Nurses’ Views on Their Profession in Turkey and Influencing Factors

Objective: The study was conducted as a descriptive and cross-sectional to determine nurses’ views on their profession in Turkey, their commitment to the profession and participation in professional activities and infl uencing factors. Methods: The study sample comprised 2253 nurses working in hospital in Turkey. The data were collected using a questionnaire developed by the researchers. For the assessment of the data, percentages, the chi square and multiple logistic regression analysis were used. Results: According to the fi ndings of the study based on the nurses’ statements, of the nurses, 62.3% chose the nursing profession willingly, 51% were satisfi ed with their profession, 75% thought that their profession was suitable for them, 59.3% might change their profession if they were offered better working or fi nancial conditions, 15.4% considered leaving their profession, 37.2% participated in professional conferences and training courses, 72.3% did not keep up with professional publications and 32.3% were the members of the National Nursing Organization. The nurses who chose the profession willingly and had higher levels of education displayed more positive attitudes to their profession than did the nurses who did not choose the profession willingly and had lower levels of education, and the difference between them was statistically signifi cant. The nurses having bachelor’s or master’s degrees participated in professional activities more than did the others, and the difference was signifi cantly high. Conclusions and Implications: As a result, it was determined that Turkish nurses had high levels of positive views regarding their profession and commitment to the nursing profession, but low levels of intentions to achieve their professional responsibilities. For nursing to gain ground in the process of professionalization, it is extremely important that its members should adopt its professional ideology, should have a positive perception of the profession and themselves, develop a positive professional identity. Therefore, nurses’ thoughts about the profession, and how well they adopt the profession should be determined and should be strengthened. This is the basis for the development of nursing as a profession. Research Article Nurses’ Views on Their Profession in Turkey and Infl uencing Factors Selma Sabanciogullari1* and Selma Dogan2 1Associate Professor, Department of Psychiatric Nursing, Cumhuriyet University, 58140 Sivas, Turkey 2Professor, Department of Psychiatric Nursing, Uskudar University, Faculty of Health Sciences, Istanbul, Turkey Dates: Received: 13 February, 2017; Accepted: 13 March, 2017; Published: 15 March, 2017 *Corresponding author: Selma Sabanciogullari, Associate Professor, PhD, RN, School of Susehri Health High, Department of Psychiatric Nursing, Cumhuriyet University, 58140 Sivas, Turkey, Tel: 90 346 21910192514; Fax: 90 346 2191260; E-mail:


Introduction
Rapid changes in the health care sector place new demands on nursing and nurses. Changes such as developments in advanced medical technology, changes in the generalpopulation structure, increased workplace diversity, market orientation, short-term hospitalizations and increases in patient expectations have made nursing services complex, and thus have increased demands for professional and competent nurses to provide high-quality nursing care [1]. However, due to these changes, nurses face many professional and managerial challenges and problems in the work environment while providing nursing services, which adversely affects nurses' perceptions of and attitudes towards the profession [2][3][4]. Nurses' perceptions of and attitudes towards the profession, and how they feel and what they think about themselves and the profession affect their work motivation, self-image, quality of care, patient satisfaction, job satisfaction, job retention rates and their ability to affect changes in health care [3][4][5]. In several studies conducted with nurses all over the world in recent years, 9 to 26% of the nurses have been determined to consider leaving the nursing profession due to their unfavorable work environment, job dissatisfaction and burnout [6][7][8][9]. In addition, in several international studies examining nurses' perceptions of their profession, it has been determined that nurses perceive nursing as a profession with low autonomy, perceived negatively by society, chosen due to employment opportunities, and not worth doing an academic career [4,10,11]. Nurses' negative perceptions of their profession adversely affect the safety and quality of patient care services [12,13] and professionalization process of the profession [2].
Members of the profession who have positive perception DOI: http://dx.doi.org/10.17352/anpc.000020 of the profession and internalize it offer a safe and quality patient care, and make an effort for the professionalization of the profession more. According to Hwang et al., (2009) for nursing to gain ground in the process of professionalization, it is extremely important that its members should adopt its professional ideology, should have a positive perception of the profession and themselves, develop a positive professional identity. Therefore, nurses' thoughts about the profession, and how well they adopt the profession should be determined and should be strengthened. This is the basis for the development of nursing as a profession [3].
As in the entire in world, although nursing profession in Turkey does not involve all the features of professional occupations, it is accepted as a scientifi c discipline, and it has made signifi cant strides in the way to professionalization [14]. In Turkey, there are a few previously conducted studies providing limited information about nurses' opinions regarding their profession [15,16] and professional qualifi cations [17,18].

Background
Professionalization process is defi ned as "a number of changes fulfi lled in the structure of the occupation to achieve professional status". Povalko (1971) determined the following criteria that an occupation should comply with knowledge, relevance to the basic social values of the community, length of the education, rendering of services to the public, autonomy, sociability, professional ethics and commitment to the profession [19]. In line with the international literature [4,20], the professionalization process of nursing in Turkey has made signifi cant improvements especially since the 1980s [19].
Today, the professionalization process of nursing in Turkey is still one of the most important endeavors nurse leaders are involved in [18].
Education is an important criterion in the process of professionalization. The establishment of the modern nursing in Turkey has been achieved since the foundation of the Republic of Turkey. Healthcare provided by Florence Nightingale for the wounded British soldiers during the Crimean War in Turkey (between 1854 and 1856) and her success played an important role in the development of nursing as a profession. The Red Crescent Nursery School, Turkey's fi rst national nursing school was opened in 1925 as a high school [21]. Nursing schools providing education for junior high school graduates and conferring diploma on the graduates were opened in 1946 by the Ministry of Health. The fi rst undergraduate nursing school was opened in 1955 at Ege University. Shortly after the start of undergraduate education in nursing, nursing schools offering postgraduate education or doctoral programs were opened in 1968 and 1972 respectively [21,22]. After the diploma-based and associate of science-degree nursery programs were closed in 1996, 76 Vocational School of Health Services offering undergraduate education were opened nationwide [22].
Finally, in 2007, the nursing law was changed and the new law required that the basic nursing education should be given at the undergraduate level [18]. However, due to the great need for nurses in the country, it was decided to continue some of the  [23]. However, this number can be considered rather insuffi cient given the number of nurses in our country is close to 100.000. In addition, there are approximately 25 nursing associations in different fi elds of nursing. However, the number of the members of these associations is not at the desired level either [24,25].
The law of occupation is another important professional criterion. In Turkey, the nursing law was fi rst enacted in 1954. It was revised in 2007 since it failed to meet the needs [22]. In the revised law, nursing education was required to be given at the undergraduate level, gender discrimination was eliminated, and specialization in nursing was identifi ed. In 2010, job descriptions, roles and responsibilities of nurses who would work as a manager, general duty nurse or clinical nurse specialist were defi ned with regulations [22,23]. In addition, in recent years, issues such as continuous nursing education, post-graduate certifi cate programs and encouraging nurses to participate in research have gained importance [18].
With the start of master's and doctoral programs in Turkey, the number of studies contributing to the steady accumulation of professional knowledge has increased. Therefore, today, there are more than 20 scientifi c and professional nursing journals published by the nursing schools, professional associations and other organizations [25,26]. The Journal of Turkish Nurses, fi rst published in 1953, is the fi rst nursing magazine in Turkey.
Professional autonomy is another professionalization criterion. Nursing autonomy is defi ned as competence in DOI: http://dx.doi.org/10.17352/anpc.000020 making nursing decisions for the care of a patient and being independent while performing nursing practices [27]. In our country, despite the increase in the number of well-educated nurses, nurses cannot fully use their autonomy in the present health care system. Those who have a voice in health services are physicians, and the notion that nurses are auxiliary staff has not been eliminated yet. Several studies on the issue have determined that nurses in our country cannot demonstrate their professional autonomy truly [14,27].
Another important criterion in the process of professionalization is commitment to the profession. In order for an occupation to be carried out by its members effectively and to advance in the process of professionalization, it needs members who internalize their professional identity and greatly commit themselves to the profession [19,28]. If an occupation is internalized by its members, then it is welcomed by the community as well [28]. Hwang et al., (2009) state that it is possible to achieve professionalism by developing the professional identity. In a study conducted in Turkey, professional qualifi cations of nurses were found to be low [14].
Another criterion of professionalism is to render essential services to the public. It can be said that the public image of the nursing profession and the public's perception of the nursing profession are of great importance in the professionalization process of nursing Turkish [29,30] and international nursing literatures [5,31], indicate that although the public image of nursing profession and nurses is more positive than it was in the past, it still has not improved adequately. Several studies of various groups in society (public, physicians, students) conducted in the 2000s in Turkey have revealed that nurses are perceived as people who assist a physician, give an injection or measure blood pressure and that the nursing profession is perceived as a low status profession with diffi cult working conditions [32,33]. It can be said that the public's negative perception of nurses and nursing profession in Turkey may negatively affect young people's intentions of preferring nursing profession as a career. In practice, the status of nursing as a profession is not at the desired level. The health system in Turkey is mainly based on hospital treatment services, and almost all of the nurses' work in hospitals. In this system, nurses, in general, work "task-centric". In the health care system, physicians have the leading role, and thus nurses are often unable to perform their healthcare functions independently of physicians [27]. On the other hand, salaries paid to nurses by private hospitals in Turkey, the number of which is rapidly increasing, are rather low. In Turkey, the distribution of healthcare workers across the country is not balanced. While a large number of nurses are employed in big cities and in the western part of the country, the number of nurses employed in the eastern and central parts of the country is insuffi cient. According to the data released by the Ministry of Health in 2010, the number of nurses per 1,000 people is 1.56 [34]. Due to shortage of nurses, nurses are generally obligated to work overtime. Job satisfaction [35,36] and burnout levels of nurses [37] in Turkey are moderate. Most of the nurses who work actively in nursing have an associate's degree [14].

Design and sample
The study was conducted as a descriptive and crosssectional study. The study population consisted of nurses working in hospitals in Turkey. The number of nurses working in hospitals is approximately 55.000 [34]. For the sample selection, the stratifi ed sampling method was used. Turkey was divided into seven geographical regions, and then the number of nurses working in each region was determined.
For the determination of the desired sample size, the values considered signifi cant were as follows: alpha=0.05 and d = F 1. The sample included 2365 nurses from the seven regions.
Using the simple random sampling method, two university and two state hospitals from each region were selected, and thus nurses working in 14 university and 14 state hospitals were included in the sample. Of the 2365 nurses in the sample, 112 were excluded from the study since they did not fi ll out the forms correctly. Therefore, the study was completed with 2253 nurses (the participation rate of the sample is 95.3%, and the percentage of the population represented in the sample is 4.1%).

Data collection tool
The data were collected with a questionnaire developed by the researchers using the literature [5,38]. The validity and comprehensibility of the questionnaire was tested in a pilot study with a sample group of 30 nurses. During the pilot study, content validity of the questionnaire was investigated, and similar questions were excluded. Questions in the questionnaire comprise the basic variables studied. In addition, the questionnaire were administered to the nurses three weeks later using the test-retest method, and the response ratio between the two applications (response rate of the fi rst application / response rate of the second application) was found to be 0.92 [39]. All ambiguities were corrected before the administration of the questionnaire to the fi nal sample.
The evaluation of their results indicated no problems in terms of the clarity and the implementation of the form.

Data collection procedure
To fi ll out the questionnaires, 28 interviewers (one from each of the hospitals included in the sampling) were employed. DOI: http://dx.doi.org/10.17352/anpc.000020 Interviewers were chosen from university students studying in the fi eld of health. Prior to the application, an informational meeting on the implementation of the study was held with the interviewers. Before the application, the interviewers met with the hospital's head nurse in each hospital to inform them about the study, and upon the approval of the head nurse, they interviewed nurses in the clinics. Data collection forms were distributed to the nurses by the interviewers after oneto-one interviews. The interviewers explained the purpose and importance of the study to the nurses, and the nurses who agreed to participate in the study fi lled in the forms themselves. Nurses were asked not to place their names on the form. The forms were collected on the same day. It took about 20-25 minutes to fi ll in the form.

Data analysis
For the evaluation of the data, SPSS 14.0 package program was used. For the statistical analysis of the data, percentages, the chi square and multiple logistic regression analysis test were used.

Ethical approval
This study was reviewed and approved by the research ethics committee of the author's institution (Decision no: 83116987-051). Before the data were collected, the written permissions of the institutions where the nurses worked were obtained.
In addition, verbal consents of the nurses participating in the study were obtained after the purpose of the study was explained to them. The study was conducted according to the Declaration of Helsinki.

Demographic characteristics
The mean age of the nurses was 31.51 ± 6. 10  Of the nurses, 75% considered the nursing profession as an appropriate profession for themselves, 25% stated the opposite, a great majority (83.9%) were proud of being a nurse, a small number (6.7%) were not comfortable about this issue, 69% considered nursing as a profession essential for public health, 36.6% said that they would suggest other people to involve in nursing as a profession and 41.5% said that they would not.

The nurses' commitment to their profession and their views on nursing
When the nurses' opinions about nursing and about whether they chose it willingly were compared ( Table 2) it was determined those who chose the profession willingly considered leaving or changing their profession signifi cantly less than those who did not (p<0.01). The number of the nurses who stated that they were satisfi ed with the profession and would choose it again was signifi cantly higher among those who chose the profession willingly than among those who did not (p<0.01). In addition, the number of the nurses who considered nursing is suitable for them, who would suggest it to others, who would not mind saying they were nurses and who regarded nursing as an essential profession for public health was signifi cantly higher in those who chose the profession willingly than in those who did not (p<0.01).
The number of the postgraduate nurses who considered nursing is suitable for them, who were optimistic about the future of the profession, who would recommend it to others and 1.54 times more likely to comfortably tell others that they were nurses and 1.77 more likely to suggest nursing as a profession to others than were those who did not choose the profession willingly (Table 3).

Nurses' participation in professional activities
In order to improve their professional skills, of the nurses,  (Table 4).
It was determined that the undergraduate and graduate nurses participated in professional courses and conferences, kept up with publications and became members of professional association more than did the associate degree graduates, and the difference was signifi cantly high (p<0.001). The nurses who had 0-1-year work experience participated in professional conferences and kept up with publications more than did the others (p<0.001). The nurses who had worked 11 or more years or were over age 41 followed the publication less than did the others (p<0.001). Charge nurses and head nurses participated in professional courses and conferences, kept up with publications and became members of professional association more than did the other nurses, and the difference was signifi cantly high (p<0.001). (Table 5).
According to the results of the logistic regression analysis, of the nurses, those who had an undergraduate or graduate degree, those who were charge nurses or head nurses, and those who did not want to leave the profession applied for membership of professional associations more. Of the nurses, those whose length of service was 0-1 years, those who chose the profession to provide care to people and those who

Demographic characteristics
Views of the members of the nursing profession give important clues to the evaluation of the status of nursing in the professionalization process. It was determined that most of the nurses were in the 20-30 age group, and that the number of the nurses in the 40 and over age group was low. The fi ndings of our study were similar to those of a previous study conducted [14], on the same topic. This fi nding supports the data that nurses leave their profession at a young age, and is similar to the fi ndings of other studies conducted [40,41], across the world on the shortage of nurses. The study determined that, of the nurses who were actively working, 34% had undergraduate education and only 2.3% had post-graduate education. According to this result, it can be said that the education level of the nurses working in Turkey is still insuffi cient for a professional job. In this study, the number of specialist nurses who were actively working was rather insuffi cient. This may be explained with the fact that specialization in nursing in Turkey is quite a new phenomenon which was fi rst introduced in the nursing law revised in 2007. As in other countries, the vast majority of the nurses working in Turkey are female. Only 3.9% of the nurses in this study were male. In Turkey, male students have been enrolled in nursing schools since 1995. At present, approximately one third of the students attending nursing schools are male.

The nurses' commitment to their profession and their views on nursing
In our study, more than half of the nurses indicated that they chose the profession willingly. A similar study [42], carried out in Turkey in recent years support this fi nding. This fi nding may suggest that the nursing profession is now recognized as a career more and that it is advancing in its way to become a profession preferred more. In the international literature, among the reasons why nurses choose nursing as a profession are that nursing has social and humanitarian aspects, that they want to help others, and that nursing has the potential to contribute to the society [43,44]. However, in this study, whereas only one-fi fth of the nurses stated that they chose the nursing because they wanted to provide healthcare for people, nearly half of them stated that they chose it due to employment opportunities. According to the studies by Aktas et al. [45], Unsal, Yıldırım, & Aymelek. [42] and Varaei et al. [4], advantages such as "no risk of being unemployed" and "making good money" took the fi rst place among the reasons why students chose nursing. This fi nding suggests that nurses in our country generally choose the nursing profession for economic reasons.
In line with the study [46], conducted in Turkey in previous years, this present study indicated that half of the nurses were satisfi ed with their profession. When the fact that nurses' job satisfaction level infl uences the quality of care they provide is taken into consideration, this result can be regarded as positive. On the other hand, half of the nurses stated that they were satisfi ed with the profession very little or not at all. The health system in Turkey is mainly based on treatment services provided in hospitals, and in this system, almost all of the nurses work "task-centric" and thus they are inadequate in "primary care" and "evidence-based care" applications. In health services, physicians have the leading role, and thus nurses cannot perform their healthcare functions independently. On the other hand, in many institutions, nurses' salaries are low. It can be said that all these conditions affect nurses' professional satisfaction, which should be taken into account by the nurse managers while assessing the quality of health care, and services and the factors leading to dissatisfaction.
The nurses' inclinations to change their profession were high but to leave their profession were low, which is in line  with the fi ndings of the studies conducted by Varaei et al. [4], in Iran and by Korkmaz & Gorgulu [19], in Turkey. This can be interpreted as nurses achieve their jobs unwillingly or they perceive nursing not as a profession but as a task they are supposed to carry out in order to earn their livings. Nearly half of the nurses stated that they would not choose nursing as a profession again whereas one-quarter of them stated they were undecided whether to choose the profession again. The fi ndings of the studies conducted by Karamanoglu et al. [46], in Turkey and by Siebens et al. [40], in Belgium support the fi ndings of this study. However, 90.5% of the nurses in the study conducted by Sharbaugh [38], in the U.S.A. and 78.2% of the nurses in Milisen et al. [43], study conducted in Belgium stated that they would choose nursing as a profession again.
When Turkey is compared with other countries, it can be said that in Turkey, nursing is less preferred and nurses' working conditions and professional personal rights are not satisfactory.
More than half of the nurses in the study considered nursing profession as a decent career for themselves. Additionally, the majority of the nurses in the study perceived nursing as an essential profession, did not mind telling other people that Sharbaugh [38], determined that professional commitment, job satisfaction and professional identity levels of nurses

Nurses' participation in professional activities
Evaluation of the nurses' professional performance revealed that most of the nurses were not the members of national nurses association. However, the proportion of the members in this study (32.3%) was signifi cantly higher than that in a previously conducted study [19]. In addition, in many studies, it has been pointed out that the awareness of building professional organization among nurses is low [24,25,48]. That the number of nurses who are the members of professional associations is limited might be due to the fact that membership is not mandatory. In line with this result, it can be said that in our country, nurses' awareness of building professional organizations is not at a desired level.
Among the nurses, the rate of keeping up with publication on nursing and participating in vocational courses and congresses is low. Previously studies support this fi nding too [46,49].
The result might be due the fact that nurses working in the fi eld of healthcare are mostly associate-degree graduates.  [18].

Strengths and limitations of the study
One of the strengths of this study is that it was conducted with the participation of nurses across Turkey. The second one is its large sample size. The fi rst limitation of the study is that the data collection form is based on nurses' own statements.
The second one is the sample includes only the nurses working in hospitals.

Conclusions and Recommendations
Based on the results of this profi le study conducted in In the study, the nurses' participation in professional activities was determined to be generally inadequate. More than half of the nurses neither kept up with publications on nursing nor joined activities such as courses, conferences, etc. nor became members of nursing organizations. This is especially true for diploma and associate degree nurses, clinical nurses, and nurses in advanced age. Therefore, it is recommended that institutions should encourage elderly nurses and clinical nurses with a lower level of education to develop their professional performance, provide training on raising awareness, motivate nurses to join occupational activities and develop institutional policies accordingly. In addition, in order to increase the number of the members of nursing associations, membership to the national nurses association should be compulsory and attempts to build a united nurses association should be accomplished. Since participation in professional activities is directly related to the level of education, it is recommended to continue and conclude nationwide endeavors aiming at giving nursing education at least at an undergraduate level.