Professional Behaviors of Nurses in Geriatric Health Services Facility in Japan

Background: The characteristics of geriatric health services facilities (GHSFs) in Japan include provision of care focused on the life of the residents, and there is a need for cooperation between care workers and physical therapists responsible for the care. Our goal is to create an organizational system that allows nurses to succeed professionally. To do this, we must first discuss the professional behavior of nurses in GHSFs. Objectives: The aim of the present study was to clarify the professional behavior of nurses in GHSFs using a questionnaire survey. Method: We used a descriptive, cross-sectional design. The study was conducted in 1000 GHSFs all over Japan. The instrument used for data collection was a questionnaire. The questionnaires consisted of 24 items for determining the professional behavior of nurses, the background information of respondents. The professional behavior of nurses was ana-lyzed using principal factor analysis (Promax rotation). Results: A total of 1189 nurses participated. Of those, 91% (n = 1084) were women, and mean age was 48.2 years. Most participants were staff nurses (n = 791; 66%). We extracted 16 items by factor analysis, which were classified into four factors (professional development, autonomy, positive assertiveness to colleagues, and advocating for patient). Conclusion: The professional behaviors as identified in this study are similar to those reported in previous studies of clinical nurses in hospital. However, some subscale results are specific to the characteristics of GHSFs. The ability to understand professional behaviors has significant implications in terms of affirming and identifying sources of quality of care and creating a professional practice environment within GHSFs.


Introduction
The average lifespan in Japanese society has increased with the increase in welfare levels. This, in turn, has led to a rise in the rates of the older people within the general population. As a result of these demographic changes with respect to the increase in the average lifespan, restrictions occur in the daily care activities of individuals. Older people require more social, economic, and health protection, as well as better nursing care on various levels. In geriatric patient care, as with all age groups, nurses obtain a patient's health history, determine his/her needs, develop a comprehensive care plan, provide treatment and care, and evaluate the results. While carrying out all these tasks and fulfilling their responsibilities, nurses experience several problems and difficulties in patient care within their work environments. The difficulties experienced by nurses in geriatric patient care include the inadequacy of physical conditions and technical equipment in hospitals; care problems experienced due to patients' physical restrictions; administrative difficulties; communication problems experienced with the patient or family caregiver; difficulties arising from insufficient knowledge, skills, and experience in geriatric patient care; prejudice of older patients and family caregivers toward the hospital environment and health personnel; and lack of appreciation for the care provided to the patients. These problems and difficulties experienced by nurses give rise to an increase in workforce loss, care moves, and job suspension. They also contribute to early retirement rates among nurses, a decrease in work efficiency, delays in returns to work, and an increase in medical treatment costs. Additionally, nurses experience physical problems and psychosocial problems due to the difficulties they face in geriatric patient care. Realizing and solving these difficulties will enable nurses to be more satisfied with their jobs, thus enabling them to provide patients with a more satisfactory care service. Provision of professional nursing care reportedly results in improved patient satisfaction and positive health outcomes [1] [2]. Therefore, to improve the quality of nursing care for residents of geriatric health service facilities (GHSFs), it is crucial to reconsider nurses' professionalism.
Professionalism is defined as the degree of commitment by individuals to the values and behavioral characteristics of a specific career identity [3] [4]. Although professionalism is viewed as a framework for identifying a particular type of work within a social context, the emphasis on value commitments is specifically directed toward more meaningful aspects of that work [5].
Over the years, many nursing scholars have defined characteristics of the nursing profession, and a considerable body of nursing inquiry relevant to professionalism exists [6] [7] [8]. Hall [3] [9] [10] developed a professional model and identified five attitudinal attributes that characterize the most mature professions, such as those of a lawyer and physician. Hall's model and its corresponding instrument, the Professionalism Inventory scale, were chosen for the current study. In Japan, several researchers also identified attitudinal attributes of professionalism [11] [12]. Although these studies found that social, cultural, scientific, and technological factors all influence the development of the nursing profession, most of them were conducted in medical facilities. Thus, we aimed to clarify the professional behavior of nurses in GHSF using a questionnaire survey in order to improve quality of care.

Participants
The study was conducted with 1000 GHSFs across Japan. After obtaining agreement from the organizations involved, questionnaires were distributed by nursing directors to each individual employee who met the study criteria. Written guidelines were given to the administrators of the questionnaire to assure that each nurse received the same directions and information. After the questionnaire was completed, the nurse mailed the questionnaire in a sealed envelope to assure anonymity. The information provided by the participants was completely anonymous. No names or identifying numbers were collected on any of the instruments.

Measures
A quantitative, cross-sectional design was adopted using a self-completion questionnaire survey. The questionnaires were divided into three parts. Part one consisted of the subjects' background information and nurses' professionalism.
The following demographic data were collected: age; gender; marital status; overall work experience; status (nurse director, nurse manager, or staff); academic background (associate degree, nursing diploma, junior college diploma, or university/graduate degree, and work experience within the current facility).
Nurses' professionalism behaviors were measured by a 13-item index developed by Hall [3] assessing professionalism behaviors among nurses. The Japanese version of the scale was translated by Tao [13] and was converted to a revised 13-item Japanese scale. Cronbach's alpha for these items was found to be reliable, at 0.81. We added 3 items in reference to a previous study [14] concerning nurses' professionalism behaviors in GHSFs. Participants responded to the items using a 5-point Likert scale, with responses ranging from "fully agree" to "fully disagree".

Data Analysis
All statistical analyses were performed using IBM ® SPSS ® Statistics 22.0 for Windows. Using the responses to 16 questions related to professionalism behaviors of nurses, we performed a factor analysis (promax rotation) that excluded items that had many overlapping factors, using a load of 0.4 as a reference point.

Ethical Approval
This study was approved by the Ethics Committee of Mie University Graduate School of Medicine. The questionnaires included the researchers' contact details, and the information collected was both voluntary and anonymous.

Factors Related to Nurses' Professionalism Behaviors
We extracted 16 items that were classified into four factors regarding nurse professionalism. Factor one consisted of active continuous education in the profession such as "I always try to gain new knowledge and learn techniques to provide good patient care", and "I regularly read a specialist magazine related to work".
These were categorized as "Professional development". Factor two consisted of items related to autonomous behavior such as "I always work with awareness that I'm a professional", "I always try to look back on my own work", and "I am

Nurses' Demographic Characteristics
Ninety percent of the participants were female, and 90% of them were 40 years or older. Fifty percent were certified nursing assistants. Though 90% of the participants were 40 years old or older, 64% had nine years of experience or less at their present workplaces; thus, many of them had likely changed their jobs.
These results are consistent with the present situation of nursing jobs at GHSFs [15] therefore, the results of this study can be generalized.

Factors Related to Nurses' Professionalism Behaviors
Cronbach's alpha for the scale used in this study was 0.86, with sufficient reliability for all cases.
Factor one, "Professional development" The development and understanding of professional knowledge is important to the professional socialization process [16]. The application of knowledge and critical thinking skills is essential to establishing sound clinical judgement in nursing practice. The significance of education in enhancing professionalism is stressed by several researchers. The Nursing Activity Scale (NAS) was used to measure professional autonomy among nurses. Williams and McGowan [17] revealed that the NAS scores of nurses taking the professional development program on nurse autonomy were significantly higher when compared to the nurses who were not taking the course. Knowing that autonomy is one of the essential traits of professionalism, providing structured educational activities may assist in supporting and enhancing nurses' professionalism. In addition, increased level of education is positively associated with higher degree of professionalism [18]. However, most participants in this study had an associate's degree. Therefore, it is more necessary for nurses at GHSFs to enhance their professional knowledge by accessing educational resources (e.g. libraries, conferences, and Factor two, "Autonomy" Autonomy is considered essential for a professional individual. The concept of autonomy may be defined, categorized, and demonstrated in various ways. It refers to the ability of nurses to achieve a desirable outcome by making independent and informed decisions [19] [20]. The essence, or the ultimate definition, of autonomy is determined by decision-making behaviors [4]. These professional behaviors reflect the characteristics of geriatric care. Nurses of GHSFs are expected to be more autonomous, making definitive decisions when physicians are absent. Most of the medical care provided in facilities involves tube feeding, intravenous feeding, and pressure ulcer care [21]. Recently, the number of residents who are highly dependent on medical care and who are critically ill has increased in medical facilities [22].   [30]. In addition, Linzer [31] discussed the ethical dilemma involved with the elderly refusing nursing home placement as a conflict between respecting the patient's autonomy and acting on behalf of their welfare. Understanding and resolving these difficulties will enable nurses to be more satisfied with their jobs and enable them to provide patients with more satisfactory care. To overcome these barriers, nurses can involve themselves in shaping health policies that can improve their work environments and patient outcomes.
The nursing profession is indirectly affected by rapid changes in health services. As the number of quality studies has increased in recent years, the involvement of nurses in these studies has been critical. Study findings reveal that nurses are aware of these health service changes and how these changes affect them as professionals. They are also aware of their own roles and responsibilities, behave autonomously, think critically, make their own decisions, respect other medical professionals, and they are sensitive to the ethical values of the profession.

Limitation of This Study and Future Research
Our participants consisted of only staff members in GHSFs. The perspective from patients or residents was not considered. Therefore, further investigation on nursing administrators is needed.

Conclusion
The concept of professional behaviors as identified in this study is similar to that reported in previous studies of clinical nurses. However, some subscale results are specific to the characteristics of GHSFs, such as autonomous decision-making when a physician is absent and comprehensive care of the patient according to the life model. The ability to understand professionalism has significant implications in terms of affirming and identifying sources of quality of care and creating a professional practice environment within GHSFs.