Recruitment & retention report
Research study:
Professional values and retention
By Susan Yarbrough, RN, PhD, Danita Alfred, RN, PhD, and Pam Martin, RN, PhD
urses around the world adhere to a com-
N
mon set of professional values; terminol-
ogy may vary, but basic beliefs and un-
derlying meanings are similar. These
professional values include respect for
human dignity, protection of patient pri-
vacy, protection from harm, and personal and
professional responsibility and accountability.1,2
Nurses, it has been shown, have an ethical obli-
gation to advocate.3 Through the processes of ed-
ucation and socialization, professional nurses
also have a strong sense of right and wrong. Pro-
fessional and healthcare organizations have
promulgated codes of ethics to guide values de-
velopment and ethical decision making in educa-
tion, practice, and research. Across these codes of
ethics, three major thematic categories are recog-
nized: nursing values related to the profession, to
patients, and to society.4 For example, the Ameri-
can 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 profes-
sional values are in conflict with the values of the
employing organization, dissonance occurs and
nurses become disenchanted and disenfran-
chised.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 asso-
ciated with the “stress of conscience” that occurs
when nurses can’t provide the quality of care in-
herent in their practice.6 For example, environ-
mental 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 inter-
est 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
10 April 2008 Nursing Management
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 pa-
tients’ well-being and preventing negative out-
comes 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 work-
place put moral values to the test and create con-
flicts when nurses are pressured to act in ways that
may not be congruent with their professional val-
ues. 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.
Method
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 sur-
vey. Four hundred and fifty-three surveys were
completed and returned, resulting in a 23% par-
ticipation rate. All states except Hawaii were rep-
resented 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 sam-
ple, including gender, ethnicity, education, age,
years of experience, and clinical specialty, posi-
tion, and worksite, are described in Table 1.
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Recruitment & retention report

Table 1: Sample descripton

Gender Frequency Percent (%)*
Male 23 5.1
We used the Nurses Professional Discussion
Female 428 94.5
Values Scale (NPVS) to measure the Although it’s clear
importance of 11 core ethical values that nurses in dif- Ethnicity Frequency Percent (%)*
derived from the 1985 ANA Code of ferent clinical spe- Caucasian 368 81.2
Ethics for Nurses. The ANA Code cialties and roles African American 36 7.9
Native American 1 0.2
has been updated since 1985; how- and at different
Asian American 17 3.8
ever, the core values reflected in the worksites have Hispanic 13 2.9
1985 iteration are still relevant for similar value pri- Other 8 1.8
today’s nurse. The NPVS is a 44- orities, this study
item, norm referenced instrument identified minor Basic education Frequency Percent (%)*
Diploma 91 20.1
with responses on a Likert scale differences be-
Associate 109 24.1
ranging from 5 (most important) to 1 tween nurse ad- Bachelor’s 240 53
(not important). Subscales and the ministrators and Master’s 7 1.5
corresponding values statements are staff nurses.
provided in Table 2 along with the Nurse administra- Highest degree Frequency Percent (%)*
Diploma 9 2
sample mean and relative rank for tors and staff
Associate 28 6.2
each subscale. nurses have es- Bachelor’s 110 24.3
sentially the same NP (non-Master’s) 16 3.5
Results value priorities, Master’s 256 56.5
Survey results indicated that the five but organizational Doctorate 33 7.3
most important individual priority ethics creates
Mean age (SD) Range N
items to survey participants and the challenges for 47.81 (9.04 ) 25 to 72 436
item mean were: both groups.
♦ item 31—maintain competency in Findings suggest Mean years of
area of practice (4.75) that the primary experience (SD) Range N
22.93 (10.56 ) 28 to 50 429
♦ item 30—accept responsibility and ethical conflict ex-
accountability for own practice (4.74) ists when health- Top five clinical
♦ item 28—provide high-quality care executives specialties Frequency Percent (%)*
nursing care in accordance with stan- fail to recognize Medical-surgical 99 21.9
dards (4.66) the cause and ef- Mental health 90 19.9
Gerontology 37 8.2
♦ item 36—act as a patient advocate fect of workplace
Pediatrics 35 7.7
(4.62) dissonance (the Family 29 6.4
♦ item 39—provide care without difference be-
prejudice to clients of varying tween organiza- Top five roles Frequency Percent (%)*
lifestyles (4.60). tional and clinical Nurse practitioner 101 22.3
Staff/general duty 92 20.3
The item identified by partici- values). The nurse
Administration 56 12.4
pants as least important was item administrator is in Faculty/educator 47 10.4
37—participate in nursing research the unique but Supervisor 46 10.2
(3.54). Values priorities, represented difficult position
by the NPVS subscales, for the entire of having to Top five worksites Frequency Percent (%)*
Hospital 206 45.5
sample of RNs are included in Table bridge the gap
School/college 64 14.1
2. Collectively, the top three values that exists be- Med/dental office 28 6.2
for the entire sample were safe- tween organiza- Community health 27 6
guarding privacy, respect for human tional and clinical Private practice** 23 5.1
dignity, and assuming accountability values. Home health** 23 5.1
and responsibility for actions. A de- When examin- * percents don’t equal 100
** equal number of respondents
tailed picture of value priorities for ing the priorities
the five most frequently identified by nursing role of staff, supervisor, group to prioritize responsibility and
clinical specialties, nursing roles, and administrator (Table 2), only two accountability, and staff nurses are the
and worksites can be seen in differences in these groups exist: only group to identify conditions of
Table 3. Nurse administrators are the only employment. The relative importance

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 Recruitment & retention report

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 environ-
ment is to improve communication. One study found that
only 10% of providers were comfortable with communica-
tion 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 Em-
power nurses to impact changes in organizational values
by giving them seats on committees that review matters rel-
evant to values interpretation, such as staffing, financial pri-
orities, patient safety, and ethics review boards.
♦ Institute a task force to examine the primary issues of val-
ues 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 clini-
cal sides of healthcare.
♦ Identify and eliminate the barriers that prevent nurses
from practicing in accordance with the standards estab-
lished by professional codes.
♦ Foster effective communication in the work environment

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Recruitment & retention report

Table 2: NPVS subscales and associated value statement

NPVS Value statement: ANA Code of Abbreviated title Survey sample Relative
subscale Ethics for Nurses (1985) mean (SD) rank
1. The nurse provides services with respect for Human dignity: Measured by 4.371 (0.52) 2nd
human dignity and the uniqueness of the client, items 20, 21, 34, 35, 39
unrestricted by considerations of social or
economic status, personal attributes, or the
nature of health problems.
2. The nurse safeguards the client’s right to privacy Privacy: Measured by 4.399 (0.57) 1st
by judiciously protecting information of a items 6, 22, 40
confidential nature.
3. The nurse acts to safeguard the client and Safeguard client: Measured 4.096 (0.57) 9th
the public when healthcare and safety by items 7, 23, 36, 41
are affected by the incompetent, unethical,
or illegal practice of any person.
4. The nurse assumes responsibility and accountability Responsible and accountable: 4.332 (0.56) 3rd
for individual nursing judgments and accountability Measured by items 12,
for individual nursing judgments and actions. 15, 30, 44
5. The nurse maintains competence in nursing. Competence: Measured 4.319 (0.48) 4th
by items 1, 13, 16, 31
6. The nurse exercises informed judgment and Informed judgment: Measured 4.287 (0.53) 5th
uses individual competence and qualifications by items 2, 14, 17, 26
as criteria in seeking consultation, accepting
responsibilities, and delegating nursing activities
to others.
7. The nurse participates in activities that contribute Contributes to knowledge: 3.875 (0.78) 11th
to the ongoing development of the profession’s Measured by items 8, 37,
body of knowledge. 42, 43
8. The nurse participates in the profession’s efforts Improve standards: Measured
to implement and improve standards of nursing. by items 9, 10, 24, 29 4.128 (0.67) 8th
9. The nurse participates in the profession’s efforts Conditions of employment:
to establish and maintain conditions of employment Measured by items 11, 25, 4.201 (0.58) 6th
conducive to high-quality nursing care. 28, 38
10. The nurse participates in the profession’s effort Maintain integrity: Measured 4.160 (0.58) 7th
to protect the public from misinformation and by items 3, 27, 32
misrepresentation and to maintain the integrity
of nursing.
11. The nurse collaborates with members of the Collaborate: Measured 3.879 (0.65) 10th
health professions and other citizens in promoting by items 4, 5, 18, 19, 33
community and national efforts to meet the
health needs of the public.
to improve outcomes and increase them to address issues of values dis- looming nursing shortage will need to
morale, leading to increased retention. sonance and make the organization a act quickly. Proactive planning that in-
♦ Examine the turnover rate and better place for the nurses who re- cludes alignment of organizational
identify the financial cost of this main. values and professional nursing val-
turnover. List all the things that can ues will position the organization to
be done to improve quality of care if Value realignment for the future better retain qualified, experienced
the nursing turnover rate is reduced. For far too long, healthcare adminis- professional nurses. NM
♦ Institute exit interviews using non- trators have closed their eyes to the
threatening and impartial interview- impact that values dissonance has on REFERENCES
1. Weis D, Schank MJ. Toward building
ers, such as faculty or graduate stu- their nursing staff. The costs are high an international consensus in profes-
dents from a local university. Ensure for the healthcare organization, nurs- sional values. Nurse Educ Today. 1997;
confidentiality of information shared ing staff, and patient care. There’s sub- 17(5):366-369.
in exit interviews. stantial evidence that values disso- 2. Weis D, Schank MJ. Exploring common-
♦ Organize an intergenerational nance exists, but little information is ality of professional values among nurse
educators in the United States and Eng-
group of nurses who are close to re- available about efforts to decrease or land. J Nurs Educ. 2000;39(1):41-44.
tirement and new graduates who are eliminate this dissonance. Healthcare 3. MacDonald H. Relational ethics and
just beginning their careers. Challenge organizations wanting to survive the advocacy in nursing: literature review.

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Recruitment & retention report
Table 3: Values priorities by clinical specialty, role, and worksite
Clinical specialty (n)
Medical-surgical (99)
Mental health (90)
Gerontology (37)
Pediatrics (35)
Family (29)
Role (n)
Nurse practitioner (101)
Staff (92)
Administrator (56)
Faculty (47)
Supervisor (46)
Worksite (n)
Hospital (224)
School/college (64)
Medical/dental office (28)
Community health (27)
Private practice (23)*
Home health (23)*
* equal number of respondents
J Adv Nurs. 2007;57(2):119-126.
4. Sawyer LM. Nursing code of ethics: an
international comparison. Int Nurs Rev.
18
1st value 2nd value 3rd value
Privacy Informed judgment Competence
Privacy Human dignity Responsible and accountable
Responsible and accountable Privacy Maintain integrity
Human dignity Privacy Responsible and accountable
Privacy Competence Human dignity
1st value 2nd value 3rd value
Privacy Human dignity Competence
Privacy Human dignity Conditions of employment
Privacy Safeguard client Responsible and accountable
Responsible and accountable Privacy Improve standards
Privacy Human dignity Safeguard client
1st value 2nd value 3rd value
Privacy Human dignity Responsible and accountable
Responsible and accountable Privacy Safeguard client
Competence Privacy Informed judgment
Human dignity Privacy Competence
Competence Human dignity Privacy
Responsible and accountable Human dignity Privacy
1989;36(5):145-148. Statements. Available at: http://www.
5. American Nurses Association. Code of nursingworld.org/ethics. Accessed
Ethics for Nurses with Interpretative April 26, 2007.
6. Glasberg Al, Eriksson S, Norberg A.
Burnout and “stress of conscience”
among healthcare personnel. J Adv
Nurs. 2007;57(4):392-403.
7. Holly CM. The ethical quandaries of
acute care nursing practice. J Prof
Nurs. 1993;9(2):110-115.
8. Sørlie V, Kihlgren A, Kihlgren M. Meet-
ing ethical challenges in acute nursing
care as narrated by registered nurses.
Nurs Ethics. 2005;12(2):133-142.
9. Bonczek ME, Woodard EK. Who’ll re-
place you when you’re gone? Nurs
Manage. 2006;37(8):30-34.
10. Martin P, Yarbrough S, Alfred D. Pro-
fessional values held by baccalaureate
and associate degree nursing stu-
dents. J Nurs Scholarsh. 2003;35(3):
291-296.
11. Kelly B. The professional values of
English nursing undergraduates. J Adv
Nurs. 1991;16(7):867-872.
12. Cooper RW, Frank GL, Hansen MM,
Gouty CA. Key ethical issues encoun-
tered in healthcare organizations: the
perceptions of staff nurses and nurse
leaders. J Nurs Adm. 2004;34(3):149-156.
ABOUT THE AUTHORS
At The University of Texas at Tyler College
of Nursing and Health Sciences, Tyler,
Tex., Susan Yarbrough is associate dean
for graduate nursing programs, Danita
Alfred is associate professor, and Pam
Martin is associate dean for undergradu-
ate nursing programs.
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