Nurse Professionalism Scale: Development and

Psychometric Evaluation
Ana Vaz De Braganca (  [email protected] )
Institute of Nursing Education, Bambolim Goa https://orcid.org/0000-0003-1508-828X
R. Nirmala
Goa Business School. Goa University, Goa.

Research

Keywords: Code of conduct, nurses, professionalism, psychometric properties, self report

Posted Date: April 20th, 2020

DOI: https://doi.org/10.21203/rs.3.rs-21673/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Background
Professionalism is a key trait connecting the nurse and patient, and Code of Professional Conduct, a
professional legitimacy in considering nursing as a profession and an essential tool that facilitates nurse
practice. This study aims to develop Nurse Professionalism Scale using the Code of Professional
Conduct for Nurses in India and test the psychometric properties.

Methods
A sample of 1054 registered nurses working in various work areas at different levels and sectors of health
care was selected using stratified random sampling. Data were collected through self-report from
registered nurses and multi-source feedback from their supervisors and colleagues. A total of 830 self-
reported data sets, 687 supervisor and 747 colleague responses were received. Following data cleaning,
complete sets of 644 self-supervisor-colleague responses were used for analysis using exploratory factor
analysis in SPSS version 25 and confirmatory factor analysis in AMOS 22.

Results
Reliability estimate for internal consistency of the 38 item scale was .910 (self report), .951 (supervisor
feedback) and .952 (colleague feedback). Exploratory factor analysis using self-reports extracted five
factors with 22 items at Eigen values > 1. Items with communalities ≥ .4 and factor loadings ≥ .5 were
retained. Five factors explained total cumulative variance extracted at 51 percent and KMO value of .893
indicated sample adequacy. Bartlett Test of Sphericity was significant (χ2 = 3318, df = 231, p < .000). The
factors are labelled with reference to the original code and higher factor loading. CFA using supervisors
feedback (CMIN/DF = 2.938; GFI = .926, TLI = .927; CFI = .939 and RMSEA = .055) and colleagues
feedback (CMIN/DF = 3.165; GFI = .921, TLI = .908; CFI = .923 and RMSEA = .058) yielded acceptable
model fit indices confirming the psychometric properties.

Conclusions
The scale can be used as a tool to evaluate professionalism among nurses across different settings.
Multisource feedback from stakeholders can also be considered as an effective method of gathering data
on this construct.

Background
Across every health system, health workers determine the provision of the nature and quality of services.
Surprisingly, most health systems on a global stage face nursing shortage, which further differs across
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states and rural-urban settings.1 India is still a developing country.2 Nurses structure the major segment
of country’s health human resource and nursing services amount to an integral fraction of preventive and
curative phases which is evident through the provision of care from tertiary level to every doorstep even
beyond the availability of doctors. However, despite the central role, nurses remain unrecognized in the
health care delivery system.3

The national estimates indicate shortage of nurses which is further compounded by the international
migration of this valuable resource due to varied professional, social and economic reasons. This adds to
the non-availability of skilled, standard and quality health services particularly to the under privileged
sections in the country.1 Inadequate workforce and deficient quality care further escalates the morbidity
and mortality rates in the country further resulting in overburdened workforce. Thus the vicious cycle
continues and hampers the progress of nursing profession in the country.

Nurses are perceived as a compliment ‘package’ or ‘quick’ trained caregivers filling up the health provider
shortage. However, they are seldom considered while contributing to ideas and views related to client
needs or interventions or any form of health care modalities. Also, scenario does not synchronize with the
fact that nurses are ‘round the clock’, well-educated health care providers and constitute the largest group
of professionals in the health care delivery system. Hence, amidst tremendous development,
professionalism among nurses is essential to promote a transition in the profession.4

Adams et al.,5 stated that nursing professionalism necessitates nurses to demonstrate definite behavior
illustrating beliefs of the profession in terms of knowledge, attitudes and skills signifying professional
identity and commitment to the profession. These features are consistent with the characteristics
sketched in the “Registered Nurses Association of Ontario-Best Practice Guideline” (RNAO-BPG),
‘Professionalism in Nursing’6 and “Miller’s model” the ‘Wheel of Professionalism in Nursing’.7

Several researchers have developed instruments to explore and or evaluate professionalism among
nurses. Miller’s Model or the ‘Wheel of Professionalism in Nursing’ was an extension of Hall and
Friedson’s works. Miller also used “The Social Policy Statement, Code for Nurses with Interpretative
Statements and recommendations and policies from the American Nurses Association” as a basis for the
behaviors represented in the Wheel which served as a guide for every nurse in monitoring professional
behavior. Subsequently, Miller et al.,7 developed an evaluative “Behavioral Inventory Form for
Professionalism in Nursing” based on the Model which is widely used to evaluate professionalism
among nurses.8–11

Several other researchers explored professionalism among nurses using RNAO-BPG6 questionnaire, an
adaptation of Registered Nurses Association, Ontario-Best Practice Guidelines,12,13 and “Hall's
Professionalism Inventory” scale.14 “The Professionalism and Environmental Factors in the Workplace
Questionnaire, was developed based on literature, code of ethics and jurisdictional practice standards.15

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Relevant literature review on the construct professionalism across various professions revealed that most
researchers have described, adopted, adapted or developed instruments based on the professional code
of conduct and ethics. Physician Charter on Medical Professionalism is a product of the collaboration
between American Board of Internal Medicine Foundation, American College of Physicians Foundation,
and European Federation of Internal Medicine. This document highlights the principles and
responsibilities fundamental to professionalism in medicine.16–18 Some others have used standards
from the “Accreditation Council on Graduate Medical Education”.19,20 The “Code of Ethics for
Pharmacists and the American Association of Colleges of Pharmacy” and “The American Council on
Pharmaceutical Education Accreditation Standards” describing the attitudinal and behavioural
components have been considered in pharmaceutical care.21 “The College of Medical Laboratory
Technologists of Ontario’s Code of Ethics and Standards of practice” serve as the foundation of their
professionalism.22 Pollard23 explored ethical performance contributing to authority, control and social
responsibility as the hallmark of professionalism among news workers. American Bar association and
the judicial statements on professionalism serve as the basis for evaluating professionalism among
lawyers.24

This study aims to develop and evaluate the psychometric properties of Nurse Professionalism Scale
(NPS) which is based on the Code of Professional Conduct for Nurses in India, framed by the national
regulatory body, Indian Nursing Council. The Code serves the interests and needs of the profession and
illustrates individual nurse’s professional responsibility and accountability, nursing practice,
communication and interpersonal relationships, valuing human being, management, professional
advancement. It reminds the nurses about the attempts mandatory towards upholding the profession
while providing direct care, teaching students, conducting research, supervision and management.
Stakeholders and administrators also contribute to the sustenance and improvement of professionalism
among nurses.4 Multi-source feedback is a method of data collection through supervisors, peers and
other staff that helps develop a broad gauge of practice patterns. It aims to raise self-awareness
regarding performance, seek encouragement and improvement through feedback.25 It can highlight
concerns and fuel awareness regarding professionalism among nurses amidst the shortage and the
overburdened schedule in developing countries.

Methods
Development of the Nurse Professionalism Scale (NPS)
The process followed in the development of the scale is based on the steps enlisted by Boateng et al.,26
and Carpenter.27

Phase 1
I.1. Item Generation
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Following review of literature, the national Code of Professional Conduct for Nurses in India” consisting
of 38 items and six dimensions, was identified as a comprehensive measure to identify professionalism
among nurses. This crucial document is readily available for nurses as a guide in making ethical
decisions; hence no formal permission is obtained for using the code. The code was reviewed by four
nurse educators, two clinical nurses and three management faculty for readability, comprehensiveness
and appropriateness of items. Based on the discussion and feedback, items were re-worded without
changing the meaning. Since it was the national professional code, no items were deleted at this stage. It
was decided to use the code as a Nurse Professionalism Scale on six point likert scale with 0 as Not
Applicable (NA) and from 1 = never to 5 = always. Two versions of the instrument were created; self-
assessment for clinical nurses and multi-source feedback for supervisors and colleagues to evaluate
those nurses’ behaviour.
I.2. Content Validation
‘A measure has content validity when its items accurately represent the thing being measured’.15 The tool
was sent for content validation to the experts; 16 in nursing and 7 in health care management, who were
requested to validate the tools on relevance and clarity with a 4-point rating scale. Fifteen experts
provided valid response, comments and suggestions and 6 experts gave suggestions and comments
only. Score of one and two was considered as zero and score of three and four were considered as one
during calculation of item as well as scale content validity. However, some experts suggested reframing a
few items. Changes were incorporated and the tool was resent to 15 experts from among the initial
experts. Five nursing and three health care management experts validated the tool and provided their
valuable comments and suggestions. The calculated I-CVI and the S-CVI were above 0.9.

Ethical considerations
Approval was obtained from the ethical review committee. Written permission was obtained from the
authorities of the private and autonomous settings. Informed consent was obtained from the
respondents after explaining the purpose, benefits, risks and anonymity and confidentiality assurance.

Phase II: Scale Development

II. 1. Pre-testing
“Pre-testing helps to ensure that the items are meaningful to the target population before the survey is
actually administered”.26 The tool was administered on conveniently selected 55 clinical nurses working
in primary health centres. The participants did not indicate any difficulty in providing responses on the
tool.

II. 2. Survey Administration and Sample Size

Registered nurses working in the medicine, surgery, obstetrics and gynaecology, paediatrics, emergency
and intensive care unit, psychiatry and community at tertiary, secondary and primary levels in the private,
government and the autonomous sector of health care were selected using stratified random sampling.
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The inclusion criteria were to include settings which gave written permission and had more than five
registered nurses. Data were collected through self report from clinical nurses and as multi-source
feedback from their supervisors and colleagues. The tool was administered to 1054 registered nurses
personally. To avoid researcher presence bias or compulsion for favourable responses and considering
their demanding work schedule, the participants were given one week period to complete their responses.
While collecting the tool back it was noticed that many participants had not completed their responses
owing to their hectic work schedule. To avoid high attrition the participants were requested to complete
the response within another week.

A total of 830 self reported data sets, 687 supervisor and 747 colleague responses sheets were received.
However, following data entry, the data were checked for missing and incomplete responses and outliers.
Complete set of self-supervisor-colleague responses contained in 644 data sheets (Table 1) received from
respondents working across different work areas, different levels and different sectors was used for
overall analysis. Reliability estimate for internal consistency of the 38 item NPS using Cronbach α was
.910 (self report), .951 (supervisor feedback) and .952 (colleague feedback).

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Table 1
Sample demographics.
I Area of work Frequency Percentage

1 Medicine 130 20.2

2 Surgery 136 21.1

3 Obstetrics and Gynaecology 42 6.5

4 Paediatrics 88 13.7

5 Emergency and Intensive Care Unit 144 22.4

6 Psychiatry 28 4.3

7 Community 76 11.8

Total 644 100

II Levels of Health Care

1 Tertiary 400 62.1

2 Secondary 195 30.3

3 Primary 49 7.6

Total 644 100

III Sector of Health Care

1 Private 151 23.4

2 Government 479 74.4

3 Autonomous 14 2.2

Total 644 100

Results
II.3. Extraction of Factors
Factor analysis is used to demonstrate the basic goal of obtaining groups of highly inter-correlated
variables into distinct factors.28 Exploratory Factor Analysis (EFA) evaluates the construct validity in the
initial phase of an instrument development and after an initial set of items have been identified, it is used
to inspect the item set underlying dimensionality and the extracted factors explain the maximum variance
in the scale. Thus, a large set of items can be grouped into meaningful subsets which measure different
factors.29

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EFA was performed with the aim to reduce and group items together so that each factor would represent
a consistent content area. In order to exclude the measurement errors in this study, Maximum Likelihood
and Promax rotation was used. The aim was to retain factors extracted with Eigen values greater than 1
and items with communalities above .4 which confirms the common variance shared by each measured
item with other items of the construct on which it loads. The Scree test identifies the optimal number of
factors which can be extracted in a graphical presentation. The scree test of the data set also indicated
five factors above one (Fig. 1).

Factor loadings of ± .5 and greater are measured as practically significant.28 The factor loadings
obtained are between .84 and .5 (Table 2). Four factors are explained by 4–6 items. A two item factor can
also be retained and considered acceptable if the items are strongly correlated (r > .70; or > .60) and
reasonably uncorrelated with other variable.29,30 Hence the factor with two items (r = .62) was also
retained in this study. In social sciences a factor solution accounting for the total variance extracted up to
60 percent,28 or at least 50 percent is acceptable.31 Five factors measured by 22 items explained the total
cumulative variance extracted at 51 percent. Kaiser-Meyer-Oklin measure of sample adequacy value of
.893 indicated sample adequacy. Bartlett Test of Sphericity was significant (χ2 = 3318, df = 231, p < .000)
and indicated sufficiently large correlations among items.

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Table 2
Item loadings in Exploratory Factor Analysis
Factors Items Loadings

I Man9 Works with patients to identify their needs and sensitizes policy .771
makers and funding agencies for resource allocation.

PA2 Contributes to the development of nursing practice (by conducting .740

research or trying out new methods of care).

PA5 Contributes to core of professional knowledge by conducting and .734

participating in research.

MAN8 Participates in policy decisions related to patient care services. .687

II MAN Facilitates conducive work culture in order to achieve patient care .853
4 objectives.

VHB 2 Considers relevant facts while taking decisions in the best interest .671
of patients.

PA1 Takes responsibility for updating my/her/his own knowledge and .585
competencies.

PRA 8 Provides adequate information to patients and significant others .570

that allows them to make informed choices.

PA 4 Ensures the protection of the human rights while pursuing the .560
advancement of knowledge (while conducting research or trying out
new methods of care).

MAN Uses judgment in relation to individual competence while delegating .524

3 responsibility to colleagues, patients, relatives.

III NP 6 Ensures safe practice of care for self and patients. .708

PRA 2 Maintains standards of conduct/practice which adds to the .641

respect/status of the profession.

CIR 1 Establishes and maintain/maintains effective interpersonal .613

relationships with patients and their significant others.

PRA 7 Takes responsibility for continuous improvement of current nursing .580

care practices.

NP 2 Treats patients and their significant others with human dignity while .561
providing holistic nursing care.

PA 3 Participates in determining and implementing quality care. .517

IV PRA 5 Accepts accountability for her/his own decisions and actions. .709

MAN Ensures appropriate allocation and utilization of available .595

1 resources.

PRA3 Carries out nursing responsibilities within the framework of .543

professional boundaries.

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Factors Items Loadings

PRA1 Has a sense of self-worth as a nurse professional and nurtures it. .516

V VHB 3 Encourages and supports patients in their right to speak for .781
themselves on issues affecting their health and welfare.

VHB 1 Takes appropriate action to protect patients from harmful and .742
unethical practice.

Labelling the factors or the dimensions

Variables with higher loadings on a particular factor are considered as more significant and more
representative of the factor. Hence the factor is labelled with reference to the variable with higher factor
loading.28 In this study, factors are labelled considering higher factor loadings. In Factor I, the variable
PA2 with highest loading and PA5 are originally from the dimension “Professional advancement”. Items
MAN9 and MAN8 reflect development of the profession through working with other stake holders and
participating in policy decisions. Hence, the factor is labelled as “Professional Advancement
/Development”. In Factor II, two variables with higher factor loadings (MAN4 and MAN3) are originally
from the dimension “Management”, the variable VHB2 reflects decision making which can be considered
as a management function. Hence the second factor is labelled as “Management”. Factor III, is majorly a
reflection of nursing practice besides having the variable NP6 with the highest loading on that factor,
which originally is from the dimension “Nursing Practice”. Factor IV is explained by three variables; PRA5,
PRA3 and PRA1, hence the label “Professional Responsibility and Accountability”, is retained as from the
original code. Factor V is explained by two variables from the original dimension “Valuing Human Being”,
as seen in Table 3.

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Table 3
Label of factors in the Nurse Professionalism Scale (NPS)
I Professional Advancement/Development

Man9 Works with patients to identify their needs and sensitizes policy makers and funding
agencies for resource allocation.

PA2 Contributes to the development of nursing practice (by conducting research or trying out new
methods of care).

PA5 Contributes to core of professional knowledge by conducting and participating in research.

Man8 Participates in policy decisions related to patient care services.

II Management

Man4 Facilitates conducive work culture in order to achieve patient care objectives.

VHB2 Considers relevant facts while taking decisions in the best interest of patients.

PA1 Takes responsibility for updating my/her/his own knowledge and competencies.

PRA8 Provides adequate information to patients and significant others that allows them to make
informed choices.

PA4 Ensures the protection of the human rights while pursuing the advancement of knowledge
(while conducting research or trying out new methods of care).

Man3 Uses judgment in relation to individual competence while delegating responsibility to

colleagues, patients, relatives.

III Nursing Practice

NP6 Ensures safe practice of care for self and patients.

PRA2 Maintains standards of conduct/practice which adds to the respect/status of the

profession.

CIR1 Establishes and maintain/maintains effective interpersonal relationships with patients and
their significant others.

PRA7 Takes responsibility for continuous improvement of current nursing care practices.

NP2 Treats patients and their significant others with human dignity while providing holistic
nursing care.

PA3 Participates in determining and implementing quality care.

IV Professional Responsibility and Accountability

PRA5 Accepts accountability for her/his own decisions and actions.

Man1 Ensures appropriate allocation and utilization of available resources.

PRA3 Carries out nursing responsibilities within the framework of professional boundaries.

PRA1 Has a sense of self-worth as a nurse professional and nurtures it.

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I Professional Advancement/Development

V Valuing Human Being

.613

.549

VHB3 Encourages and supports patients in their right to speak for themselves on issues affecting
their health and welfare.

VHB1 Takes appropriate action to protect patients from harmful and unethical practice.

Phase III. Scale Evaluation

III. 1. Tests of Dimensionality through Confirmatory Factor
Analysis
“Tests of dimensionality determine whether the measurement of items, their factors, and functions are
the same across two independent samples or within the same sample at different time points. Such tests
can be conducted using independent confirmatory factor analysis (CFA)”.26 It is a form of psychometric
evaluation that permits for the systematic comparison of alternative a-priori factor structure on the basis
of systematic model fit evaluation procedures and assess the relationship between latent constructs.27
Obtaining a good model fit to the data in a different sample supports the factor structure reliability and
validity of the scale.29 CFA using AMOS version 22 was conducted using the supervisor and colleague
feedback data separately. Confirmation of factors is based on the fit indices which range from 0 to 1, and
values closer to 1 suggest good model fit.30 SEM researchers advocate .95 as a more desirable level.
“Root mean square error of approximation (RMSEA) at or less than .05” indicates secure model fit.29 In
this study the model fit indices obtained (CMIN/DF = 2.938; GFI = .926, TLI = .927; CFI = .939 and RMSEA
= .055) for supervisor data and (CMIN/DF = 3.165; GFI = .921, TLI = .908; CFI = .923 and RMSEA = .058)
using colleague data confirmed the factors in the Nurse Professionalism Scale.

Discussion
This study aimed the development of “Nurse Professionalism Scale” using the Code of Professional
Conduct for Nurses in India, Indian Nursing Council. EFA using self reported data resulted in extraction of
five factors. Supervisor and colleague feedback regarding the professional behaviours of registered
nurses confirmed the items and factors. Solomon et al.,13 adapted behaviours from RNAO guideline on a
5 point likert scale which consisted of 34-item and 8 dimensions; Knowledge, Ethics, Accountability,
Advocacy, Spirit of Inquiry, Collaboration and collegiality, Autonomy and Innovation & visionary. To derive
common factors reflecting professionalism, exploratory factor analysis was used. Principal component
analysis resulted in the extraction of a single 6-item latent factor. Professionalism is a multi-faceted
concept that offers opportunities for nurses’ personal and professional growth.32 This key trait is the

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relationship involving the nurse and the patient. Nursing professionalism mirrors the approach in which
nurses analyze their work and serves as a lead in their practice towards ensuring patient safety and
quality care.11,32 The code guides and assists nurses at every phase of nursing practice from carrying out
responsibilities of prevention of illness, promotion and restoration of health, and alleviation of suffering
among individuals, families and communities.4 It is a vehicle for self and peer-evaluation of the care
quality delivered to consumers. It provides ethical framework and standards for practice.6 Nurses need to
be aware of the important professionalism accents, attitude and behaviours that will aid in the
formulation of their identity as indispensible health care providers. Multi-source feedback can be
considered as an important method in exploring these behaviours.25 Limitations: This research has a few
limitations. Self reported data from the respondents could involve social desirability bias although
multisource feedback was obtained. The busy schedule amidst the shortage of nurses and the
complexity in the wording of the items could have led to some amount of response error.

Conclusion
Every practicing nurse is expected to share the responsibility of self-regulation and practice in accordance
with the professional standards and code of ethics as these define values and beliefs in nursing
profession. This code is viewed as a professional legitimacy for considering nursing as a profession and
an essential tool that facilitates nurse practice. The instrument can be used to explore professionalism
and gather baseline data through individual nurses’ self-reflection or as multi-source feedback of
professional behaviour within varied practice settings in a developing country like India. Further studies
comparing nurses working in private and public settings, and comparison among nurses working in
different areas can be conducted using the scale.

Abbreviations
RNAO-BPG
Registered Nurses Association of Ontario-Best Practice Guideline
NPS
Nurse Professionalism Scale
I-CVI
Item Content Validity Index
S-CVI
Scale Content Validity Index
EFA
Exploratory Factor Analysis
AMOS
Analysis of Moment Structures
CMIN/DF
Chi-Square by Degrees of Freedom

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GFI
Goodness of Fit Index
TLI
Tucker Lewis Index
CFI
Comparative Fit Index
RMSEA
Root Mean Square Error of Approximation
SEM
Structural Equation Modeling
SPSS
Statistical Package for Social Sciences

Declarations
1. Ethics approval and consent to participate: Approval is sought from the Institutional ethics
committee, Goa Medical College and hospitals, and Ethical committee, Directorate of Health Service,
Government of Goa. Informed consent was sought from the participants.
2. Consent for publication: Not applicable
3. Availability of data and materials: The datasets is not provided as the same is part of the data which
the researcher is currently using to pursue the Doctoral degree. However the data can be made
available from the corresponding author on reasonable request.
4. Competing interests: The authors declare that they have no competing interests
5. Funding: Nil
6. Authors' contributions: Both authors have substantial contributions in this work.
7. Acknowledgements: Not Applicable

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Figures

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Figure 2

Scree test plot indicating extraction of Factors

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