Nurses around the world adhere to a common set of professional values; terminology may vary, but basic beliefs and underlying meanings are similar. These professional values include respect for human dignity, protection of patient privacy, protection from harm, and personal and professional responsibility and accountability.1,2Nurses, it has been shown, have an ethical obligation to advocate.3 Through the processes of education and socialization, professional nurses also have a strong sense of right and wrong. Professional and healthcare organizations have promulgated codes of ethics to guide values development and ethical decision making in education, practice, and research. Across these codes of ethics, three major thematic categories are recognized: nursing values related to the profession, to patients, and to society.4 For example, the American Nurses Association (ANA) Code of Ethics for Nurses has undergone several revisions, but the thematic categories have remained constant over time.5 Therefore, when nurses find their professional values are in conflict with the values of the employing organization, dissonance occurs and nurses become disenchanted and disenfranchised.6,7
Age is only one reason that nurses are leaving the workforce. Adding to the shortage is the loss of experienced, caring nurses due to moral strain caused by values dissonance. This strain is associated with the "stress of conscience" that occurs when nurses can't provide the quality of care inherent in their practice.6 For example, environmental barriers, such as a lack of support for nurse involvement in ethical decision making and a lack of concern for nurses' security and the institutional hierarchy, can prevent nurses from acting in ways that they feel are in the best interest of patients and are consistent with their own values.7 This conflict may contribute to high staff turnover rates and subsequent staff shortages. In addition, advances in technology and expansion of nursing roles continue to create chaos in the healthcare arena. This chaos leads to frustration and subsequent career abandonment when nurses aren't able to address the complex ethical moral dilemmas common in the profession today.
The enormous responsibility of ensuring patients' well-being and preventing negative outcomes can be a major stressor for nurses.6 If nurses lack time for adequate patient interactions, they may feel that their altruism is constantly being tested, leading to feelings of inadequacy in their role of professional nurse. Stresses in the workplace put moral values to the test and create conflicts when nurses are pressured to act in ways that may not be congruent with their professional values. When a mismatch between workers' values and job environment exists, there's good reason for burnout or for abandoning the profession entirely.8 Thus, value congruence is a vital piece of worker satisfaction and influences individuals' decisions about remaining in the workplace.
Using the ANA Code of Ethics for Nurses as a framework for examining professional values, we used cross-sectional survey methodology to profile the value priorities of a random sample of RNs living in the United States, obtained from the ANA membership list. A random sample of 2,000 nurses received a mailed copy of the survey. Four hundred and fifty-three surveys were completed and returned, resulting in a 23% participation rate. All states except Hawaii were represented in the sample. The five states having the greatest return rates were New York (59), New Jersey (26), Pennsylvania (25), Florida (23), and Illinois (23). Only one response was returned from four states: Utah, Wyoming, Montana, and Indiana. Demographic characteristics of the sample, including gender, ethnicity, education, age, years of experience, and clinical specialty, position, and worksite, are described in Table 1.
|Table 1: Sample descripton|
We used the Nurses Professional Values Scale (NPVS) to measure the importance of 11 core ethical values derived from the 1985 ANA Code of Ethics for Nurses. The ANA Code has been updated since 1985; however, the core values reflected in the 1985 iteration are still relevant for today's nurse. The NPVS is a 44-item, norm referenced instrument with responses on a Likert scale ranging from 5 (most important) to 1 (not important). Subscales and the corresponding values statements are provided in Table 2 along with the sample mean and relative rank for each subscale.
|Table 2: NPVS subscales and associated value statement|
Survey results indicated that the five most important individual priority items to survey participants and the item mean were:
* item 31-maintain competency in area of practice (4.75)
* item 30-accept responsibility and accountability for own practice (4.74)
* item 28-provide high-quality nursing care in accordance with standards (4.66)
* item 36-act as a patient advocate (4.62)
* item 39-provide care without prejudice to clients of varying lifestyles (4.60).
The item identified by participants as least important was item 37-participate in nursing research (3.54). Values priorities, represented by the NPVS subscales, for the entire sample of RNs are included in Table 2. Collectively, the top three values for the entire sample were safeguarding privacy, respect for human dignity, and assuming accountability and responsibility for actions. A detailed picture of value priorities for the five most frequently identified clinical specialties, nursing roles, and worksites can be seen in Table 3.
|Table 3: Values priorities by clinical specialty, role, and worksite|
Although it's clear that nurses in different clinical specialties and roles and at different worksites have similar value priorities, this study identified minor differences between nurse administrators and staff nurses. Nurse administrators and staff nurses have essentially the same value priorities, but organizational ethics creates challenges for both groups. Findings suggest that the primary ethical conflict exists when healthcare executives fail to recognize the cause and effect of workplace dissonance (the difference between organizational and clinical values). The nurse administrator is in the unique but difficult position of having to bridge the gap that exists between organizational and clinical values.
When examining the priorities by nursing role of staff, supervisor, and administrator (Table 2), only two differences in these groups exist: Nurse administrators are the only group to prioritize responsibility and accountability, and staff nurses are the only group to identify conditions of employment. The relative importance that staff nurses assign to conditions of employment is noteworthy. Greater insight into this priority can be seen by examining the specific items from the NPVS that solicit this value priority (subscale 9). These items include:
* item 11-initiate actions to improve working conditions
* item 25-participate in determining terms and conditions of employment
* item 28-provide high-quality nursing care in accord with standards
* item 38-foster working conditions conducive to practice by established standards.
Implications for nurse leaders
Companies with business savvy develop long-range plans to ensure a continual source of qualified employees.9 Astute healthcare organizations are anticipating the impending nursing crisis and may be more amenable to proactively addressing critical issues that affect nurse retention. The perspectives of nurse administrators and staff nurses should be utilized throughout the organization to enhance shared decision-making in order to decrease dissonance. Because of their pivotal position, nurse administrators have the opportunity to bridge the gap between organizational and clinical values. One way to improve the work environment is to improve communication. One study found that only 10% of providers were comfortable with communication related to important issues, but those few individuals were more satisfied and more likely to stay in their work environment.10
Incorporating wisdom gleaned from the literature along with findings from this study, we propose the following recommendations to answer the question: What can nurse administrators do to ensure that qualified, energetic nurses are available to care for patients?
* Institute a dialogue between healthcare administration, nursing administration, and nursing staff regarding value priorities for each group.
* Share the power. Nurses perceive that they're powerless to impact change in large healthcare institutions.11 Empower nurses to impact changes in organizational values by giving them seats on committees that review matters relevant to values interpretation, such as staffing, financial priorities, patient safety, and ethics review boards.
* Institute a task force to examine the primary issues of values dissonance in which values of the nursing staff conflict with the business ethics of the healthcare organization.12
* Formulate and implement a plan to diminish the values chasm that ebbs and flows between the business and clinical sides of healthcare.
* Identify and eliminate the barriers that prevent nurses from practicing in accordance with the standards established by professional codes.
* Foster effective communication in the work environment to improve outcomes and increase morale, leading to increased retention.
* Examine the turnover rate and identify the financial cost of this turnover. List all the things that can be done to improve quality of care if the nursing turnover rate is reduced.
* Institute exit interviews using nonthreatening and impartial interviewers, such as faculty or graduate students from a local university. Ensure confidentiality of information shared in exit interviews.
* Organize an intergenerational group of nurses who are close to retirement and new graduates who are just beginning their careers. Challenge them to address issues of values dissonance and make the organization a better place for the nurses who remain.
Value realignment for the future
For far too long, healthcare administrators have closed their eyes to the impact that values dissonance has on their nursing staff. The costs are high for the healthcare organization, nursing staff, and patient care. There's substantial evidence that values dissonance exists, but little information is available about efforts to decrease or eliminate this dissonance. Healthcare organizations wanting to survive the looming nursing shortage will need to act quickly. Proactive planning that includes alignment of organizational values and professional nursing values will position the organization to better retain qualified, experienced professional nurses.