Communication Skills, Problem-Solving Ability, Understanding of Patients’ Conditions, and Nurse’s Perception of Professionalism among Clinical Nurses: A Structural Equation Model Analysis

This study was intended to confirm the structural relationship between clinical nurse communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Due to changes in the healthcare environment, it is becoming difficult to meet the needs of patients, and it is becoming very important to improve the ability to perform professional nursing jobs to meet expectations. In this study method, structural model analysis was applied to identify factors influencing the perception of professionalism in nurses. The subjects of this study were 171 nurses working at general hospitals in city of Se, Ga, and Geu. Data analysis included frequency analysis, identification factor analysis, reliability analysis, measurement model analysis, model fit, and intervention effects. In the results of the study, nurse’s perception of professionalism was influenced by factors of communication skills and understanding of the patient’s condition, but not by their ability to solve problems. Understanding of patient’s condition had a mediating effect on communication skills and nursing awareness. Communication skills and understanding of the patient’s condition greatly influenced the nurse’s perception of professionalism. To improve the professionalism of clinical nurses, nursing managers need to emphasize communication skills and understanding of the patient’s condition. The purpose of this study was to provide a rationale for developing a program to improve job skills by strengthening the awareness of professional positions of clinical nurses to develop nursing quality of community.


Introduction
Changes in the environment related to climate and pollution are causing health problems and various diseases such as respiratory and circulatory problems, metabolic disorders, and chronic diseases. Moreover, access to modern healthcare facilities has created greater expectations among patients receiving personalized healthcare and high-quality healthcare. As the difficulty of satisfying the demands of patients increases, enhancing nursing capabilities has become increasingly important [1]. To improve this, hospitals are making efforts to change the internal and external environments so as to increase the number of nurses, reduce the length of hospital stays, and enable efficient nursing practice. Despite these efforts, the workloads of nurses and the demand for clinical nurses are continuously increasing [2,3]. As a result, nurses are developing negative attitudes and prejudices toward patients, as well as negative perceptions of professionalism. To address this, the cultivation and strengthening of nursing professionals' capabilities is essential.

Study Participants
The structural equation model has less than 12 measurement variables. The sample size usually requires 200 to 400 participants [23]. A total of 250 participants were selected for the study. In line with ethical standards and practices, participants received a full explanation on the purpose of the study. They were briefed that the information collected would be used for research purposes only. Furthermore, they were informed that they could withdraw from the study at any time.

Data Collection Method
Data collection for this study was performed by two researchers unrelated to the hospital from April 20 to May 1, 2019. A questionnaire was used to collect data from clinical nurses working in five hospitals in Seoul, Gyeonggi, and Gangwon provinces. Of the 250 questionnaires disseminated, we received 225 completed returns. However, 54 were considered inaccurate, inconsistent, or unsatisfactory for coding purposes. Thus, 171 fully completed valid questionnaires comprised the final dataset for analysis.

Communication Skills
In this study, the communication skill instrument developed by Lee and Jang [24] was used. Its contents were modified and supplemented to clearly understand the communication skills of nurses. Our questionnaire comprised 20 questions with five questions each concerning "interpretation ability," "self-reveal," "leading communication," and "understanding others' perspectives." The answers were rated on a five-point Likert scale ranging from 0 = "strongly disagree" to 4 = "strongly agree." For this study, the Cronbach's alpha value was 0.81.

Study Participants
The structural equation model has less than 12 measurement variables. The sample size usually requires 200 to 400 participants [23]. A total of 250 participants were selected for the study. In line with ethical standards and practices, participants received a full explanation on the purpose of the study. They were briefed that the information collected would be used for research purposes only. Furthermore, they were informed that they could withdraw from the study at any time.

Data Collection Method
Data collection for this study was performed by two researchers unrelated to the hospital from April 20 to May 1, 2019. A questionnaire was used to collect data from clinical nurses working in five hospitals in Seoul, Gyeonggi, and Gangwon provinces. Of the 250 questionnaires disseminated, we received 225 completed returns. However, 54 were considered inaccurate, inconsistent, or unsatisfactory for coding purposes. Thus, 171 fully completed valid questionnaires comprised the final dataset for analysis.

Communication Skills
In this study, the communication skill instrument developed by Lee and Jang [24] was used. Its contents were modified and supplemented to clearly understand the communication skills of nurses. Our questionnaire comprised 20 questions with five questions each concerning "interpretation ability", "self-reveal", "leading communication", and "understanding others' perspectives". The answers were rated on a five-point Likert scale ranging from 0 = "strongly disagree" to 4 = "strongly agree". For this study, the Cronbach's alpha value was 0.81.

Problem-Solving Ability
The tool developed by Lee [25] was used to measure the problem-solving ability of clinical nurses. The survey comprised 25 questions, with five questions each concerning "problem recognition", "information-gathering", "divergent thinking", "planning power", and "evaluation". Items were scored on a five-point Likert scale ranging from 0 = "strongly disagree" to 4 = "strongly agree". The internal consistency confidence value Cronbach's alpha was 0.79.

Understanding Patients' Condition
To measure nurses' understanding of patients' conditions, we developed 10 questions by revising and supplementing items from an existing understanding-measurement tool [26]. With a total of ten questions, we measured "diagnostic name", "patient-treatment planning", and "nursing intervention processes". Items were scored using a five-point Likert scale ranging from 0 = "strongly disagree" to 4 = "strongly agree". The internal consistency confidence value Cronbach's alpha was 0.81.

Nurse's Perception of Professionalism
Nurse's perception of professionalism was measured using a tool developed by revising the 25 questions created by Kang et al. [1]. With a total of ten questions, we measured "vocation" and "autonomy". Items were scored using a five-point Likert scale. The internal consistency confidence value Cronbach's alpha was 0.81.

Data Analysis
To identify the relationships among the set variables, the data were computed statistically using the program included in IBM SPSS 24.0 and AMOS 23.0. (IBM Corp., Armonk, NY, USA). The analysis methods were as follows: 1.
Frequency analysis was conducted to identify the subjects' demographic and general characteristics.

2.
The reliability of the questionnaire was verified using Cronbach's α coefficients.

3.
Confirmatory factor analysis (CFA) was performed to verify the convergent validity of the selected measurement tool. 4.
The normality of the data was determined through analyzing the skewness and kurtosis of the measurement variables.

5.
The fitness of the model was verified using structural equation modeling (SEM). 6.
Bootstrapping was utilized to verify the mediating effect in the set study model, as well as the mediating effects of the nurses' problem-solving ability and understanding of patients' conditions.

Demographic Characteristics
The demographic and general characteristics of the study subjects are shown in Table 1. Overall, 71 respondents were aged 25-29 years (41.5%), representing the most numerous age group. University graduates comprised 113 (66.1%) of the sample, while 50 (29.2%) held graduate degrees, with eight (4.7%) holding master's degrees. Fifty-three respondents (31.0%) had over seven years of clinical experience, 43 (25.1%) had two to three years of experience, 42 (24.6%) had four to six years of experience, and 33 (19.3%) had less than two years of experience. Additionally, 121 respondents (70.8%) worked at secondary hospitals, while 50 (29.2%) worked at tertiary hospitals; 159 respondents (93.0%) reported that they were general nurses.

Technical Metrics of the Measurement Variables
The multivariate normality of the findings related to the factors of the latent variables was verified through standard deviations, skewness, and kurtosis. The present study meets the criteria for the skewness and kurtosis values mentioned by Hu and Bentler [27].
All sub-factors of the latent variables secured normality. In this study, a normal distribution was obtained for each of the four sub-factors of communication skills, five sub-factors of problem-solving ability, three sub-factors for understanding the patient's condition, and two sub-factors of the nurse's perception of professionalism as shown in Table 2.

Correlations between the Measured Variables
The correlations between the measurement variables were analyzed using Pearson's product-moment correlation coefficient analysis ( Table 3). The correlations among all individual measurement variables were found to show a positive correlation.

Confirmatory Factor Analysis of the Measurement Model
This study examined how well the measurement variables represented the latent variables in the measurement model. Each set path coefficient was evaluated using non-standardization factors, standardization factors, and standard errors. The path coefficients refer to the factor loadings in CFA.
The standardization factors of the individual paths were shown to be at least 0.50 (except for vocation: 0.36), and the critical ratio (CR) was at least 1.96. This indicated that the measurement tool had good convergent validity (Table 4).

Verification of the Structural Model
The structural model for relationships among clinical nurses' communication skills, problem-solving ability, understanding of patients' condition, and nurse's perception of professionalism that would be suitable for predicting the influencing relationships was verified. Since the fitness index of the modified model was shown to be higher than that of the initial model, the final model for this study was set as shown in Figure 2.
The structural model for relationships among clinical nurses' communication skills, problemsolving ability, understanding of patients' condition, and nurse's perception of professionalism that would be suitable for predicting the influencing relationships was verified. Since the fitness index of the modified model was shown to be higher than that of the initial model, the final model for this study was set as shown in Figure 2.

Influencing Relationships between Variables of the Study Model
The standardization factors and CR values of the final model were examined to determine whether there were direct relationships between communication skills, problem-solving ability, understanding of patients' conditions, and nurse's perception of professionalism. The results are shown For the relationship between communication ski in Table 5.lls and problem-solving ability, the standardization factor was 0.85 and the CR value was 7.37; communication skills showed a statistically significant effect. Consequently. The relationship between communication skills and understanding of patients' conditions also showed a statistically significant effect. Consequently, Hypothesis 1 was supported.
For the relationship between communication skills and nurse's perception of professionalism, the standardization factor was 0.54, and the CR value was 2.02. Communication skills showed a statistically significant effect. Consequently. For the relationship between problem-solving ability and nurse's perception of professionalism, the standardization factor was −0.056, and the CR value was −0.39. Problem-solving ability had no statistically significant effect. Consequently.
The relationship between nurses' understanding of patients' conditions and nurse's perception of professionalism had a statistically significant effect. Consequently Figure 2 shows the influencing relationships between the study variables of the final study model, considering non-standardization and standardization factors of the relationships between the study variables.

Direct and Indirect Effects of the Variables
To grasp the significance of the mediating effect in the final study model, the direct and indirect effects of each variable were examined. To examine the mediating effect of the problem-solving ability and understanding of patients' conditions variables, the bootstrapping method provided by the AMOS 23.0 program included in IBM was utilized. The results are shown in Table 6. Table 6. Mediating effect analysis.

Directions
Direct Effects

Gross Effects
Nurses' communication skills

Relationship between Nurses' Problem-Solving Ability and Nurse's Perception of Professionalism
We found clinical nurses' problem-solving ability to have no positive effect on their perception of professionalism. This contrasts with previous studies, which reported that problem-solving ability is helpful for such perception of professionalism [36]. We also found that problem-solving ability does not affect nursing professional perception through a mediating effect.
The present findings indicate that the distinctiveness of the fields of nursing should not be overlooked. In nursing organizations that have a culture of discouraging diversity, when negative results are obtained from attempts to solve nursing problems, confusion regarding the identity of nursing professionals means perception of the profession is not reinforced; in many cases, the opposite perception is formed. Furthermore, for those in lower-level positions, nurse's perception of professionalism is thought to be low because they cannot voice their opinions and have difficulties such as excessive workloads. Although few previous studies have directly examined this, Vermeir et al. [18] explained that, as the role expectation for nurses increases, factors for job turnover increase as a result of a sense of confusion regarding the nurses' role and increases in stress. These findings indicate that factors that degrade nurses' problem-solving ability induce skepticism regarding nursing and possibly career change, thereby supporting the findings of this study.
However, in the present study, positive results with low levels of relevancy in the structural model but high correlations were found. It is expected that, if nurses' environmental conditions are improved and their nursing capabilities are developed so that they can solve nursing problems with confidence, their nursing professional perception will improve.

Relationship between Nurses' Understanding of Patients' Conditions and Nurse's Perception of Professionalism
Our findings indicated that the relationship between nurses' understanding of patients' conditions and nurse's perception of professionalism was statistically significant. This supports Nilsson et al. [21] and Philip et al. [29], who reported that, in the fields of nursing, when patients accurately understand nurses' instructions or explanations and health information, they can participate in, independently adjust, and engage in creative decision-making related to self-nursing.
McGlynn et al. [35] suggested that understanding patient problems is an important element in resolving negative situations; meanwhile, Heo and Lim [37] indicated that clinical nurses provide high-quality nursing services and develop self-efficacy when they apply professional knowledge and a desire to understand patients' problems. These study findings accord with our own findings.
The aforementioned findings suggest that the development and application of programs that can enhance nurses' understanding of patients' conditions should be emphasized, and that studies of various patient types, the characteristics of patients by age group and hospital areas, as well as the introduction of simulation education programs to improve nurses' understanding of patients' conditions should be continuously implemented.

Conclusions
This study aimed to verify the structural relationships between clinical nurses' communication skills and their problem-solving ability, understanding of patients' conditions, and nurse's perception of professionalism. We also aimed to identify, through a structural model, the mediating effects of nurses' problem-solving ability and understanding of patients' conditions in the relationship between communication skills and nurse's perception of professionalism.
The findings of this study are as follows (all significance levels = 0.05). In the relationship between communication skills and problem-solving ability, the value of the standardization factor was 0.85 and the CR value was 7.37, indicating that communication skills had a statistically significant effect. In the relationship between nurses' communication skills and understanding of patients' conditions, the value of the standardization factor was 0.61 and the CR value was 6.35, indicating that communication skills had a statistically significant effect. In the relationship between communication skills and nurse's perception of professionalism, the value of the standardization factor was 0.54 and the CR value was 2.02, indicating that communication skills had a statistically significant effect. However, in the relationship between problem-solving ability and nurse's perception of professionalism, the value of the standardization factor was −0.05 and the CR value was −0.39, indicating that problem-solving ability has no statistically significant effect. Finally, in the relationship between nurses' understanding of patients' conditions and nurse's perception of professionalism, the value of the standardization factor was 0.56, and the CR value was 2.14, indicating that nurses' understanding of patients' conditions has a statistically significant effect.
There are some limitations to this study. First, as we only examined nurses at secondary and tertiary university hospitals, our findings may not be generalizable to all clinical nurses. Replication studies examining a range of levels of medical institutions and associated workers are necessary. Second, the structural relationship between problem-solving ability and the nurse's perception of professionalism turned out to be insignificant or mediated. Subsequent studies on the various approaches to revisit this structural relationship should be performed. Third, theories should be systematically developed to establish the values of the nursing profession, and additional studies are necessary to explore other variables.