workplace stress, as well as high patience and tolerance as one of the effective factors in professional behavior in the nurse have been considered important in terms of management support and appropriate relationships in enduring job pressures.

Empowering nurses psychologically increases their ability to deal with stressors in the workplace.23 The study conducted by Heidari et al. highlights the importance of considering factors such as meeting the mental and emotional needs of employees and reducing stress levels in order to retain staff.24 Self-confidence plays a pivotal and transformative role in the growth of professional values and the creation of a professional identity. Lakobasi et al. showed that senior students have high self-esteem and intrinsic values.25

In this study, the mean score of behavior based on professional values and human dignity was 75.11. In fact, human ethics and values including observing justice in providing care regardless of the patient's gender, religion, and culture, keeping patient information confidential, providing safe and appropriate care, obtaining patient satisfaction, patient support, answering patient questions, providing information and correct explanation to the patient try to protect patient’s privacy, and patient participation in decision-making. But the results of research conducted in the country showed a lack of professional values and respect for the human dignity of the patient.26

In addition, other results of this study showed a mean score of 73.79 for the professional development of nursing students. In fact, not paying attention to the design of care plan for each patient due to workload and excessive emphasis on procedures were considered as weaknesses of the nursing education system. According to The International Council of Nurses (ICN), accountability refers to “the individual nurse being responsible and answerable for their own or others” actions or inactions’ and relates to nurses’ legal liability and responsibility in daily practice.27

Dickman quotes Hampton as saying that a professional is a body of knowledge acquired through formal education, a wide range of skills, a certificate of entry into the profession, and a set of well-known norms of behavior defined in the profession.28 Another finding of this study was that students with perfect regular participation in their internship scored significantly higher than other students. The Najafi Kalyani et al study highlights the necessity of improving clinical environment and clinical experience education for the professional development of nursing students.29 One of the main concerns of nursing educators is to involve students in meaningful learning experiences. Absence reduces the amount of time nursing students engage in such experiences. Kosta identifies problems related to student nurses’ absenteeism includes internal and external factors that affect a person's motivation for life and work tasks. Internal factors include competence, independence, and communication. Students feel rewarded and motivated when their inner needs are met. Such feelings lead to increased participation in learning and tasks. Internal factors include reward systems, such as scoring on an exam.30 It is necessary to pay attention to the prevention of absenteeism. The overall goal of absenteeism strategies should be to engage students in learning. Students face more complex social and emotional challenges; therefore, the faculty should communicate with students in a safe manner to find the reasons for absenteeism. Once faculty members understand the root cause of absenteeism, they can more easily provide appropriate resources to students.

The findings of this study showed some strengths and weaknesses of professionalism in nursing internship students. For improving the components of professionalism in nursing students, modifying the educational curricula of nursing students before the internship is recommended. In fact, in addition to the importance of familiarity of undergraduate students with the concepts of professionalism in theory, practical training of these concepts through experienced instructors and role models can be an effective step in developing professionalism in nurses after their graduation. One of the most important factors leading to nurses' job dissatisfaction is insufficient financial payment. The results of this study showed an appropriate level of professionalism in nursing students. These students were in their final semester and will enter the field of work immediately after graduation. If we expect professional nurses in the health care system, we should pay special attention to their financial payments

Professionalism plays an important role in shaping the professional identity of nursing students. In general, a structured nursing curriculum with professional concepts that are associated with appropriate clinical codes and related occupational care standards, as well as considering the prevailing socio-cultural factors in medical universities guarantees a professional nurse. In addition, the curriculum should include training, modeling, evaluation, and monitoring standards. Finally, in addition to evaluating the formal curriculum, it is suggested that the impact of the informal, hidden curriculum, which affects thinking, action, and attitudes about professionalism, be examined and evaluated.

The authors received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.