Professional Values in Guiding Professional Behavior of Nurses: A Phenomenological Study

International Journal of Nursing and Health Services (IJNHS) Volume 4, Issue 6, December 20th, 2021 http://doi.org/10.35654/ijnhs.v4i6.497 E-ISSN: 2654-6310 Introduction: Nurses must have knowledge and awareness concerning professional values as standards to provide safe and high-quality care. Objective: The study aimed to explore the professional’s value in directing nurses’ behavior. Method: A qualitative study design with a phenomenology approach was applied in this study. We involved ten nurses with ten years of working experience and acting as role models in nurse managers. The data analysis used the Colaizzi method. We found the professional nursing values among nurses, including human dignity, integrity, professional practice, altruism, and compassion. Dimensions that underlying the professional values are knowledge, skill, and attitude. Results: The following four themes reflected how to apply nurses value: 1) Competence in facing challenges; 2 Nurses provided services based on knowledge and skills, a sense of help and compassion for love as a form of worship and commitment to the profession; 3) feeling satisfied in undergoing the nurse profession; 4) expectations of professional development. Professional nurses have a positive attitude and a hope for professional development. Conclusion: The hospital could improve nursing education and research by providing evidence-based practices for selfdevelopment. Recommendation: Nurse managers also can provide services based on science, skills, and attitudes as a form of worship and commitment to the profession, becoming a role model for the nurse-led.


INTRODUCTION
The professionalism of nurses as Professional Caregiver (PPA) in Indonesia has not been able to meet the demands of patient expectations that affect patient satisfaction. This can be seen from society's stigma, which still assumes that the nurse is bitchy, talkative and rarely smile, and less competent. The previous study (1) obtained 58% of patients feel unsatisfied with nurse service in a hospital. Another study was conducted that was obtained from in-depth interviews revealed that the patients are disappointed toward nursing service, including their attitudes and behaviors. The attitudes and behaviors of the nurses will affect the patient's satisfaction as a recipient of service.
Patient satisfaction is essential in determining the quality of health services, especially nursing services. Customer satisfaction is one of the indicators of health service quality (2). Patient's satisfaction as the impact of fulfilling the expectation of his needs as a patient of the service, the patient expects to give the patient a sense of comfort, the performance of the patient's desired service (3), and the attitude of the health team in providing health services (4). Patient satisfaction can be manifested by realizing the patient's expectation of health care through the professional attitude of healthcare personnel in providing services.
PPA is required to serve the community well and professionally at the level of Public Health Center (Puskesmas) to the hospital. As part of the PPA in accordance with the Law of the Republic of Indonesia 2014 about health workers, the nurses are required to be professional and competent in nursing service. A previous study mentioned that professional nurses are the nurses who can fulfill three attributes of nursing professionalism, namely cognitive abilities, psychomotor, and attitude (5). The public perception is that a nurse is a professional when the nurse has ethical and caring behavior in providing service (6). The nurses as professionals should offer a competent service through ethical and caring behavior based on cognitive, psychomotor, and attitude.
Value becomes a necessity to direct the professional behavior of nurses in establishing a relationship with the patient. The value represents the fundamental belief to guide one's behavior (7). In the 19th century, Florence Nightingale suggested that nursing should include scientific knowledge and technical skills and should be a profession that has professional values (8). A study stated that the professional value in nursing practice could help improve the quality of nursing care (9). The deep relationship between nurses with patients, affectionate affection, empathy, comfort, and care given to the patient is a part of the nurse's attitude and behavior (10). It proves that professional value is one of a nurse's elements.
Patient satisfaction in the hospital where the research was conducted can fulfill the patient's expectations. Customer satisfaction figures in January-September 2018 almost fulfilled the set target of 84.28%, while the expected target was 85%. Interviews with some patients and their families in one hospital said they were satisfied with the nurse's service. Researchers took data in November 2018 during the residency practice through a Nursing Professional Value Scale and Nurse Questionnaire. The questionnaire results were the professional values perceived by the implementing nurse in the good category was 101, 31. The phenomenon encourages researchers to explore the professional values of nurses who direct the professional behavior of nurses in providing nursing services.

OBJECTIVE
The study aimed to explore the professional's value in directing nurses' behaviour.

Study design
This research was a qualitative study with a descriptive phenomenological approach. Qualitative research is the research design to explore a problem or issue, identify variables that are not easily measured, and get a detailed and complete understanding of the issues for research. The descriptive phenomenology was to explore, analyze, and describe directly the phenomena examined by the maximal expression of the researcher's intuition to the observed phenomenon. This design was precisely used because it was used to explore the professional values of nurses in guiding professional behavior in the Public Center Hospital in Jakarta, Indonesia.

Participants
A purposive sampling was used to select practical nurses working in the Cipto Mangunkusumo Public Center Hospital in Jakarta. The Participants were ten nurses that have inclusion criteria having a minimum of ten years experience in an Outpatient Department (OPD), Intensive Care Unit (ICU), Emergency Department (ER), Operating room (OR), pediatric ward, Endoscopy Unit, an adult ward, graduated from diploma in nursing or bachelor in nursing, a nurse with high commitment and a role model in service and recommended by the nurse manager.
Participants were recruited by nurse manager recommendation. (11) stated that the number of respondents was needed to deepen their understanding of the phenomenon. The researchers selected heterogeneous characteristics for 3-15 participants.
Consideration of the participants' variation became one of the provisions often recommended by the experts in qualitative method research design. Researchers analyzed data using a triangulation process with used the method of interview, observation, and survey of the research site. This is done to obtain the correct information and a complete picture of the information provided by the respondent. The data is then compared with the relevant theoretical perspectives to avoid the researcher's individual bias on the findings or conclusions generated.
Checks to validate the results of interviews that have been carried out by returning transcripts of interview results to participants. Internal audit is carried out by involving research supervisors to audit all research activities to obtain data stability.

Data collection
The data were collected through indepth interviews with interview guidelines.
Before conducting the interview, the researcher first explained the informed consent and if agreed to sign the informed consent. Interviews were conducted in a comfortable room at the hospital, with the interview duration ranging from 40 to 60 minutes. Expert validity of the instrument used with conducted interviews and test recording devices.
After that, a self-evaluation was carried out by listening to the contents of the recording for analysis. The implementation of interviews was not always at the hospital but depended on the agreement between researchers and participants. The agreement was made based on consideration of comfort and without participants' compulsion to provide honest and open information. Interviews were conducted from April 2019 -May 2019 on conducive and fulfilling criteria to safe interviewees' privacy and avoid the disruption of outside parties.

Data analysis
The research was conducted to explore the professional values of nurses in a referral center of a public hospital in Jakarta. Data were analyzed immediately after data collection through transcribed verbatim and content analysis. Categories and coding were developed from the raw data inductively and analyzed simultaneously to test data saturation.
Trustworthiness of the coding scheme on a sample of text was done by testing the clarity and consistency of category definition. The data were interrelated and needed to explain the whole context in terms of the process after reading and re-read. Multiple groups of thematizing supported this single level of thematizing. It figured in the mind mapping diagram. This process was used to make easy understanding to find some critical themes.
The themes and sub-themes were expressed in phrases that could link and explain categories together and had relevance to updating capability to provide care. Conclusions were drawn from the coded data by making inferences, and constructions of meanings were then derived from the data. Findings were written in a descriptive format.

Trustworthiness
Triangulation data of this study was addressed using multiple methods for gathering data to compare various data sources to meet the accuracy of study findings. Peer debriefing was also undertaken between the researcher and experienced research supervisor to validate these findings to reduce bias and guarantee confirmability.

Ethical consideration
The ethical approval was obtained from the Research Ethics Review Committee of the Faculty of Nursing University of Indonesia (approval number: No. 91/UN2. F12. D/HKP. 02.04/2019 on March 14th, 2019) Director of Central General Hospital Cipto Mangunkusumo Jakarta. The ethical approval to conduct research was obtained from all nurses participating in the study. Participants were free to withdraw their information anytime, and that their inclusion in the study was purely voluntary. Informed consent was obtained before audio-taping interviews and depth interviews. Also, participants were asked to select their pseudonyms for de-identification throughout the written transcripts. The participant needs to have confidentiality throughout the process of research. There is no harm to their health and life.

RESULTS
This research was conducted in a big government hospital in Jakarta, Indonesia. The study was conducted to explore the professional values of nurses in a referral center of a public hospital in Jakarta. The participating nurses were ten, 10% were male, and the remaining 90% were female. The ranged age of participants was at the age of 33 to 48 years, and the length of work was 10 to 29 years. The level of participants' education in this study was as follow: 60% of the participants were News, 20% of the participant was continuing the education of master degree of nursing, and 20% was specialist in surgical medical nursing. The participants' competency in clinical nurse III was 50%, and the working area was varied.
Data analysis was conducted based on the data transcript of in-depth interviews related to the professional values of nurses that direct to the professional behavior of nurses. The four themes that had been successfully identified can be displayed in Six participants revealed that nurse managers have competence in facing the challenges of a nurse so that the service objectives can be achieved. The statement is as follows "I give an example to them (nurses), I treat the patient, I directly involve to the patient, I treat wounds, change bandages, bath them. So I do not only talk but give an action also because we must know the patient…" (P7) Indeed, the ability of the nurse to communicate and also the experience of the nurse also greatly influences (P1) we work well, friendly. Usually, our needs are met, so the communication is good, God willing, it's okay (P2) So, we can handle complaints and are also able to communicate more (P4) Yes, so you can modify the environment so that the goal is achieved (P8) I have to understand them (nurses), their needs, but also, I have to tell them if this is what the company or hospital asks for (P9) I have to fulfill what the management said with the operator, but because for this operation he is comfortable with tool A, I have to be able to convey to the management whether or not this operation will run smoothly, the outcome will be good, what are all kinds of things like that (P3) We have to know quality control and cost control too. Fortunately, this is a hospital. Moreover, the government assists, most of our patients are BPJS patients. Sometimes, for example, the patient fee is 150 million, but what BPJS pays is only 75 million, so that's where we do it (P10) Theme 2: Nurses provide services based on knowledge and skills, a sense of help and compassion, as a form of worship and commitment to the profession.
Six participants revealed that the nurse provided nursing care based on curiosity. An example of a participant's statement is as follow: "... Just being human, sometimes there will be fatigue, there will be joy, but we are the ones who act as worshipers..." (P4) Category 2: "...So, we are mutually committed to being willing to hold one patient for transplant surgery, for example. So, we have to want to be disturbed, because the hemodynamic count is not every 8 hours or 6 hours…" (P5) Category 3: "...I don't know, love may be, we have to care for the patient because he is a human being, has self-respect, he is a living being that needs to be respected, has integrity, has a heart, and he will return to society, return to his environment." (P7) Category 4: "...So being a nurse you can do everything so that you can do many things, it depends on how knowledgeable you are in doing the nursing profession..." (P3)

Theme 3: Feel the satisfaction of running a profession as a nurse.
Six nurses revealed that the satisfaction of the nurse did not lie in the award or reward received by the nurse but when looking at the patient's positive response to the treatment provided. Here is an example of a participant's statement "… Treating a bad patient, having a bad condition until they go home. That is an awesome experience for me. Even they say thanks or not. It is not a big problem for me if they can meet their family at home. Burns is not easy, they come in bad condition, and they can go home safely, meet their family, and have a qualified life. It gives me a satisfaction…" (P7) "…Taking care of a bad patient, having a bad condition, until he comes home. Well, that was the most interesting experience for me. Whether he's grateful or not. It's not... it's not important to me. The important thing is that he can go home to meet his family. Burns is not easy. He can come in all kinds of bad conditions, go home safely, meet his family, and have an outstanding quality of life. It already gives satisfaction…" (P7)

Theme 4: Hope towards the development of the nursing profession.
Six nurses revealed that nurses have a hope against the equality of the nurse profession with other professions.
Here is an example of a participant's statement: "...Hopefully, the nurse must read, be interested in reading and explore the latest things. This is still lacking from this ICU unit or nursing globally regarding Evidence-Based practice. Here, nurses are still only based on the hereditary pattern of inheritance…" (P3) "…I hope that the nursing profession can continue to advance so that we can become friends with doctors. Can work together with doctors so that we can be equal to doctors…" (P6) "...Developing that, nursing education and research, which is still not widely promoted in this RSCM..." (P3) "...If I hope that I can continue my education again because I want to say anything, I am still an undergraduate, of course, the doctors here who are prof doctors and fertility consultants..." (P1)

DISCUSSION
Healthcare is changing rapidly. It is undeniable that nursing managers have an essential role in the organization's success, the success of nurses, and patient care. The competence of nursing managers is critical to the organization's success, the success of nurses, and patient care (12). The role of nursing managers can affect staff engagement, patient safety, and care practices (13). Competence is one part of the caring concept, according to Roach (1987), which is reflected through knowledge, understanding, cognitive skills, psychomotor techniques, personality, attitudes, and behaviors. Caring nurses have an opportunity of 4.92 times to provide patient satisfaction compared to less caring nurses (14). Nurses who have competence can perform caring to improve patients' satisfaction.
The changing demands of nursing managers to have competence in making some efforts to deal with the changes (15). successfully identify the manager's skills related to communication, collaboration, staff resources, provision of non-human resources, effective decision making, leadership, ensuring quality patient services, and supporting the environment of professional practice. Nurse Managers are a liaison key between the patient, nursing staff, medical staff, clinical and other supplementary staff, and hospital administration as they manage human and capital resources (16). As a liaison key between service providers that exist in service practice, the most critical competency managers are the ability to communicate to build and integrate all the resources in the organization to provide a professional service.
The communication ability of managers can help the effectiveness of patient care through the collaboration practices of Professional Caregiver (PPA). Communication is the principal of the relationship between the caregiver and the patient at all levels of nursing practice aimed at creating positive interpersonal relationships, exchanging information, and making treatment-related decisions. Practical nurse communication is essential to ensure patient safety (17). Effective communication between nurses and physicians can guide comprehensive care to patients (18). With effective communication, managers can facilitate more effective interaction between patients and another caregiver team to provide safe service and strengthen the service system.
The nurse profession is unique compared to other professions, so it needs basic nursing service. Nurses centered on the patient through nursing care as the essence of nursing in providing services (19). Nursing Service is a professional service through the care given to individuals, families, groups, or communities, both in sick and healthy conditions, even death (20). The unique function of the nurse is to provide support and assistance that facilitates growth for patients; it helps individuals who are sick or healthy in the performance of activities that contribute to their health or recovery (or peaceful death) that will be done. Florence Nightingale realized in the nineteenth century that nursing should be scientific knowledge and technical skills and a profession founded on specific humanitarian values (21). Therefore, professional service must be built on science, skill, and attitude.

Professionalism
becomes an integral part of professional service. (5) succeed in identifying the attributes of nursing professionalism which consist of cognitive, attitude, and psychomotor. Various efforts related to the enhancement of professional nurses have been conducted through the development of ongoing education for the enhancement of nursing abilities in terms of knowledge, skills, attitudes, and behaviors (23). The results showed that the nurses provide nursing care based on knowledge, skills, and curiosity, attitude, and compassion, which proves that the nurse has qualified professional nursing services in providing the service.
Knowledge, skills, and attitudes are essential to guide and provide quality nursing service practices. Nursing practice is supported by science (23), which takes a part of the realm of cognitive (24). Knowledge can form an action. According to (11), caring can be demonstrated by action. Without the act of treatment, it is just merely emotions. Psychomotor skills are helpful for professional practice (25).
Critical skills and thinking can assist the nurse in making the right decisions that refer to the necessary behaviors as a result of sensory, mind, and muscle collaboration to provide safety, professional care for nurses and patients (6). Attitude is an affective domain and response that arises from the stimulus or object (26). These three aspects can be competent when integrated and applied (27).
The study results revealed that nurses areas form of worship and commitment to the profession in providing nursing services. Spiritual becomes one of the fundamental necessities and the highest achievement of a man in his life regardless of tribe or origin (28). Selfactualization is a spiritual step that relates to meaning and purpose in life (29). Assisting the fulfillment of human needs is one of the caring "karatif" factors, according to Watson (8). The service provided by nurses as a form of worship proves that fulfilling the needs of nurses will actualize themselves in the spiritual, so the nurse can offer a spiritual-based treatment as a form of caring that is the essence of nursing.
When the nurses give a service, they should have spiritual well-being to maintain their physical and mental health to provide holistic nursing care. Spiritual well-being is essential for the health, wellbeing, and quality of life that guides the habits of everyday life and is a source of support for a person (16). According to Watson (8), a help fulfills basic needs with caring awareness based on the intention to make the essence of human care. It can strengthen the soul, body, mind, integrity, and unity in all aspects of care. Loss of confidence or spiritual confidence can lead to physical and mental illness (17). The spiritual domain of the human being is one aspect of the holistic approach, such as the bio-psychosocial component (31). Nurses are essential to fulfill the patient's spiritual needs as a caring form to maintain a competent and professional nursing service.
Satisfaction manifests one's perception and a comparison between results and expectations. Satisfaction is a positive response to the work experience performed by a person (31). The different opinions expressed by (33) say that job satisfaction embodies an individual's general attitude toward his work. One of the work satisfaction theories (34) states that a person is satisfied when the desire and perception of the fact have no difference. Professional nurses have the satisfaction of the care given to the patient.
Professional nurses have hope for the development of the nursing profession. Based on Watson's nursing point, the nurses are not to control or change others but to understand. According to Watson, one of the ten "carative" factors of caring is awakening faith and hope (8). Raising confidence and hope can be done by the nurse's presence sincerely. They also enable, sustain and respect the faith, hopes, and system of deep belief and the lives of the patients that are being treated.
Someone's belief in faith and hope becomes essential in the patient's care process. Hippocrates (35) argues that the mind and soul of the sick must be inspired before the disease is cared for. Caring for the "karatif" factor boosts the patient's belief and feels respected as a significant influence in enhancing and maintaining the patient's health (35). Regardless of the medical treatment of a person, the nurses should keep the person's faith, hope, and profound belief system. Although there is nothing to do medically, the nurses can still provide care by nurturing the patient's confidence and expectation on something or someone.
The hope of nurses can be a source of motivation to do their job well. The power that motivates a person to work actively depends on the reciprocal relationship between what is desirable and necessary from the result of the work (14). Hope is one of the drivers that underlies a person to act. Because of the hard work, the results will be in accordance with the purpose. The hope emphasizes the results be achieved. One's personal goals influence the desired outcome in covering needs. In this theory, one will maximize the advantage and minimize detrimental to reach its final goal.

CONCLUSION
The competence of nurse managers can guide the staff by being a role model to improve the professional behavior of nurses, the delivery of quality services, and the image of professional nursing. The professional nurse serves as worship and commitment to the profession in providing services based on the science, skills, and curiosity to help and compassion. A professional person has hope for his development. A person who has hope does not mean unsatisfied with the achievement, but hope is a motivation for the nurse to continue developing themselves through the profession's development. The research results got a variety of information about the implementation of professional values in nursing practices, so researchers can conclude that professional nurses have a positive attitude and hope for professional development.
Hospitals, as one of the nursing services, can undertake to improve the competence of nurses. These efforts can be made by enhancing education and research development in hospitals where nurses work. It can be a means for nurses to conduct self-development as a necessity of self-actualization. On the other hand, as the impact of fulfilled actualization, nurses have job satisfaction that can improve the performance and quality of nursing services.
Nursing managers as nursing leaders can inspire, engage, and positively influence nurses at various levels. Communication skills through various approaches and providing nursing services based on knowledge, skills, and attitude of curiosity to help is a form of worship and commitment to the profession which can help change the attitude and behavior of the nurse to achieve the expected goal. Managers can influence staff to provide optimal service by being role models for the team from all aspects, especially attitude aspects.
Caring, a sense of help based on science and skills, can be applied to values in educating nursing students. It can also be applied as consideration for assessing the graduation of nursing students by professional values for nursing professions. The requirement is to fulfill the attitude aspect of a nursing graduate who can be professional. The values identified in this research are used in the recruitment process and in consideration of increasing the career level of nurses. So, the chosen nurse fulfills the criteria as a professional nurse.