Evaluation of the relationship between job satisfaction and professional behaviors in pediatric nurses

Introduction and aim. Pediatric nurses play an important role in ensuring quality healthcare through job satisfaction and professional behaviors. This study aims to examine the relationship between job satisfaction and professional behaviors in pediatric nurses. Material and methods. This was a descriptive and cross-sectional study.The sample of the study consisted of 244 pediatric nurses who worked in tertiary university hospitals in Turkey and agreed to participate in the study. Data were obtained through face-to-face interviews using a personal information form, the job satisfaction scale for nurses (JSSN), and the behavioral inventory form for professionalism in nursing (BIPN). Data were analyzed using the SPSS 22.0 software and evaluated using descriptive statistics, independent t-tests, one-way ANOVA, Pearson correlation, and simple linear regression analysis. Results. The nurses’ JSSN and BIPN means scores were 3.42±0.59 and 5.69±4.05, respectively. A statistically significant moderate positive relationship was found between the pediatric nurses’ professional behaviors and job satisfaction (R=0.342; p<0.001). The regression analysis revealed that professional behaviors significantly and positively influenced job satisfaction in pediatric nurses (β=0.050; p<0.001). Conclusion. This study found that pediatric nurses had a moderate level of job satisfaction and a low level of professional behaviors, and as their professional behavior increased, their job satisfaction also increased.


Introduction
According to the State of the World's Nursing 2020 report by the World Health Organization (WHO), nurses are the largest professional group in the healthcare sector worldwide, numbering 27.9 million. 1However, nursing shortages continue to be a significant problem in global health services.The WHO estimates that an additional nine million nurses will be needed worldwide by 2030. 2 Pediatric nurses work with children who have different biopsychosocial characteristics and are unable to fully express themselves verbally and cognitively. 3Job satisfaction is defined as positive emotions and expecta-tions from work resulting from one' evaluation of their job and influences one's intention to leave their job. 4Job satisfaction in health professionals has a significant impact on patient care and treatment. 5Job satisfaction in pediatric nurses also affects the quality of care they provide to children. 6,7Therefore, it is important to examine job satisfaction and related factors in pediatric nurses.
Professionalism is considered a process associated with acquiring professional knowledge, skills, values, norms, and behaviors, and fulfilling both roles and responsibilities of a specific profession. 8Professionalism is necessary and important for establishing nursing stan-dards and providing quality services. 9Nowadays, it is not enough for nurses to have experience; they should also have high compatible professional behaviors in line with the changes and developments in the healthcare sector. 10 To foster the development of nursing profession, there is a need for professional nurses who embrace professional identity, consider ethical values, have a high level of autonomy and problem-solving skills, follow scientific advancements and publications, and engage in continuous development. 11,12The Wheel of Professionalism in Nursing Model, developed by Miller provides a framework for understanding professional behaviors among nurses. 13Professional behaviors are important for pediatric nurses in elevating the significance and values of nursing profession and establishing a framework for providing quality and ethical care. 14,15ecent studies have suggested a relationship between nurses' job satisfaction and several concepts such as professional behaviors and professional values.However, evidence-based research is needed to further elaborate this relationship. 15,16This study aims to provide comprehensive data in this field and lay the groundwork for future research.Various practices can be implemented to enhance job satisfaction among pediatric nurses, and one of them is increasing their professional behaviors. 11,14Increased professional behavior can enhance the knowledge, skills, autonomy, and empowerment of pediatric nurses, which in turn can lead to job satisfaction. 17When nurses are highly committed to their profession, they can derive more satisfaction from their work. 18Therefore, higher levels of professional behaviors are considered important to retain nurses in the profession. 11,14There are only a few studies in the literature that examine nurses' job satisfaction and professional behaviors.Most of these studies have focused on determining the job satisfaction and professional behaviors of nurses working outside pediatric clinics. 10,11,17,180][21][22] However, to the best of our knowledge, there is no study specifically on the impact of professional behaviors on job satisfaction among pediatric nurses.Therefore, this study aims to determine the relationship between job satisfaction and professional behaviors among pediatric nurses in Turkey.The results of this study are considered to reveal an important factor that increases job satisfaction among pediatric nurses.This, in turn, will shed light on healthcare institutions, professional organizations, research centers, and all other units related to nursing, providing guidance for planned projects in the field.

Aim
This study was conducted to determine the relationship between job satisfaction and professional behaviors in pediatric nurses.

Research questions
-What are the job satisfaction scores of pediatric nurses according to their professional characteristics?-What are the professional behavior scores of pediatric nurses according to their professional characteristics?-Is there a relationship between the job satisfaction and professional behavior scores of pediatric nurses?

Ethical approval
For conducting the study, an ethical approval was obtained from the non-interventional clinical research ethics committee of a training and research hospital (decision no: 18/10, decision date: 16.01.2018),and institutional permissions were obtained from the hospitals where the study was conducted (Number: E-77597247-604.02/E-50687469-799/E-98206329/770).The study was conducted in line with the Declaration of Helsinki, and the nurses were informed about the purpose and content of the study.They were also explained that their data would be used only for scientific purposes, and then their written consent was obtained.

Design and sample
This descriptive correlational study was conducted with pediatric nurses working in three tertiary university hospitals in İzmir and Ankara provinces in Turkey, which provide services in accordance with the Quality Standards in Health.The total sample in the three hospitals consisted of 320 pediatric nurses.Therefore, no sampling method was used.Twenty nurses who were on maternity leave, on sick leave, on annual leave, etc., and 56 nurses who did not agree to participate in the study were not included in the sample.A total of 244 nurses who agreed to participate in the study were included in the study.The participation rate in the study was 76.25%.The power of the study was calculated using the "G.Power-3.1.9.2" program with α=0.05.Based on the analysis conducted on 244 participants, the effect size was found to be 0.342, and the post-hoc power of the study was calculated as 0.99.The minimum power value required for post-hoc analysis is 0.67.Therefore, the achieved power level is acceptable, and the data size is sufficient. 23

Instruments
The data were obtained through face-to-face interviews using a personal information form, the Job satisfaction scale for nurses (JSSN), and the behavioral inventory form for professionalism in nursing (BIPN).

Personal information form
This form consists of 10 questions regarding the pediatric nurses' demographic and professional character-istics, including gender, education and marital status, nursing experience, motivation for choosing nursing, working clinic, pediatric nursing experience, type of work shift, participation in scientific activities, and membership in professional organizations.

Job satisfaction scale for nurses (JSSN)
This scale was developed by Muya et al. in Japan.It consists of 27 items and four subscales, including "Positive emotions toward work", "Appropriate support from superiors", "Perceived significance in the workplace", and "Pleasant working environment". 24Its Turkish validity and reliability study was conducted by Türe Yıldırım and Yılmaz. 25This is a 5-point Likert type scale, scoring from "1=strongly disagree" to "5=strongly agree." The 6th and 20th items in the scale are reverse scored.There is no cut-off point for the scale.A higher scale score indicates greater job satisfaction.The internal consistency of the scale cronbach's alpha was reported as 0.90.In this study, the cronbach's alpha value for the scale was determined as 0.91.

Behavioral inventory form for professionalism in nursing (BIPN)
This scale was developed by Miller et al. and its Turkish validity and reliability study was conducted by Karadağ et al. 26,27 It consists of a 7-item demographic information form and two sections with 39 items, measuring professional behaviors across nine subscales.The subscales include educational preparation, publication, research, participation in a professional organization, community service, competence and continuing education, code for nurses, theory, autonomy.Each subscale has a total score of 3, and the total possible weighted score on the scale is 27.A higher scale score indicates greater level of professional behaviors.The Cronbach's alpha value of the scale is 0.78-0.87,and the test-retest reliability coefficient is 0.86.In this study, the Cronbach's alpha value for the scale was determined as 0.80.

Data collection
The study was conducted between February 1, 2018, and April 29, 2018, at three university hospitals located in Ankara and Izmir provinces of Turkey.These hospitals were chosen because they provide specialized inpatient treatment services to patients with various health problems in the field of pediatrics, allowing access to a wide population of nurses specializing in pediatrics.During data collection, the unit head nurses were initially informed about the study, followed by the full-time nurses who agreed to participate in the study.It was emphasized that the participation was voluntary.Both surveys and informed consent forms were provided to pediatric nurses in sealed envelopes.The data collection forms did not include the names of the nurses.Filling out the data collection tools lasted around 10 minutes.The participants left the completed surveys at the designated drop-off locations in each unit, and the authors returned to the study site on the same day to collect the completed surveys.

Evaluation of data
The data were analyzed by using the Statistical Package for Social 22.0 program (SPSS, IBM, Armonk, NY, USA) and evaluated using descriptive statistics such as frequency and percentage.The skewness and kurtosis statistics were utilized to test whether the data were normally distributed. 28The student's t test was used to compare the means between two groups, and ANOVA to compare the means among three or more groups.Post-Hoc analyses were performed where appropriate using Bonferroni correction.Pearson's correlation analysis was used to determine the relationship between job satisfaction and professional behaviors of pediatric nurses.Simple linear regression analysis was conducted to examine the effect of professional behaviors on job satisfaction.The level of significance was accepted as p<0.05 in all analyzes.

The characteristics of pediatric nurses
Of the pediatric nurses, 91% were female, 67.6% were married, 75.4% had a bachelor's degree, 59.0% had over 5 years of experience in the nursing profession, 50.4% chose the nursing profession due to job opportunities, 28.7% worked in general pediatric departments, 57.8% had 5 years or more of nursing experience in pediatric clinics, 61.1% worked in rotating day and night shifts, 91.0% did not participate in any scientific nursing activities, and 93.4% were not members of a nursing association (Table 1).

Job satisfaction scale for nurses and behavioral inventory form for professionalism in nursing scores
The pediatric nurses' JSSN and BIPN mean scores were 3.42±0.59and 5.69±4.05,respectively (Table 2).

Comparison of the pediatric nurses' JSSN and BIPN scores according to their professional characteristics
A statistically significant difference was found between the pediatric nurses' JSSN mean scores according to work experience in pediatric units, willingness to choose nursing profession, working department, and shift type (p<0.05).An advanced analysis was conducted to determine which groups the difference originated from.Accordingly, the pediatric nurses with more than 5 years of work experience had significantly higher JSSN mean score than those with 0-2 years and 2-5 years of experience (p=0.002).In addition, the pediatric nurses who willingly chose the nursing profession had significantly higher JSSN mean score than those who chose the profession due to their family's request or job opportunities (p<0.001).Furthermore, the pediatric nurses from pediatric intensive care and pediatric emergency departments had significantly higher JSSN mean scores than those from general pediatric departments (p<0.001).
The pediatric nurses working pediatric intensive care, pediatric emergency, and neonatal units hid significantly higher JSSN mean scores than those working in pediatric surgical departments (p<0.001).Finally, the pediatric nurses who worked in day shifts had significantly higher JSSN mean score than those who worked in rotating or night shifts (p=0.016)(Table 3).
A statistically significant difference was also found between the pediatric nurses' BIPN mean scores according to department and shift type (p<0.05).The pediatric nurses from the pediatric intensive care, pediatric surgery and neonatal units had significantly higher BIPN mean scores than those from the pediatric emergency unit (p=0.003).In addition, the pediatric nurses who worked in day shifts had significantly higher BIPN mean score than those who worked in rotating or night shifts (p=0.034)(Table 3).

The relationship between job satisfaction and professional behaviors of pediatric nurses
There was a moderately positive statistically significant relationship between the pediatric nurses' professional behaviors and job satisfaction (r=0.342;p<0.001) (Table 4).

Examining the effect of professional behaviors on job satisfaction in pediatric nurses by simple linear regression
Table 5 present the results of the regression analysis performed to determine whether professional behaviors of pediatric nurses affect their job satisfaction.Accordingly, the regression model was statistically significant (F=32.107;p<0.001), and revealed that professional behaviors of pediatric nurses positively and significantly affected their job satisfaction (β=0.050,p<0.001),where professional behaviors explained 11.7% of the variance in job satisfaction (R 2 =0.117).

Discussion
This study examined the relationship between job satisfaction and professional behaviors in pediatric nurses.

Job satisfaction scale for nurses and behavioral inventory form for professionalism in nursing scores
This study found that the pediatric nurses had moderate level of job satisfaction.30][31][32] The result of this study was consistent with those in previous studies.
Furthermore, this result is significant as it suggests that job satisfaction of nurses working in pediatric care clinics will reflect in their caregiving practices.This study determined that the pediatric nurses had low level of professional behaviors.4][35][36][37] However, a study reported moderate levels of professional behavior for nurses in Poland and Belarus. 38Higher levels of professionalism are important for nurses to enhance their autonomy, empowerment, recognition, establishment of nursing care standards, and provision of quality services. 9,39This result of our study may be because pediatric nurses have low participation in scientific activities and are not members of nursing associations.

Comparison of the pediatric nurses' JSSN and BIPN scores according to their professional characteristics
In this study, the pediatric nurses who had worked in pediatric units for more than 5 years had significantly higher job satisfaction scores.It is expected that employees who have worked in a workplace for a long time generally have a better understanding of the workplace, a harmony between their experiences and expectations, the ability to make quick decisions in times of crisis, and improved professional problem-solving skills, leading to higher levels of job satisfaction. 40Studies of pediatric nurses have also found a positive relationship between the duration of professional experience and job satisfaction. 7,22n our study, the pediatric nurses who willingly chose the nursing profession had significantly higher job satisfaction scores.Studies emphasize that choosing nursing as a profession due to family preferences or job security reasons can negatively affect job satisfaction. 22,41urses who do not only consider nursing as an economic necessity but also have a motivation to improve their profession and contribute to society can nurture their personal feelings of achievement.Güdücü Tüfekçi et al. found higher job satisfaction among pediatric nurses who chose nursing willingly. 29This may be due to the multidimensional care provided by pediatric nurses who care for children with different biological, psychological, and social characteristics from birth to adolescence, which can enhance their intrinsic satisfaction.
In this study, the pediatric nurses who worked on continuous day shifts had significantly higher levels of job satisfaction professional behaviors.3][44] Two studies found that pediatric nurses working only on day shifts had higher job satisfaction compared to others. 21,22This may be because working night shifts affects bot physiological and psychological well-being of nurses, disrupts their sleep patterns, reduces their participation in so-cial life, and has a negative impact on patient safety due to the increased workload during long hours of night shifts. 45Considering these factors mentioned in the literature, job satisfaction of nurses is negatively affected by working in night shifts.
This study found that the pediatric nurses working in pediatric intensive care, emergency, and neonatal intensive care units had significantly higher job satisfaction.Several studies have also found high job satisfaction among nurses working in units that employ technological applications, require rapid critical thinking in stressful situations, and provide health care services for complex patients. 46,48This may be because nurses working in these pediatric units provide care to pediatric patients, which increases their autonomy and level of interdisciplinary communication.
This study determined that the pediatric nurses working in pediatric intensive care, pediatric surgery and neonatal units exhibited significantly higher levels of professional behavior.This may be because nurses working in specialized pediatric units in Turkey are generally certified and use guidelines for care practices based on current knowledge and skills as required by institutional policies.

The relationship between job satisfaction and professional behaviors in pediatric nurses
This study examined the relationship between job satisfaction and professional behaviors in pediatric nurses, and found a significant moderate positive relationship between their job satisfaction and professional behaviors.This result is consistent with those in the literature, suggesting that as professional behaviors of nurses increase, their job satisfaction also increase. 35,49,50This result may be because increased professional behaviors are associated with increased nursing roles, knowledge and practical success, which positively reflects on job satisfaction.

Examining the effect of professional behaviors on job satisfaction in pediatric nurses through simple linear regression
Our study suggests that professional behaviors of pediatric nurses affect their job satisfaction.This result is consistent with those in the literature, suggesting that an increase in professional behaviors increases job satisfaction in pediatric nurse. 35,51,52In our study, the professional behavior of pediatric nurses accounted for 11.7% of the variation in their job satisfaction.

Study limitations
As one of the limitations of the study, the results of this study cannot be generalized according to gender groups, since the majority of the participants are female.

Conclusion
This study determined that pediatric nurses had a moderate level of job satisfaction and a low level of professional behaviors.The professional characteristics of pediatric nurses influenced their job satisfaction and professional behaviors.As the professional behaviors of pediatric nurses increased, their job satisfaction also increased.Additionally, the professional behaviors of pediatric nurses had an impact on job satisfaction.Based on these results, it is recommended to conduct further studies on the factors influencing professional behaviors of pediatric nurses in order to enhance their job satisfaction, and to develop, implement and evaluate relevant strategies to increase professional behaviors and job satisfaction in pediatric nurses.

Table 3 .
Comparison of the nurses' job satisfaction and professional behaviors by professional characteristics * JSSN -job satisfaction scale for nurses; BIPN -behavioral inventory form for professionalism in nursing; SDstandard deviation; Independ -F: One-Way ANOVA

Table 1 .
Demographic and professional characteristics of the pediatric nurses (n=244)

Table 4 .
The relationship between behavioral inventory

Table 5 .
The results of regression analysis between behavioral inventory form for professionalism in nursing and job satisfaction scale for nurses (n=244)