Applying professional values: the perspective of nurses of Isfahan hospitals.

Applying professional values is an important issue in nursing practice. It is also crucial to find out nurses' perspectives toward ethical and professional values in the clinical environment. For this purpose, we aimed to utilize a standard tool to survey perspectives on applying these values in nursing care in hospitals of Isfahan, Iran. This is a descriptive-analytical study in which 150 nurses working in hospitals of Isfahan, Iran in 2010 were recruited by quota convenience sampling, and their perspectives on professional values were assessed. Data were collected by the Nurses Professional Values Scale (NPVS) and analyzed using SPSS Software version 16 applying descriptive and interpretive statistics. In the present study, 84% of the participants were female and 88% had bachelor's degree in nursing. The average age was 34.2 (SD=7.3), and the average years of working in a hospital were 11 (SD=7.3). No significant association was present between demographic characteristics such as age, sex, educational level or work records and applying professional and ethical values. Results also demonstrated that respect for professional values is similar among nurses of different employment types. In this study, we addressed the most and the less important professional values specified by nurses with different types of employment and also different experiences. Iranian nurses believe in respecting the legal and ethical rights of patients as the most prominent value in the nursing profession. We suggest that these professional values be specified and assessed based on Iranian culture.

Introduction

Nursing science is engaged in practice-based roles and highlights the importance of professional values which have been founded on specific human values (1). Nursing is a combination of knowledge and skills for an effective professional care (2). By regarding ethics as a form of knowledge, nurses can develop their professional values. These values are the standards for action and also provide a framework for evaluation (3). Nurses are expected to be aware of the ethical dimensions of nursing practice and apply them in their work (4). Ethical principles are among the fundamentals of nursing, so any form of care should meet patients’ rights based on these standards (4). Nurses are expected to provide physical, social, and psychological care (5) that should be moral and ethical as well. The new rapid changes caused by technology can influence these values (6), and therefore professional and ethical standards must be set to fulfil professional obligations (3) New evidence has shown that these standards and values are not fully respected by most of the nurses (7). On the other hand, it should be considered that nurses face complex professional and ethical issues in their workplace, such as different levels of personnel, developments in technology, and budget constraints (8, 9). They face many professional challenges while interacting with clients and organizations so they need to deal with them professionally to provide care with confidence and peace of mind (10) because of the moral and ethical sensitivity of their job (2, 11). If nurses do not engage actively with these daily ethical issues, they will fail to deliver the optimum standard of care (12). Many situations in nursing practice have a potential for ethical dilemmas. To respond effectively to these dilemmas, nurses should have knowledge of their professional values (13). Nursing values influence nurses’ goals, strategies and actions. They can be considered as resources to guide nurses when involved with ethical challenges (14, 15). Among some studies on nurses’ professional values, McNeese-Smith and Crook stated that knowledge about these values can improve nurses’ practice, assist in team performance and cohesion, and aid in performance of counselling. These are all traits of the nursing profession that require attention (16). Chitty and Black introduced some of the professional and ethical values from the nurses’ perspective such as: accountability and responsibility for own actions, balancing cure and care, benevolence, caring as a foundation for relationships, collaborative multidisciplinary practice, compassion, and competence (17).

In nursing education, studies have shown that professional values and moral ideals of nurses in the clinical environment are often considered as dilemmas (18). However, in some cases nurses have shown a poor ethical performance. Tefagh et al. assessed observation of professional ethics regarding medication and found out that most of the participants had a poor performance in medication process and respecting values (19). Arzani et al. aimed to evaluate nurses’ respect for professional and ethical values from their own perspective. They found that only 40% of nurses fully consider these values in their practice (20).

Applying professional and ethical values in nursing is an important subject which has been neglected for many reasons. Nurses will face dilemmas, not only in nursing care, but also in relation to other health professions, their work place, and their own profession. Among the barriers in applying professional ethics, however, most of the challenges are mainly about the nurse-patient interaction (21). In addition to finding and implementing strategies to enhance nurses’ ability in ethical care, it is recommended to survey their perspective about applying ethical values in their profession. Therefore, this study was designed with the aim of evaluating nurses’ perspective on applying professional values in Isfahan hospitals in 2010.

Method

This is a descriptive-analytical study that was conducted in selected hospitals in Isfahan to survey application of professional values from nurses’ perspective. The hospitals in this study consisted of four educational hospitals, two hospitals affiliated to the Social Security Organization, and two private hospitals. Study samples were nurses in all roles who met the cited inclusion criteria of having a nursing bachelor’s degree or higher, were listed in the category of formal nurse, contract nurse, corporate nurse, and planed nurses, were of Iranian descent, and had graduated from official universities of Iran.

According to the number of nurses in each hospital that was assigned as a research area, and also based on the intended sample size of 250 nurses, a quota was determined for each study area in sampling method. All the questionnaires were given to the nurses in different shifts with prior coordination with the director of nursing. At first, permission from the research committee of the Iranian Nursing Organization was obtained and offered to the hospital authorities. Then, the aim of the study was explained to the subjects and their informed consent was obtained. Since an interval was needed to take back the questionnaire, it was adjusted with the subjects at first.

Data were collected using a two-part questionnaire, including demographic characteristics and professional values data. The first part was a researcher made tool for gathering the demographic data of participants, and the second part was a standard tool titled “Nursing Professional Values Scale (NPVS)”. Weis and Schank have designed and used this instrument in a study with the aim of describing nurses’ professional values (13). This scale includes 26 items; each item in this scale is a short descriptive phrase reflecting a specific code of ethics from the American Nursing Association in 1985. This is a norm referenced with likert type format ranging from 1 (not important) to 5 (most important), and ranges above 3 indicate strong professional orientation. The possible range of score is 26 to 150, and therefore scores above 78 were considered as respecting professional and ethical values. The reliability and validity of this questionnaire was approved by Weis and Schank measuring the Cronbach’s alpha coefficient of 0.94 by using pre-test post-test method (22). In another study by Martin et al. performed on 1366 participants, Cronbach’s alpha was 0.95. The content validity was established by experts in the field of ethics (23). In a study by Parvan et al. in Iran, the reliability of this tool was approved with a Cronbach’s alpha that was 91% (24). In the present study, due to cultural differences, the questionnaire was translated into Persian and sent to six ethics experts for content validity. With a few changes, it was translated back into English.

Of the 250 distributed questionnaires, 162 were returned, whereas 12 were not fully completed. Therefore, 150 questionnaires were analyzed by means of the statistical software SPSS version 16. To determine the relationship between gender, level of education, work experience, different categories of employment, and place of employment and professional values, Pearson correlation, independent t-test and ANOVA test were applied. To show the relation between age and score of professional values, Spearman correlation test was used.

Results

In this study, of the 150 participants, 84% were females and 88% had bachelor degree in nursing. The mean age was 34.2 (SD=7.3), and the average years of employment as a nurse was 11 (SD=7.9) years.

No significant association was found between demographic characteristics such as nurses’ age (P = 0.975), gender (P= 0.169), education (P= 0.150), and work records (P= 0.148) and their perspective on applying professional ethical values (Table 1).

Table 1

Correlation of demographic characteristics and scores of professional values

Demographic characteristics		Number	Frequency (%)	Score for professional ethics (mean)	P value
Age(year)	>30	59	39.3	4.02	0.878
	30 to 40	60	40	3.97
	<40	31	20.7	3.03
Sex	Male	24	16	4	0.169
	Female	126	84	4.06
Education	Bs	144	96	4.02	0.558
	Ms	2	1.3	4.48
	PhD	1	0.7	4.46
Work records (year)	>5	52	34.7	3.9	0.384
	5 to 15	60	40	3.98
	15 to 25	27	18	4.16
	<25	11	7.3	4.05
Type of employment	Formal	47	31.3	4.12	0.103
	Contract	23	15.3	3.98
	Corporate	53	35.3	3.99
	Planned nurse	17	11.3	3.84

Bs= Bachelor degree; Ms= Master of science; PhD= Doctor of philosophy.

The mean of professional values score among participants was 101.53 (SD=18.12), and considering the standard average of values score that is 78 for this questionnaire, it can be concluded that all the participants had a positive perspective toward applying professional values in nursing practice.

No significant association was found between variables such as the type of hospital nurses’ position (P= 0.258) and the type of their employment (P= 0.196) and applying nursing professional values.

There was no significant association between samples’ employment types and applying professional values. The most prominent criteria of professional values that were noted by nurses were: protecting the health and safety of the public (mean = 4.35), protecting the moral and legal rights of patients (mean = 4.21), practice guided by principles of fidelity and respecting individuals (mean = 4.13), and respecting patients’ right to privacy (mean = 4.33) (Table 2).

Table 2

Professional values according to the assessment scale

Nurses professional values	Not important	Somewhat important	Important	Very important	Most important	Mean	SD
Engage in on-going self-evaluation	2.8	13.2	28.5	25	30.6	3.65	1.12
Request consultation/collaboration when unable to meet patient needs	2	8.8	21.8	36.7	30.7	3.84	1.02
Protect health and safety of the public	0.7	5.4	12.8	18.9	62.2	4.35	0.96
Participate in public policy affecting distribution of resources	6.8	20.5	37.7	20.5	14.4	3.15	1.02
Participate in peer review	0.7	8.2	17.8	31.5	41.8	4.04	1
Establish standards as a guide for practice	1.4	4.8	16.3	32.7	44.9	4.13	0.96
Promote and maintain standards where planned learning activities for students take place	0.7	6.9	22.1	34.5	35.9	3.97	0.96
Initiate actions to improve environments of practice	1.49	9.7	11	39.3	38.6	4.02	1
Seek additional education to update knowledge and skills	1.4	10.2	15	31.3	42.2	4.01	1.06
Advance the profession through active involvement in health related activities	1.4	8.9	22.6	34.9	32.2	3.88	1
Recognize role of professional nursing associations in shaping health care policy	4.1	14.3	26.5	32	23.1	3.56	1.11
Promote equitable access to nursing and health care	2.7	9.6	15.1	36.3	36.3	3.91	1.07
Assume responsibility for meeting health needs of the culturally diverse population	2.7	11.6	21.2	35.6	28.8	3.74	1.07
Accept responsibility and accountability for own practice	0.7	8.9	21.2	34.9	34.2	3.91	.097
Maintain competency in area of practice	1.4	6.2	12.4	42.8	37.2	4.05	0.93
Protect moral and legal rights of patients	0.7	4.3	11.5	30.2	53.2	4.21	0.94
Refuse to participate in care if in ethical opposition to own professional values	5.1	11.7	17.5	31.4	34.3	3.77	1.13
Act as a patient advocate	0.7	5	15.7	32.1	46.4	4.13	0.91
Participate in nursing research and/or implement research findings appropriate to practice	2.8	8.5	19.9	38.3	30.5	3.87	1
Provide care without prejudice to patients of varying lifestyles	2.1	11.3	17.7	33.3	35.5	3.85	1.07
Safeguard patient’s right to privacy	1.4	7.1	23.4	36.9	31.2	3.87	0.95
Confront practitioners with questionable or inappropriate practice	2.2	13.7	20.1	41	23	3.68	1.02
Protect rights of participants in research	1.5	6.6	19	41.6	31.4	3.91	0.93
Practice guided by principles of fidelity and respect for person	1.4	5	12.1	39	42.6	4.13	0.91
Maintain confidentiality of patient	1.4	4.3	5.7	25.7	62.9	4.33	0.97
Participate in activities of professional nursing associations	6.4	10.7	25	30.7	27.1	3.60	1.15

Discussion

The overall results indicated that no significant association was present between demographic characteristics such as age, gender, education, and nurses’ work records and the nurses’ perspective on applying professional values. Some other studies have reached the same result as well. Leduc and Kotzer aimed to use NPVS as an instrument to evaluate nurses’ perspective on applying professional ethical values in nursing students, newly graduated nurses, and seasoned professionals. They came to the conclusion that these three groups of nurses are the same in applying professional values. Therefore, the claim that nursing experience can be effective in promoting professional values was not approved (25). In their study, Lynn et al. have found no significant difference between the professional and ethical values of senior baccalaureate and associate degree nursing students (26). The similarity between the results of this study and other studies in this area shows that people who choose nursing as their job consider ethical values among the important and essential fundamentals of their profession.

The results of this study revealed that the association between age and nurses’ perspective on applying professional values is reversed. It might mean that as the nurses get older, their respect for professional values will be decreased, although some studies have shown that no significant association is present between professional values scores and age of the samples (23).

In their study, Parvan et.al have shown a significant negative correlation between age and the total score of values in nursing students. This means that as the nurses grow older, their respect for professional and ethical values decreases (24).

The most prominent criteria of professional ethics in this study were: protecting the health and safety of people, respecting the moral and legal rights of patients, practice guided by principles of fidelity and respecting individuals, and protecting patients’ right to privacy. Shih et al. found out, however, that the most important criteria according to the perspective of nurses in Taiwan are: caring for clients with a humanistic spirit, providing professionally competent and holistic care, fostering growth and discovering the meaning of life, experiencing the ‘give-and-take’ of caring for others, receiving fair compensation, and raising the public’s awareness of health promotion (27). According to Silen et al, nursing professional values as specified by Thailand nurses’ association can be viewed as: sublime states of mind, loving kindness, compassion, and sympathetic joy and equanimity (28).

In the study conducted by Weis and Schank the most important professional values of nurses were related to the provision of nursing care and believing in the importance of the process of professionalization (22). Shahriari et al. have expressed that ethical values of nurses from the perspective of Iranian nurses include maintaining patients’ dignity, commitment and work ethics, human communication, fairness, honesty and integrity, and striving to promote personal and professional competence (29).

Parvan et al. showed the most important statements from the students’ perspective were “maintaining confidentiality of patients” and “maintaining clinical competency”. Nursing faculty and students’ awareness of the need for strong professional values is important in preparation of nurses capable of managing patient care in an ethical and professional manner (24).

The difference between moral professional values in various studies reflects the differences in societies in terms of dominant values based on cultural, social, economic and religious situations. Hence it is essential to identify nurses’ professional values as well as factors influencing disrespect of professional ethics and standards in patient care (7).

It is obvious that nurses cannot avoid facing ethical dilemmas, but they should be capable enough to manage these challenges through receiving proper training. As a matter of fact, this is not exclusively related to nurses; rather, all of the treatment team encounter such challenges and manage them based on their knowledge and training.

In their study regarding the purpose of determining ethical conflicts in nurse practitioners and physician assistants in managed care, Ulrich et al. have found that nurses encounter ethical challenges more than physicians. Some of the participants (44%) believed that they had been well prepared for managing these challenges because they had been well trained (15). Thus, the role of education in preparing nurses and other health care providers for facing ethical dilemmas is further highlighted.

The important point here is that despite the great importance of ethical issues, we still encounter many cases of non-compliance with the ethical values, and challenges in the field of patients’ rights. Rezaei et al. have showed that in the emergency departments of a total of ten hospitals in Lorestan (province of Western Iran) which were assessed for their compliance with professional ethics standards and patient’s rights, these items have not been fully met (30). The fact here is that it is not enough to train nurses and other health care providers to achieve desired outcomes; following relevant feedbacks in the system is important as well.

Conclusion

In this study, we addressed the most and the less important professional values specified by our nurses with different types of employment and different experiences. Iranian nurses believe in respecting the legal and ethical rights of patients as the most prominent value. It is concluded that nurses’ professional values must be specified and assessed based on each country’s circumstances to sensitize students and nurses about ethical issues and problems. In addition, identifying and removing barriers to professional ethics play an important role in applied professional values in nursing.

More studies with greater sample size are needed for generalization of the outcomes.