DEVELOPMENT AND VALIDATION OF A SELF-REPORT
INVENTORY FOR PROFESSIONAL NURSING VALUES
by
ANITA KAY OCHSNER, B.S.N., M.S., M.A.Ed.
A DISSERTATION
IN
HIGHER EDUCATION
Submitted to the Graduate Faculty
of Texas Tech University in
Partial FulfiUment of
the Requirements for
the Degree of
DOCTOR OF EDUCATION
ADDFoved
^
/
December, 1996
M
Copyright 1996, Anita Kay Ochsner
;
ACKNOWLEDGMENTS
I am indebted to Dr. Oliver D. Hensley, my chairman,
whose challenge to find new ways of looking at knowledge and
new ways of approaching research provided an exciting
adventure.
His confidence in my creative abilities provided
the impetus to begin and complete this research.
I also wish to thank other members of my committee
including Dr. Arturo Olivarez, Jr., whose enthusiasm for
statistics, coupled with common sense, is contagious; Dr.
Albert B. Smith and Dr. Michael Mezack III, whose experience
in educational research and dissertation reading was most
valuable; and Dr. Virginia G. Miller and Dr. Teddy L. Jones,
whose colleague support and meticulous readings of proposal
drafts were most helpful.
Finally, I would like to recognize my mother, the late
Kathleen Smithee Green, without whose enthusiasm, encouragement, and untiring clerical assistance this research would
have been considerably delayed.
unfailing.
11
Her confidence in me was
CONTENTS
ACKNOWLEDGMENTS
ii
ABSTRACT
vi
LIST OF TABLES
v
LIST OF FIGURES
v
CHAPTER
I.
II.
I N T R O D U C T I O N T O T H E STUDY
1
P u r p o s e Statement
1
P r o b l e m Statement
6
T h e s i s Statement
14
Research Questions
17
Assumptions
25
Scope and L i m i t a t i o n s
27
Study J u s t i f i c a t i o n Statement
28
Summary
29
REVIEW OF RELATED LITERATURE
31
M o r a l P u r p o s e of E d u c a t i o n
31
Nursing Ethics
44
V a l u e s : T h e o r e t i c a l and O p e r a t i o n a l
D e f i n i t i o n s and T h e i r R e l a t i o n s h i p
to N u r s i n g
46
S t a n d a r d s of N u r s i n g P r a c t i c e
51
K n o w l e d g e B a s e for C o n s t r u c t i o n and
V a l i d a t i o n of O c h s n e r ' s I n v e n t o r y of
Professional Nursing Values
60
Summary
61
iii
Ill.
RESEARCH METHOD AND PROCEDURES
The Setting
Sample Characteristics
Development of the Inventory
Procedures for Analyzing Data
Milestones
IV.
PRESENTATION AND ANALYSIS OF DATA
Purpose
Procedures
Data Analysis
Summary of Chapter IV
V.
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Summary
Conclusions
Recommendations
Speculations
LIST OF REFERENCES
APPENDICES
A.
AMERICAN ASSOCIATION OF COLLEGES OF NURSING
"ESSENTIALS" VALUES, ATTITUDES
AND PROFESSIONAL BEHAVIORS
B.
SURVEY COVER LETTER AND
OCHSNER'S INVENTORY OF PROFESSIONAL
NURSING VALUES (IPNV)
C.
A SCHEMATIC OF THE PROCESS FOR
VALIDATING SYSTEM MODELS
D.
TEXAS TECH PROTECTION OF HUMAN SUBJECTS
SUBJECTS APPROVAL FOR PROFESSIONAL
NURSING VALUES (SURVEY)
E.
INSTITUTIONS INCLUDED IN SAMPLE
iv
ABSTRACT
Moral beliefs and values form a basis for ethical nursing practice.
The interlocking of personal and professional
values directly influences nurses' decisions and actions.
The need for a measuring instrument to assess development of
professional values in nursing is addressed through construction and validation of a self-report inventory:
Ochsner's Inventory
of Professional
Nursing
Values
(IPNV).
A national study was conducted in order to validate the
IPNV.
Subjects were drawn from a random cluster sampling of
89 National League for Nursing (NLN) accredited baccalaureate nursing programs representing 47 states plus Washington,
D.C.
From 875 inventories distributed to fulltime nursing
educators, 413 usable responses were returned (47.2%).
Demographic data confirmed all respondents as "nurse
educator experts."
Two modes of inquiry were utilized.
An expert systems
design, transferred from computer technology, was used to
establish a knowledge model of nursing values.
This model
served as a theoretical base for IPNV content and structure.
A psychometric analysis design for developing measurement
instruments was used to identify items that best describe
behaviors, attitudes and personal qualities reflective of
professional nursing values.
Statistical analyses for
V
validation purposes included exploratory and confirmatory
factor analyses and coefficient alpha estimates.
A final IPNV measurement model is presented.
Four
underlying value dimensions for professional behaviors and
for attitudes and personal qualities were identified and
named.
Thirty-three professional behaviors and 34 attitudes
and personal qualities were identified as best descriptors
of their respective value dimensions.
VI
LIST OF TABLES
1.
Subject characteristics
2.
IPNV Section I items:
3.
IPNV Section II items:
4.
IPNV Section I: Mean ratings
for 50 nursing behaviors
88
IPNV Section II: Mean ratings for
50 attitudes and personal qualities
91
IPNV Section I: Confirmatory factor analysis.
Goodness-of-fit indexes
98
5.
6.
7.
70
Summary by origin
Summary by origin
75
78
IPNV Section I: Final measurement model,
decimals omitted
101
IPNV Section II: Standardized regression
coefficients. Rotated factor pattern: Promax
(Oblique) method. Decimals omittted
106
9.
IPNV Section II:
109
10.
Inventory of Professional Nursing Values
(IPNV). Usefulness ratings for
Section I: Behaviors
112
Inventory of Professional Nursing Values
(IPNV). Usefulness ratings for Section II:
Attitudes and personal qualities
113
Inventory of Professional Nursing Values
(IPNV). Comprehensiveness ratings for
Section I: Behaviors
115
Inventory of Professional Nursing Values
(IPNV). Comprehensiveness ratings for
Section II: Attitudes and personal
qual ities
116
Essential Values: American Association of
Colleges of Nursing. (1986, pp. 6-7)
146
Institutions included in sample
161
8.
11.
12.
13.
14.
15.
Final four-factor model
VI 1
LIST OF FIGURES
1.
Ochsner's professional nursing values model
2.
Final measurement model for Ochsner's Inventory
of Professional Nursing Values (IPNV)
126
A schematic of the process for validating
system models
157
3.
VI 1 1
80
CHAPTER I
INTRODUCTION TO THE STUDY
Purpose Statement
The purpose of this investigation is to construct and
validate a self-report inventory to assess development of
professional values in nursing.
The inventory consists of
behaviors, attitudes and personal qualities deemed essential
for professional nursing practice.
The content for a number
of items comes from the American Association of Colleges of
Nursing's Final Report (1986) on Essentials of College and
University Education for Professional Nursing (Appendix A ) .
Several of the activity items stem from the Pew Health
Professions Commission Report: Healthy America: Practioners
for 2005 (1991).
The proposed Inventory of Professional
Nursing Values is in keeping with tenets of the American
Nurses Association's Code for Nurses (1985).
Disciplinary Imperatives for Nursing
Values Study
Two main areas of nursing research are nursing theory
and nursing ethics.
Moral beliefs and values are postulated
to form a key portion of the knowledge base for nursing
ethics (Yeo, 1991).
Deeply held values and beliefs of both
nurse and client permeate nursing actions.
For nursing, health is an obvious value; however,
concern for client health may conflict with competing values
1
such as truthfulness, confidentiality, and justice.
Therefore, nurses must attend to the profession's value
dimension.
Every nursing intervention has the possibility
of promoting or denying some value.
Yeo (1991) states,
"Whatever the situation, knowing what one values and being
sensitive to the values of others is an essential condition
of responsible and ethical practice" (p. 12).
If one agrees
with Yeo, then the nursing profession must support the
systematic study of values and find a method for assessing
if those values are being taught and practiced.
During the 1990's, changes in the health care system
changed how care is delivered.
Movement toward a new health
system requires that health practitioners, especially nurses
in practice and in education, be sensitive to care issues.
Crisham (1992) recognized a need for nursing ethicists to
investigate the relationship between resolution of nursing's
moral dilemmas and quality health care.
Gournic (1994)
echoed Crisham's call by emphasizing the need for nurse
researchers to bridge the gap between hypothetical and reallife situations.
Rheba de Tornyay (1992), professor of
nursing, states, "The attitudes and values of practitioners
shape the fundamental ways in which care is provided."
concludes, "These attributes are developed during the
formative years in professional education" (p. 301).
Elfrink and Lutz (1991) investigated ways in which
nursing educators provided opportunities to learn and
She
practice professional nursing values.
They found values
were predominantly included in the informal lesson plan.
A nonsystematic approach to teaching values "...could limit
professional nurses' understanding of the meaning of humanistic nursing care:
hence, the quality of nursing practice
could be influenced negatively" (p. 244).
Examples of professional value behaviors.
A real life
example of nursing's humanistic approach is the 1995 march
of more than 25,000 RNs on Washington to protest unsafe
patient care resulting from widespread hospital restructuring.
A few days after the protest, Marullo (1995,
April/May) quoted one federal nursing chief as saying "it
has been nursing and ONLY nursing that has committed to the
education of the public with regards to health care consumerism."
Marullo goes on to say that the heart of nursing's
message [at the march on Washington] was "--the right of the
consumer to choose and receive nursing care" (p. 5).
Another exaimple, the Texas for-profit psychiatric
hospital scandal of 1991, is related to the expansion of a
marketplace mentality into health care deliveries.
Mohr
(1995, February) reviewed extensive testimony from patients,
families and health care professionals on the demeaning,
dehumanizing, and devaluing of psychiatric adolescent
patients.
After reading thousands of pages of testimony,
Mohr described how her emotions took a "roller coaster ride"
between cynicism and hope:
"I have seen the degradation of
mountains of unbridled greed juxtaposed against the glimmer
of the pristine, the goodness that, I believe with all my
heart, must exist in this world" (p. 9). The lack of
awareness of many providers (including nurses) of the
environmental context within which they were working was
staggering, even to Texas senators who heard their testimony.
However, there were some providers (including RNs)
who did speak out and in the process suffered personally and
professionally.
Mohr demonstrated that her emotions ended
with hope:
I have relearned the definition of courage.
I have been deeply moved at the resoluteness of
many nurses who have labored under difficult,
often impossible circumstances and have never
lost sight of their decency. These nurses have
refused in many different ways to countenance the
unspeakable and the intolerable in a mental
health system perverted by the drive for profits
over people.
...[Some of these nurses]...voiced concern
and felt as though they have stood alone, yet
even though they had little to gain they stood
by to advocate for their patients. That is a
pretty good description of courage and it has
renewed and strengthened my resolve to advocate
for my own profession and the reason for its
being--the patients, (p. 9)
Code for Nurses.
The importance of the practice of
professional nursing values is reiterated by the Board
(1995, March) of the American Nurses Association (ANA).
Two of the revised position statements are as follows:
"Code for Nurses with Interpretive
Statements" explicates the goals, values and
ethical precepts that direct the profession of
nursing. ANA believes the "Code for Nurses"
is nonnegotiable and that each nurse has an
obligation to uphold and adhere to the code of
ethics, (p. 17)
ANA'S
ANA believes that the state nurses
associations should be a vital source for the
nurse and the profession on ethics and human
rights matters. ANA supports the development
of mechanisms to promote the ethical competence
of nurses, (p. 17)
In keeping with disciplinary mandates of nursing, this
writer proposes to contribute to nursing education and
practice by developing an inventory that will be comprehensive, valid and useful in assessing and promoting the
development of professional values.
Specific Objectives
Three specific objectives were proposed.
1.
Develop and validate a self-report inventory to
assess professional behaviors, attitudes and personal
qualities reflective of professional nursing values.
2.
Build on the structure of knowledge base in nursing
ethics through ratings (importance, usefulness, comprehensiveness) of the self-report inventory by nurse educator
experts.
3.
Disseminate the self-report inventory within major
areas of nursing scholarship:
nursing education, nursing
ethics, and nursing practice.
This third specific objective
6
pertains chiefly to publication activities which will take
place post dissertation completion.
Problem Statement
Based on this writer's experience, colleague discussions, and literature review, the need for a valid and
reliable instrument to assess nurses' professional values
has been established.
Although this study will focus on
the problem related to assessment and development of
professional
nursing
values,
it is important to note that
the assessment and development of values
in higher
education
is a problem of general concern.
Higher education has a responsibility to provide an
ambience in which students can pursue moral growth and
development and learn principles of decision making.
Learn-
ing to do something well needs to be balanced with learning
how to be somebody of worth.
A carefully planned liberal
education frees one to think logically and to skillfully
communicate these thoughts.
It enables one to evaluate and
choose among better, worse, good, and bad.
The Difficulties of Integrating Nursing
Values into Nursing Actions
Ethical nursing actions require a knowledge base in
(1) fundamental concepts of moral philosophy; (2) relevant
codes, policies, and laws; and (3) moral beliefs and values.
These three areas of knowledge are generally agreed upon as
forming an essential knowledge base for nursing ethics.
The first area includes moral theories among which there are
differing views.
However, six concepts in moral philosophy
are foundational in nursing ethics:
beneficence, autonomy,
truthfulness, confidentiality, justice, and integrity (Yeo,
1991) .
The second area of nursing ethics knowledge includes
relevant codes, policies, and laws.
Codes of ethics are
usually promulgated by professional associations.
The
American Nurses Association (1985) Code for Nurses is
recommended for use by nurses in the United States.
State
Nurse Practice Acts (NPAs) vary in content; however, all
NPAs define standards of care and scope of nursing practice.
Requirements for licensure and grounds for disciplinary
action is described.
regulatory bodies.
State boards of nursing form NPA
All state boards belong to the National
Council of State Boards of Nursing.
The national council
develops licensure examinations and maintains a data base on
nurses who have been disciplined (Green, 1995, p. 37).
Institutional policies are a part of most settings
where nurses work.
Yeo (1991) advises nurses to familiarize
themselves with institutional policies and measure these
policies against personal and professional values before
entering an employment contract.
Nurses are responsible for
knowing and complying with the rules that apply to their
8
practice setting.
Green (1995) states, "A nursing board may
view failure to follow the hospital's policies and procedures as unprofessional conduct, even if the nurse's actions
would have complied with policy at other hospitals" (p. 39).
The third area of nursing ethics knowledge is concerned
with the values dimension of nursing.
The American Associa-
tion of Colleges of Nursing's (1986) seven validated essential values fit in this area of nursing ethics.
values include altruism,
dignity,
justice,
equality,
and truth.
esthetics,
The seven
freedom,
human
It is within the values dimen-
sion of nursing practice that philosophy, codes, laws, and
policies convert into real life ethical dilemmas and real
life action responses to those dilemmas.
"Adoption of the
essential values leads the nurse to a sense of commitment
and social responsibility, a sensitivity and responsiveness
to the needs of others, and a responsibility for oneself and
one's actions" (p. 5).
Integrating moral beliefs and values into clinical
decisions and action requires not only self-understanding
but also sensitivity to and tolerance for client values.
Thus, conflicts between what the nurse sees as good for an
individual client and what that same client sees as good may
be rationally approached.
client
is family,
or group,
More complexity arises when the
or community.
An ethical
question may occur when nurses must decide for whom they
will advocate.
For example, maintaining confidentiality for
an individual with the AIDS virus could eventually result in
spread of AIDS to family and/or community members.
Examples of professional behaviors guidelines.
Guide-
lines for integration of nursing values into nursing decisions and actions have been proposed by several nurse
ethicists.
The guidelines have in common the use of nursing
process (assessment and issue identification, planning,
implementation, and evaluation).
Decision making and action
permeate the process.
In the early 1980s, Crisham (1992) developed a MORAL
model for resolving ethical dilemmas.
Aroskar (1992, May)
developed a framework for dealing with common ethical
problems in health care related to access and allocation,
use of technology, and withholding medical treatment.
Becker (1991) used a grounded theory approach to explore how
nurses respond when faced with ethical situations.
Mohr
(1995, March) presented recommendations for nurses working
in a medical marketplace, and Hall (1995, April) presented
nursing ethics in relation to the legal point of view.
Michael Yeo (1989) describes communication as a key
element in moral decision making.
He said there is a lack
of communication between nurse theorists and nurse
ethicists.
Lack of communication hinders knowledge and
practice of professional nursing values in the workplace.
Even with good communication, increased awareness of
guidelines and models for ethical nurse decision-making will
10
not ensure ethical nursing practice.
Yeo (1991) said that
even though incorporating ethics models into nursing practice can be useful, these models cannot replace decisionmaking:
Decision-making requires judgement, and judgement
guides the use of any framework as much as it may
be guided by it. Hence, one should not be too
rigid in following the direction of a given model.
A good chef knows the importance of recipes, but
knows as well how to add, subtract, and substitute
ingredients as necessary. (Yeo, 1991, p. 21)
Barriers and Challenges to Interlocking
of Personal with Professional
Nursing Values
Power issues.
sional values.
Personal values interlock with profes-
Congruence between personal and professional
values will contribute to rational and satisfying decisions
and actions.
Gender-related values have influenced nursing
ethics (Yeo, 1991, p. 6). Nursing has been and still is
largely a woman's profession.
Some writers assume that
women, more than men, tend toward such values as caring and
nurturing; there is evidence that nursing has historically
been more centered on caring than on curing (Huggins &
Scalzi, 1988; Benner & Wrubel, 1989; Crowley, 1989; Bevis &
Watson, 1989).
Two other related gender issues that have existed and
to a certain extent still do exist are nursing's subordination and relative powerlessness in the health care system.
Under existing legal and institutional arrangements, nurses
11
may have neither the freedom nor the power to be ethical
(Yarling & McElmurry, 1986; Mohr, 1995, March; Becker,
1991) .
Akin to the power issue is the situation in which many
nurses find themselves with multiple professional
obligations such as commitment to individual client, to
family client, to community client, to colleagues, and to
employers.
Multiple professional obligations brings up the
issue of potential conflicting loyalties (i.e., loyalty to
individual client, to family client, to community client, to
colleagues, and to employers.
Becker (1991) said loyalties
need to be based on reflective choice.
Traditions and
conditions in the health care system along with confusion
regarding nursing's role in ethical dilemmas presents the
challenge of conflicting loyalties (p. 14).
Interpersonal issues.
Nurse-Client relationship
perspectives influence value priorities.
Yeo (1991)
concluded that the two most favored interpersonal roles
found in nursing ethic's literature are based on the
contractual
ships.
and advocacy
The contractual
models of nurse-client relationmodel
establishes expectations
regarding the extent of involvement of client and nurse in
nursing care.
Cooper analyzed three contractual-related
interactional positions:
May's covenantal relationships
concept (May, 1974), Veatch's triple contract theory
(Veatch, 1981), and Gadow's caring relationship concept
12
(Gadow, 1980).
Cooper (1988) identified a striking
commonality between these three writers:
"...their
insistence on mutuality and reciprocity within the
caregiver-patient relationship" (p. 55). Cooper states,
"May and Veatch explicitly identify fidelity and promise
keeping as central ethical principles undergirding
covenantal relationships" (1988, p. 56).
In contrast to a contractual model which establishes
mutual expectations and builds trust, the client
model
is a rights-based model.
advocacy
Yeo (1991) states, "The role
of patient or client's advocate has been adopted and
endorsed by nursing to a far greater extent than by other
health professions" (p. 9). An example of client advocacy
action can be noted in Marullo's (1995, April/May) report.
The term advocate
came into vogue with comsumerism and
the patient rights movement.
Yeo (1991) said that advocacy
conceived in terms of clients' rights developed as a
corrective for the health care system's earlier denial of
patients' rights--i.e., a paternalistic role.
Mohr's (1995)
study of the for-profit psychiatric-hospital scandals shows
that the issue of patient rights is still germane.
Gadow is
quoted as criticizing the rights-based model of advocacy and
promoting existential
advocacy
by way of consumer
protect
ion
(Yeo, 1991, p. 10). This middle course between paternalism
and acting in the service of what the client wishes would
seem to be the stance of nursing today.
13
Personal values assessment and self-report techniques.
Two personal values scales that have been most frequently
used in nursing research are the Rokeach Value Survey and
Rest's Defining Issues Test (DIT).
Other scales such as the
Allport-Vernon-Lindzey scale and Gordon's Personal and
Interpersonal Values Scales have also been used in nursing
research (Schank & Weis, 1989; Saarmann, Freitas, Rapps, &
Riegel, 1992).
An example of use of the Rokeach Value Survey in
nursing is reported by Thurston, Flood, Shupe, and Gerald
(1989).
These researchers compared personal values of
nursing faculty with those of entering nursing students.
An example of the use of Rest's DIT in nursing is reported
by Frisch (1987).
The DIT was used to measure change in a
nursing student's level of moral development.
Values assessment scales such as the above make use of
self-report techniques.
A problem considered inherent in
self-report inventories is that of impression management.
"Impression
management
is a term social psychologists use to
describe the behavior of attempting to manipulate other's
impressions
" (Cohen, Serdlik, & Smith, 1993, p. 433).
Many personality tests include items designed to detect
individuals who attempt to "fake good" or "fake bad" depending on which strategy would best suit the situation.
Values assessment tests do not usually contain items to
detect impression management.
However, analysis of values
14
assessment inventories should include comments related to
any circumstance that would trigger an impression management
response style (i.e., use for admittance to study programs,
use for job selection, etc.).
Results of self-report inven-
tories should never be used as a sole assessment method.
Adequate feedback should be provided to participants.
Problem Statement Summary
Moral beliefs and values form a basis for ethical
nursing practice.
The interlocking of personal and profes-
sional values directly influence nurses' decisions and
actions.
It is important for nurse educators to identify
methods to assess and promote development of professional
values in nursing.
Nursing
Values
The Ochsner Inventory
of
Professional
(Appendix B) is posited as one reliable and
valid tool to assess and guide interventions designed to
develop professional behaviors, attitudes and personal
qualities reflective of professional nursing values.
Thesis Statement
It is this writer's thesis that although a few professional nursing values assessment instruments have been
devised, no instrument for the assessment of professional
behaviors, attitudes and personal qualities reflective of
professional nursing values has been developed and nationally validated for important content, comprehensiveness.
15
and usefulness.
Only two national studies were identified
where all of AACN's identified essential values were
included.
In the first study, Elfrink and Lutz(1991) asked
a representative national sample of baccalaureate nurse
educators if they agreed that AACN's seven essential values
were representative of the values nurses need to know and
use.
They reported an agreement mean of 4.49 on a 5-point
Likert scale.
One of the suggested implications of this
study was the need to determine student knowledge levels and
practices related to AACN essential values.
A second national study (Eddy, Elfrink, Weis, & Schank,
1994) focused on different perceptions between students and
nursing faculty about the importance of professional nursing
values.
These authors also expressed a need for research
instruments to measure professional nursing values.
Contribution to Nursing Research
Development and validation of an instrument to measure
professional nursing values will contribute to an essential
knowledge base for ethical nursing practice.
Inventory
of Professional
Nursing
Values
The Ochsner
(IPNV) can be used
by both nurses and nursing students for reflective values
clarification.
Also, the IPNV might be adapted by nurse
educators for assessment of a student's cognitive and
behavioral knowledge of professional nursing values.
16
Modes of Incuirv
Even though values cannot be measured directly, two
modes of inquiry available and used by this researcher are
as follows:
(1) An expert
systems
design
is used for nurse
educator experts' validation of a nursing values model, and
(2) a psychometric
analysis
design
is used to identify the
best descriptive items for Ochsner's IPNV measurement
instrument.
The first mode of inquiry builds a profes-
sional nursing values structure of knowledge.
The term
expert system is taken from computer terminology and refers
to the process an expert would use in a heuristic inductive
approach to problem-solving.
The expert systems mode of inquiry process described
by Harmon, Maus, and Morrissey (1988, p. 168) is being used
in higher education research.
This mode of inquiry has been
promulgated by the International Society for Epistecybernetics (ISEE) which was founded in 1993 by a group of
scholars representing various fields of study.
this group coined a word epistecybernetics
Founders of
to describe the
science, structure, and stewardship of knowledge.
Epistecyberneticists define knowledge as the
of a generic
solution
into a problem-solving
repertoire.
Essential knowledge elements (EKE's) are seen as
problem-solving
discipline.
devices
acceptance
generic
concerned with typical problems of a
These devices are identified and incorporated
17
into a structure of knowledge for that discipline (Fedler &
Hensley, in press).
One example is A Schematic of the Pro-
cess for Validating System Models (Appendix C) developed by
Hensley and Tunstall (in press).
The Hensley-Tunstal1 sche-
matic consists of nine stages for developing and validating
system models.
These stages form a framework for develop-
ment of a structure of knowledge model from which underlying
dimensions (EKE's) of professional nursing values can be
identified.
The second mode of inquiry, a psychometric
design,
analysis
is a test development approach which occurs in seven
stages identified by Borg and Gall (1989, p. 273). This
mode of inquiry is used to identify professional behaviors,
attitudes, and personal qualities that best predict the
practice of professional nursing values.
Research Ouestions
This article will describe the evolution of research
questions for the IPNV, offer evidence for validity and
significance of the research questions, and present six
research questions with concomitant hypotheses.
Evolution of Research Ouestions
Research questions for this study evolved from a belief
that higher education has a responsibility to provide an
environment in which students can pursue moral growth and
18
development and learn principles of ethical decision-making.
For example, when potential employers ask for a nursing
school graduate reference, they are interested in more than
technical abilities.
They are looking for an individual who
can interact appropriately and act with integrity.
In 1986, the American Association of Colleges of Nursing (AACN) recognized the importance of selected nursing
values.
The AACN established content validity for seven
proposed professional nursing values.
In their final
report, the following statement is found:
The professional nurse assigns priorities
to these values within specific decision-making
contexts in the application of essential knowledge
and practice. The nurse, guided by these values,
attitudes, and personal qualities, demonstrates
ethical professional behavior with patients/clients,
colleagues, and others in providing safe, humanistic care focused on health and quality of life.
Values, attitudes, personal qualities, and consistent patterns of behavior begin to develop early in
life, but also are fostered and facilitated by
selected educational strategies and the process of
socialization to the profession. (American Association of Colleges of Nursing, 1986, p. 7)
Significance of Research Questions
Subsequent to a review of nursing literature on the
subject of values, the nurse project director for AACN's
national study on Essentials of College and University
Education (known as "the Essentials") was contacted by phone
(Betty M. Johnson, Fall, 1994).
Dr. Johnson stated that
AACN is presently involved in studies related to how extensively "the Essentials" are being used in baccalaureate
19
nursing education programs.
For background on "the Essen-
tial's" study, she suggested a journal article describing
events leading to publication of "the Essentials" (Johnson,
1987) .
A nurse educator who used "the Essential's" value study
to construct a Professional Nursing Behavior instrument (the
PNB) was also contacted by phone (Diane M. Eddy, Fall,
1994).
Dr. Eddy is presently active in nursing values
research.
She shared a copy of the PNB in which she used
AACN values behaviors in a recent national study (Eddy,
Elfrink, Weis, & Schank, 1994).
Both Dr. Eddy and Dr.
Johnson encouraged this writer to pursue further research on
the topic of professional nursing values.
In June, 1995, the Publicity Director for AACN, Dan
Mezibov was consulted in regard to use of the 1986 Essential
Values as a framework for the IPNV.
He confirmed the
"Essentials" as a public document and said there would be no
copyright problems when using items from the Essentials for
research.
If and when the IPNV is available for purchase,
copyright permission may need to be negotiated.
Mr. Mezibov
also recommended calling two Task Force Directors for
(1) Revision of the 1986 Final Report and (2) Formation of
an "Essentials" report for Master Degree level nursing
pract ice.
In June, 1995, Task Force director for the Master's
Essentials, Evelynn Gioella, was contacted by phone.
20
Dr. Gioella said that her Task Force is not addressing any
changes in the essential values as stated in the 1986
report.
She did say that ethical questions were addressed
within the context of nursing practice essentials.
The
Master's Essentials Task Force will present their findings
at the national conference of AACN planned for December,
1995.
In June, 1995, Task Force director for revision of the
1986 Bachelor's Degree Essentials, Lea Acord, was contacted
by phone.
Dr. Acord said that her Task Force had not con-
sidered any changes in the seven values component of the
1986 report.
The task force members are focusing on nursing
theory and practice essentials.
Dr. Acord expressed inter-
est in this writer's professional values research.
She
asked to be kept updated on the research progress and suggested sending a copy of the dissertation to the national
director of AACN.
Dr. Acord said that a report on revision
of the 1986 "Essentials" is in early stages of development.
Research Ouestions and Hypotheses
The research questions to be asked in this investigation are related to the study's first two specific objectives.
Question number one is intended to obtain expert
ratings on the degree of importance of IPNV items.
Question
number two addresses construct validity and alpha reliability of Ochsner's IPNV.
Question number three is intended to
21
obtain expert ratings on the degree of usefulness of the
IPNV.
Question number four is intended to obtain expert
ratings on the degree of comprehensiveness of the IPNV.
Question number five requests narrative input from the
respondents.
Research question number one (1).
Do items in
Ochsner's IPNV contain behaviors, attitudes and personal
qualities reflective of important values characteristic of
professional nursing practice?
la. Ho:
Nurse educator experts will rate IPNV
professional behavior items < 3.50 on a 5-point Likert scale
of l=not important to 5=essential.
la. Ha:
Nurse educator experts will rate IPNV
professional behavior items > 3.50 on a 5-point Likert scale
of l=not important to 5=essential (means, confidence limits,
t-tests on the mean).
lb. Ho:
Nurse educator experts will rate IPNV
attitudes and personal qualities < 3.50 on a 5-point Likert
scale of l=not important to 5=essential.
lb. Ha:
Nurse educator experts will rate IPNV
attitudes and personal qualities > 3.50 on a 5-point Likert
scale of l=not important to 5=essential (means, confidence
limits, t-test on the means).
Research question number two (2). Do items in
Ochsner's IPNV reflect important underlying value dimensions
characteristic of professional nursing practice?
22
2a. Ho:
Nurse educator expert ratings of IPNV behavior
items on a 5-point Likert scale of l=not important to
5=essential will not reflect important underlying value
dimensions characteristic of professional nursing practice.
2a. Ha:
Nurse educator expert ratings of IPNV behavior
items on a 5-point Likert scale of l=not important to
5=essential will reflect important underlying value
dimensions characteristic of professional nursing practice
(item-total-score correlations, factor analysis, coefficient
alpha).
2b. Ho:
Nurse educator expert ratings of IPNV attitude
and personal quality items on a 5-point Likert scale of
l=not important to 5=essential will not reflect important
underlying value dimensions characteristic of professional
nursing practice.
2b. Ha:
Nurse educator expert ratings of IPNV attitude
and personal quality items on a 5-point Likert scale of
l=not important to 5=essential will reflect important
underlying value dimensions characteristic of professional
nursing practice (item-total-score correlations, factor
analysis, coefficient alpha).
Question number three (3). Does Ochsner's IPNV contain
behaviors, attitudes and personal qualities useful in
development of professional nursing values?
23
3a. Ho:
Nurse educator experts will rate IPNV behavior
items < 3.50 on a 5-point Likert scale of l=not useful to
5=100% useful for the following categories:
Overall rating
and ratings for curriculum development, nursing practice,
professional self-evaluation, and career counseling.
3a. Ha:
Nurse educator experts will rate IPNV behavior
items > 3.50 on a 5-point Likert scale of l=not useful to
5=100% useful for the following categories:
Overall rating
and ratings for curriculum development, nursing practice,
professional self-evaluation, and career counseling (means,
confidence limits, t-tests on the mean).
3b. Ho:
Nurse educator experts will rate IPNV attitude
and personal quality items < 3.50 on a 5-point Likert scale
of l=not useful to 5=100% useful for the following
categories:
Overall rating and ratings for curriculum
development, nursing practice, professional self-evaluation,
and career counseling.
3b. Ha:
Nurse educator experts will rate IPNV attitude
and personal quality items > 3.50 on a 5-point Likert scale
of l=not useful to 5=100% useful for the following
categories:
Overall rating and ratings for curriculum
development, nursing practice, professional self-evaluation,
and career counseling (means, confidence limits, t-tests on
the mean).
24
Research question number four (4). Does Ochsner's IPNV
contain comprehensive content related to professional nursing values?
4a. Ho:
Nurse educator experts will rate IPNV behavior
items < 3.50 on a 5-point Likert scale of l=not comprehensive to 5=100% comprehensive.
4a. Ha:
Nurse educator experts will rate IPNV behavior
items > 3.50 on a 5-point Likert scale of l=not comprehensive to 5=100% comprehensive (mean, confidence limits,
t-test on the mean).
4b. Ho:
Nurse educator experts will rate IPNV attitude
and personal quality items < 3.50 on a 5-point Likert scale
of l=not comprehensive to 5=100% comprehensive.
4b. Ha:
Nurse educator experts will rate IPNV attitude
and personal quality items > 3.50 on a 5-point Likert scale
of l=not comprehensive to 5=100% comprehensive (mean,
confidence limits, t-test on the mean).
Research question number five (5). Will nurse educator
experts suggest modifications, deletions, or additions of
any behaviors, attitudes and personal qualities included in
Ochsner's IPNV? (Answers to an open-ended question will be
considered by this researcher on an individual item basis).
25
Assumpt ions
Development of the IPNV is based on four assumptions.
1.
Values are reflected in attitudes, personal qual-
ities, and consistent patterns of behavior.
2.
Values, although relatively stable, can and do
change.
3.
Values can be taught, learned and assessed.
4.
Educators and administrators have an obligation to
provide opportunity for students' moral growth.
Definitions and Abbreviations
AACN.
American Association of Colleges of Nursing.
Altruism.
Concern for the welfare of others (AACA,
1986).
ANA.
American Nurses Association.
Attitudes and Personal Qualities.
In this study,
personal qualities are defined as innate or learned
attributes of an individual.
Attitudes are defined as
inclinations or dispositions to respond positively or
negatively to a person, object, or situation (AACN, 1986).
Caring.
"Caring is a feeling
of dedication
to
another
to the extent that it motivates and energizes action to
influence life constructively and positively by increasing
intimacy and mutual self-actualization" (Bevis, 1981, p.
50) .
26
Character.
In this study, character is defined as "The
combination of emotional, intellectual, and moral qualities
that distinguishes an individual..." (Roget's II; The new
thesaurus, 1930, p. 145).
Client.
As an era of patient rights emerged, the term
"patient" was often considered too paternalistic.
In this
study the term "client" is used to refer to either an
individual, a family, or a group/community who receives
health care.
Epistecybernetics.
The science for structure and
stewardship of knowledge.
Equality.
Having the same rights, privilege or status
(AACN, 1986).
"The Essentials."
A report supported by the AACN
(1986) and reviewed by 1500 nurse researchers and other
health care providers.
The final report outlined values,
knowledge, and skills considered essential for baccalaureate
nursing education.
The seven essential values identified
were Altruism, Equality, Esthetics, Freedom, Human Dignity,
Justice, and Truth.
accepted by the AACN.
Definitions in this section are those
Each value has three or four examples
of professional behaviors, attitudes, and personal qualities
which were intended to reflect the presence of one of the
seven above values.
Esthetics.
Qualities of objects, events, and persons
that provide satisfaction (AACN, 1986).
27
Expert System.
Refers to a computer program based on
the pattern of a human expert's problem-solving through use
of a heuristic inductive approach.
Freedom.
Capacity to exercise choice (AACN, 1986).
Human Dignity.
Inherent worth and uniqueness of an
individual (TUVCN, 1986).
Just ice.
Upholding moral and legal principles (AACN,
1986) .
Professional Behaviors.
In this study, professional
behaviors are defined as activities which reflect an
individual's commitment to specific values (7\ACN, 1986).
Psychometric Analysis.
Refers to a test development
design which progresses in seven stages defined by Borg and
Gall (1989, pp. 273-276).
Cohen, Swerdlik, and Smith (1992,
p. 194) summarize test development stages:
(1) test
conceptualization, (2) test construction, (3) test tryout,
(4) item analysis, and (5) test revision.
Truth.
Faithfulness to fact or reality (AACN, 1986).
Values.
Beliefs or ideals to which an individual is
committed and which guide behavior (AACN, 1986).
Scope and Limitations
The population of this study is limited to a national
sample of full-time nurse educators representing baccalaureate nursing programs accredited by the National League for
Nursing.
Eighty-nine randomly selected schools from 47
28
States (USA) are included in this study.
The intention is
to include expert nurses in the field of nursing education.
Institutional rank, highest educational degree, certificates
of specialization, age and years of experience are considered as a measure of "expertness."
Although age and
years of experience do not guarantee expertness, lack of
experience is associated with novice nurses (Benner, 1984).
Since the IPNV is designed primarily for educational use in
baccalaureate nursing programs, the population is appropriate for this study.
Study Justification Statement
In December, 1994, this researcher developed an
inventory of professional nursing values for pilot testing.
Participants included a convenience sample of 90 nursing
educators and graduate R.N. students from West Texas and
Central Coast California.
The pilot test included
relevance ratings for professional attitudes and behaviors
related to AACN's essential values.
Initial validity of
content relevance and usefulness was generated through use
of content validity ratio analysis and exploratory factor
analysis.
Overall Cronbach's coefficient alphas were above
0.90 indicating internal consistency reliability.
Addi-
tional comments from 34 of 90 respondents were integrated
into later revision of the inventory. Analysis of the pilot
29
instrument and pilot respondents' comments supported the
need for an instrument to measure professional nursing
values.
Ochsner's Inventory
of Professional
Nursing
designed for multiple-purpose educational use.
Values
is
Proposed
uses include career counseling and guidance, nursing curriculum development, values clarification exercises, and
professional self-evaluation.
In addition, student self-
report evaluations could be correlated with faculty assessment of student clinical behavior.
Evaluations could also
be used to measure individual growth in and development of
values as well as effectiveness of teaching methods related
to values development.
Finally, dissemination and use of
the instrument could encourage formal inclusion of values in
nursing curricula and in National League for Nursing
criteria for accreditation of nursing programs.
Summary
Chapter I establishes the need for a method to assess
and promote development of professional values in nursing.
No instrument for the assessment of behaviors, attitudes
and personal qualities reflective of professional nursing
values has been constructed and nationally validated for
essential content.
The purpose of this study is to meet the
above need through development and validation of a selfreport inventory for professional nursing values.
30
The self-report inventory, named Ochsner's Inventory
Professional
Nursing
Values,
of
consists of nursing behaviors,
attitudes and personal qualities deemed essential for professional nursing practice.
The theoretical base for inven-
tory items comes chiefly from the Association of Colleges of
Nursing Final Report (1986) on Essentials of College and
University Education for Professional Nursing.
Ochsner's
IPNV is in keeping with tenets of the American Nurses
Association Code for Nurses (1985).
Chapter II will include an indepth literature review of
references cited in Chapter I.
There is also review of
literature on theoretical and operational definitions of
values, moral philosophy, and moral education.
CHAPTER II
REVIEW OF RELATED LITERATURE
Moral Purpose in Higher Education
Liberal Arts Education
Although
most higher education theorists stress the
inclusion of liberal arts as essential to student growth and
development, there is scarce mention of value-based moral
growth and development.
At least one influential educator
proposes the most important purpose of higher education is
moral development:
Hesburgh (1979) wrote an article for the
New York Times entitled "The Moral Purpose of Higher Education" (pp. 113-119).
Hesburgh contrasts vocational education
with liberal education--that is, learning how to do something with learning how to be somebody worthwhile.
He
believes that indeed it is important to learn how to do
something well but in the longrun "...the quality of the
person, how he or she thinks, speaks, judges, decides, and
is, will largely determine how successful one is, not to
mention how happy" (p. 113). He states that without a
liberal education, learning values is an impossible task.
A
liberal education liberates the individual from ignorance
and frees one to think clearly and logically and to skillfully communicate these thoughts.
It enables one to evalu-
ate, prefer, discriminate, and choose among better, worse.
31
32
good, and bad.
It enables one to humanize everything with
which he or she comes into contact.
Hesburgh addresses general areas in the liberal arts
and explains how each one contributes to the moral purpose
of education:
language and math stress clarity, precision,
and style; literature gives insight into good and evil;
history gives a record of mankind and depicts virtue or the
lack of it; music and art purvey a sense of beauty; physical sciences exhibit creations's orderliness; and social
sciences show man at work creating his world.
Hesburgh concludes that liberal education fails in its
function if the outcome is irrationality, valuelessness, and
anomie.
He stresses that the central factor in the success
of liberal education is the teacher-educator:
how they
teach, perceive their role, and most importantly exemplifiy
what is taught.
In any case education in values is diffi-
cult and "...practically impossible unless the work is
buttressed by the deed" (p. 119).
Administrators To Encourage Morality
Higher education administrators have a responsibility
to develop mission statements that encourage ethical
development and integrity (Chickering, 1991, p. 282).
Administration support will encourage what Martin Trow calls
the morality of scholarship (Morrill, p. 32). Trow proposes
that the practice and discipline of good scholarship itself
33
contributes to the moral development of students.
He thinks
that scholarly inquiry along with the moral influence of
teachers is sufficient moral education.
The Teaching Profession Incorporates
Values into Moral Development Education
Moran (1987) believes that it is possible to teach
morality.
He also believes that we can teach a system of
moral development.
He views teaching as a moral act, as a
"showing how" that involves bodily activity in a human
group.
He says that teaching is embodied in the community's
life (p. 149).
In the classroom situation, Moran exhorts
teachers to know their subject, remain open to learning, be
responsive to and respectful of students, and practice what
they preach.
Morrill (1980) insists that teaching values cannot be a
passive affair.
Students must be active in developing and
defending their own positions, justifying their choices,
confronting other points of view, role-playing a contrasting
point of view, and wrestling with difficult problems
(p. 101). One way in which students may become active in
developing and recognizing their own value system is through
personal values assessment.
Two personal value scales that
have been frequently used are the Rokeach Value Survey and
Rest's Defining Issues Test (DIT).
34
Rokeach believed that values can be both instrumental
(means) and terminal (end states).
He maintained that
terminal values can be both personal and social in focus
(1973, 1979).
The Rokeach Value Survey presents two lists
of 18 alphabetically arranged instrumental and terminal
values presented along with a brief definition in parentheses.
tance
The respondent ranks each list in order of impor(Rokeach, 1973, p. 355). Two of the 18 terminal
values are also identified by AACN (1986) as essential
values:
freedom and equality.
Nine of Rokeach's instru-
mental values are similar to AACN's list of professional
nursing value attitudes and qualities:
broadminded,
courageous, honest, imaginative, independent, intellectual,
logical, obedient and self-controlled.
An example of the use of the Rokeach Value Survey in
nursing is reported by Thurston, Flood, Shupe, and Gerald
(1989).
These researchers compared personal values of
nursing faculty with those of entering nursing students.
Personal values between the two groups were found to be more
alike than different.
Rokeach's works were also used by
Eddy (1989, 1990) as a framework for her studies on professional values and behaviors of men in nursing.
Rest's DIT is based on Kohlberg's six-stage theory of
moral judgement development from adolescence and continuing
into adulthood.
sequential.
Kohlberg's theory is both hierarchical and
His theory consists of three basic levels of
35
moral judgement (A = pre-conventional, B = conventional, and
C = post-conventional) with a fourth transitional level
between B and C.
Within each of the three basic levels,
Kohlberg proposed two stages of development based on the
individual's perception of what is the right thing to do or
the right way to be in relation to justice.
These six
stages of development move from doing the right thing for
fear of punishment (stage one) to doing the right thing
based on universal ethical principles (stage six).
Stages
five and six represent principled thinking (Frisch, 1989;
Becker, 1991; Copeland, 1994).
scores:
The DIT generates two
(1) a "P" score that reflects the degree to which
the subject responds to factors which represent principled
thinking and (2) a stage rank assigned to any subject with
consistent responses in one of the six stages of moral
development in Kohlberg's theory.
All subjects receive a
P score (Frisch, 1987).
An example of the use of Rest's DIT in nursing education is reported by Frisch (1987).
The DIT was used to
measure change in a nursing student's level of moral development.
Although instructional intervention produced
measurable change in some student's level of moral judgement, the most significant P score finding was the overall
low scores in both experimental and control groups.
The
scores were comparable to junior high school students.
36
Becker (1991) identifies a number of other research
studies in which nurses have consistently scored at a "low"
level of moral reasoning on the DIT.
Since Kohlberg's
longitudinal study consisted of all adolescent males, there
has been scepticism as to whether Kohlberg's model can be
generalized to women (Becker, p. 19).
It is important to
note that Gilligan has developed a feminist or caring perspective to moral decision making (Gilligan, Ward, Taylor &
Bardige, 1988).
In any case, nurses appear to approach
moral decision-making more from a care perspective than from
a justice perspective.
evident.
However, both perspectives are
Gadow's existential advocacy model as described by
Yeo (1991, p. 10) fits this combination of perspectives.
Teaching Strategies and Values Education
The literature addresses experiential methods of
teaching as being most likely to effect personal growth in
morality.
Reimer, Paolitto, and Hersh (1983) devote half of
their book to applying Kohlberg's theory of moral development to the classroom.
Hypothetical case studies are
presented in such a way as to challenge students to think
about moral dilemmas.
Kohlberg's stage theory can be very
useful in stimulating students to recognize "higher forms"
of morality.
However, Morrill (1980) points out that
challenging students' to think about moral reasoning without
37
a structure for making moral decisions reduces the student's
role to a passive onlooker (p. 31).
Presno and Presno (1980) present special activities
designed to help younger students become involved in applying intrinsic, practical, and technical values to persons,
groups of persons, and things (p. 15). These activities
could be adapted for use in higher education.
They could be
helpful in integrating values education into a myriad of
courses, including nursing.
Incorporating Values into Nursing
Educat ion
Nursing educators have long emphasized the art
nursing.
Although a greater emphasis in science
of
of nursing
emerged during the "scientific approach" era. Art of Nursing
is again being explored by prominent nurse theorists such as
Bevis and Watson (1989), Benner and Wrubel (1989), and
Leininger (1994).
Johnson (1994) analyzed nursing litera-
ture from 1860-1992 relevant to the art of nursing.
The
fifth of five identified conceptualizations concerned the
ability to morally conduct one's nursing practice.
Ethical decision-making based on professional norms and
personal integrity is a necessary part of nursing education.
Standards of practice are included in introductory nursing
courses and reinforced throughout the program of study.
Case studies, small group activities, and clinical conference discussions are utilized to help students practice
38
in accordance with these norms.
Instructor role-modeling is
an important part of nursing education (Frisch, 1987; Weis &
Schank, 1991; King, 1993).
Ethical issues such as abortion, euthanasia, organ
transplants, and genetic and reproductive engineering are
among the more dramatic topics being discussed (White, 1988;
Cohen & Jonsen, 1993; White, 1994).
Health care reform
along with equal access to care is a pressing issue today
(Healthy America:
1994).
Practitioners for 2005, 1991; Viens,
Confidentiality, documentation and safety are among
several essential elements that must be constantly practiced
by both professional nurses and nursing students (American
Association of Colleges of Nursing, 1986).
Religion and spirituality play a large part in how both
patients and nurses react to illness and dying.
These two
values form important influences in the nurse's response to
patient situations (Becker, 1991).
Spiritual
Distress
is a
nursing diagnosis approved by the North American Nursing
Diagnosis Association (NANDA).
This diagnosis is defined as
"the state in which an individual experiences a disturbance
in religious belief or value system."
categorized under Valuing
Spiritual Distress is
which is defined as "a human
response pattern involving the assigning of relative worth"
(Taptich, 1990, p. 103).
It would be appropriate for nursing educators to join
with other higher education colleagues by advocating
39
inclusion of religion and spirituality in the education
enterprise.
Robert Sollod (1992) has expressed his
disappointment in "...the lack of significant discussion
concerning the place of religion and spirituality in
colleges' curricula and in the lives of educated persons."
He concludes that this lack results in "...a narrow and
fragmented view of human experience" (p. A60).
In summary, the topic of values in higher education
(including nursing education) is timely.
Colleges are
looking for ways to produce a graduate who is expert in
his/her field and who clearly sees both personal and
professional actions in light of the totality of our human
environment.
Incorporating Values into Nursing
Practice
A number of nurse ethicists have proposed guidelines
for integration of nursing values into nursing practice.
Crisham (1992) developed a MORAL model for resolving ethical
dilemmas in the early 1980s.
At that time, 130 staff nurses
identified four nursing moral dilemmas issues: "(1) deciding
the right to know and determining the right to decide, (2)
defining and promoting quality of life, (3) maintaining
professional and institutional standards, and (4)distributing nursing resources" (p. 27). A mnemonic for remembering the MORAL model process was developed:
M=Massage the
40
dilemma, 0=Outline options, R=Review criteria and resolve,
A=Affirm position and act, and L=Look back.
Aroskar (1992, May) identified three common ethical
problems in health care:
(1) Access to health care and
allocation of health care resources, (2) Appropriate use of
technology, and (3) Difficult treatment choices, e.g.,
withholding/withdrawing of medical treatment.
Institu-
tional and societal challenges to resolving these problems
included pluralism, political/power issues, cost containment
goals and mechanisms, and structure of health care organizations.
Aroskar's framework for dealing with ethical
problems included identification of facts, identification of
ethical conflicts, identification of stakeholders, identification of alternative actions and their ethical implications, identification of practical constraints, make decision(s) and take action(s), and review and evaluate decision
making processes and results of decisions and actions.
Becker (1991) used a grounded theory approach to
explore how nurses respond when faced with ethical situations.
Responses varied depending on individuals' perspec-
tives.
Individuals with a reductionist perspective repre-
sented a medical focus with treatment of disease as the
underlying value.
Nurses with this perspective (often new
graduates) focused on providing safe care.
Individuals with
a humanistic perspective demonstrated a person-centered
focus.
The humanistic perspective evolved as new graduates
41
became more secure in their ability to administer safe care.
Becker pointed out that neither perspective is "wrong."
She said the important point was to be aware there are
multiple perspectives for ethical principles in practice.
Becker pointed out that although moral and theoretical
guides for ethical practice are important, "... nursing
needs to critically examine these theories in regard to
their application and to their relevance to explaining
ethical practice in nursing" (1991, p. 139). Becker identified the substantive theory derived from her study of
nurses' interactions as "...an ethic of human care which is
one of human connect ion.... the core of this ethic is an
underlying ethical value respect for human dignity"
(p. 139).
Respect for human dignity was found to be the
guide for nursing action.
Thus, Becker raised serious
questions regarding the use of theories (i.e., Kohlberg's)
which focus on the core value of justice as a guide for
action in
nursing practice.
As has been noted, Becker found Gilligan's care perspective more compatible with nurse decision-making than
that of Kohlberg.
Lyons (1988) contrasts a care versus
justice perspective of moralty:
(1) A justice perspective
defines individuals as "...separate/objective in relation to
others..."; a care perspective defines individuals as
"...connected in relation to others...."
(2) A justice
perspective views "...relationships as reciprocity
42
...grounded in duty and obligation..."; a care perspective
views "...relationships as response to another in their own
terms."
(3) A justice perspective generally construes moral
problems as "...issues, especially decisions, of conflicting
claims between self and others..." resolved by considering
obligations and/or principles of fairness; a care perspective generally construes moral problems as "...issues of
relationships or of response..." resolved by considering
these two issues and/or promoting the welfare of others.
(4) A justice perspective generally evaluates moral resolutions by considering how decisions are justified and/or
whether values (especially fairness) are maintained.
A care
perspective generally evaluates moral resolutions by considering how things worked out and/or whether relationships are
maintained/restored (Lyons, 1988, p. 35).
Mohr (1995, March) presented recommendations for nurses
working in a medical marketplace.
She contended that the
autonomy of nurses and physicians is being supplanted by
administrators and business persons for whom everything else
is secondary to making a profit.
In order for nurses to
protect their integrity and that of their patients, they
must (1) be mindful of the kind of environment in which they
work; (2) be more aware of ethical responsibilities, standards of care, and patient rights; (3) use intuition and
common sense; and (4) confirm observations and interpretations with trusted colleagues.
Although these general
43
recommendations were the outcome of Mohr's reflections on
the for-profit psychiatric-hospital scandals of the late
1980s and early 1990s, they are applicable in many nurse
practice settings.
Hall (1995, April) presented nursing ethics from a
legal point of view.
She outlined six values in nursing
practice/ethics/law: do good, don't harm, be free, be fair,
be true, and life.
values.
Nursing law is based on the first three
For example, malpractice (i.e., duty, breach,
causation, damages) is based on "do good."
Licensure,
abuse, and reporting statues are based on "don't harm."
Consent to procedures and advance directives are based on
"be free."
The other three values relate more generally to law.
"Be fair" applies to due process and social justice.
"Be
true" applies to confidentiality, loyalty, and veracity.
"Life" applies to laws around birth and death.
Hall pointed
out that "conflict in values" is really people with different values in conflict.
Hall presented a process for making
decisions in ethical conflicts:
Stop Again.
Stop, Look, Listen, and
"Stop" entails imagining what the outcome
should be (and thus identifying one's own bias which will
affect what information is gathered and how it is interpreted).
"Look and Listen" for (1) the facts of the case,
(2) the wishes of the people, and (3) the interests they
exhibit.
"Stop again" in order to help other people go
44
through the process.
Hall's
axiom is "Good practice is
good ethics is good law" (Hall, 1994, September/October).
Nursing Ethics
Nursing ethics is viewed by most nurse theorists as
distinct from medical ethics.
Twomey (1989) builds on
nursing's historical foundations to posit ethics as a
distinct area of nursing knowledge.
Rogers (1991) gives
philosophical support for Twomey's propositions.
She says
that the "dogmatic" statement that nursing is both art and
science may help explain why humanistic components of
nursing are incompatible with traditional views of science
(i.e.. Medical Science) represented by logical positivism
(p. 179).
Yeo (1991) identifies three socio-political factors
influencing present day bioethics.
Nursing ethics has
similarly been influenced by these factors:
(1) techno-
logical development, (2) human subject research and
experimentation, and (3) authority, consumerism, and patient
rights.
Himali discusses an emerging fourth factor:
"managed health care."
Himali (1995) quotes May
"The
switch to managed care was a paradigm shift in providing
care.
It was a dramatic departure from the typical medical
model ...where fee for service ...reimburses for high-tech
medical intervention but often does not cover preventive
services" (p. 9). Himali goes on to say
45
The idea behind managed care systems
like those pioneered by Kaiser was that by
providing a full range of services, from
prevention to acute care, and by encouraging
patients to come in and come in often with
low monthly premiums and convenient,
accessible medical centers, managed care
could catch and treat the cold before it
developed into pneumonia, requiring more
costly intervention. (Himali, 1995, p. 1)
Interpretation of managed care has frequently degenerated to
cost-containment plans; however, Himali quotes May as saying
"Where managed care is operated the way it should be, the
nurse is worth her weight in gold....Managed care is going
to change the definition of what it means to be a nurse in
the years to come" (p. 14).
Yeo (191) proposes a knowledge base for nursing ethics
which includes (1) moral beliefs and values, (2) relevant
codes, policies, and laws, and (3) six fundamental ethical
concepts:
beneficence, autonomy, truthfulness, confiden-
tiality, justice, and integrity.
These fundamental ethical
concepts are proposed by nurse ethicists (especially nurse
attorneys) as guidelines for ethical/moral behavior.
These
six concepts bear a close relationship to AACN's seven
essential values:
altruism, equality, esthetics, freedom,
human dignity, justice, and truth.
Yeo (1991) says increased reflectiveness on nursing
values will help nurses develop certain skills:
(1) sensi-
tivity to the values dimension in nursing, (2) recognition
of ethical issues when they arise, (3) ability to thoroughly
46
analyze ethical issues, (4) identification of congruence or
lack thereof between personal and professional values, and
(5) greater knowledge of moral values and principles.
concludes with a word of caution:
Yeo
"Acquiring knowledge is
not the same thing as becoming virtuous, except insofar as
acquiring knowledge can itself be said to be a virtue"
(1991, p. 15).
Values: Theoretical and Operational
Definitions and Their Relationship
to Nursing
What has been said about values depends on the philosophy and world view of the writer.
Every discipline that is
concerned with human experiences addresses values in some
way.
In general, social scientists see values as inter-
nalized standards applied to personal or group choice.
Philosophers view value as a quality or an act or thing
exhibiting that quality (Morrill, 1980, p. 146). There has
also been a tendency toward a functional analysis of
as preference
value
in sociology, anthropology, political science
and economics (p. 144). This concept of value
as
preference
can be translated into one's attitude toward and amount of
time spent on a thing or event in relation to other things
or events.
Morrill suggests that value theory needs to include
more than the above subjective and objective viewpoints.
47
He presents Niebuhr's relational model of value as being
helpful.
In this model "Value becomes a matter of what is
good for real human beings living in competitive and cooperative relations" (p. 148). Morrill emphasizes a profound
link between values and human choice and action.
He also
recognizes "...that values have an objective existence in
terms of human meaning and possibility" (p. 150). Morrill
defines values as "...standards and patterns of choice that
guide persons and groups toward satisfaction, fulfillment,
and meaning" (p. 62). Morrill's discussion and definition
sheds light on the American Association of Colleges of
Nursings' definition of values "...beliefs or ideals to
which an individual is committed and which guide behavior"
(1985, p. 5).
Boundaries and characteristics surrounding values are
described by Morrill.
The meaning of terms like values,
morals, ethics, and moral development is assessed.
Moral
education and the study of ethics and values are seen to
improve quality and sensitivity of choice and conduct in
basic areas of life.
seeking truth.
Education is more than an intellect
It is learning to be a responsible person
who seeks integrity and fulfillment.
Within these
boundaries, four variations are identified:
(1) values
clarification, (2) values inquiry, (3) moral education and
development, and (4) normative and applied ethics (1980,
p. 11) .
48
Gould and Bevis (1992) give a description of an
educated person which shows a clear picture of how the
nursing profession operationalizes the definition of values:
The characteristics of an educated person are
among these and include: critical thinking;
creativity; flexibility; emancipation from
oppressive and/or conformitive thinking;
critical social consciousness; caring; ethical
and moral commitment; insights; foresight;
anticipatory inventiveness; originality;
flexible strategizing; style; personal power,
its acquisition, use, and sharing; a sense
of the significant; ability to cut cleanly
to the core of issues; vision of the assumptions underlying issues and the assumptions
underlying assumptions; ablility to engage in
dialogue rather than polemics; skilled use of
intuition; commitment to fraternal/sororal
colleagueship/friendship; a sense of
social/professional/personal responsibility; a
continuing search for meaning; and a sense of
community connectedness and commitment, (p. 127)
History of Moral Education and
the Contribution of Nurses
In the above operational description (applied to
nurses) of an educated person, Gould and Bevis (1992)
contributed significantly to the gap which Becker (1991)
found:
Ethical practice in nursing has been poorly
operationalized in the literature.
Gould and Bevis (1992)
consider their propositions a "paradigm shift" in nursing
education and state board regulations.
Becker quotes Kelly as saying that historically, the
focus of nursing education has been on "obedience.
49
submission to rules, social etiquette and loyalty to the
physician, instead of judgement, responsibility and humanitarianism" (Becker, p. 12). One example that shows remnants
of this paradigm is the questioning of some authors whether
nurses have a mind set to be moral, or whether the nurse is
even able to be moral in a bureaucratic setting (Aroskar,
1982; Yarling & McElmurry, 1986).
In light of the two paradigms above, it is well to note
that the founder of modern nursing, Florence Nightingale,
emphasized an inductive scientific methodology in nursing's
search for truth.
Macrae quotes Nightingale:
"If you
cannot get the habit of observation one way or other, you
had better give up the being a nurse, for it is not your
calling, however kind and anxious you may be" (1995, p. 9).
Moral Philosophy and Moral Education
Moran (1987) traces the history of moral education to
Aristotle who states that "Every act and every inquiry, and
similarly every action and pursuit, is thought to aim at
some good" (p. 20).
In this context, the "good" was seen as
a natural response to the reason that structures the
universe.
Teleological theories propose that "morality lies
in the consequences of one's actions.
Actions themselves
are right or wrong insofar as they produce good outcomes and
maximize the good" (Becker, 1991, p. 21).
The above inter-
pretation of teleology is in contrast to the modern
50
utilitarian form of teleology which sees the "good" as
whatever the human reason determines is contributing to the
general welfare.
Graves (1992, May, p. 11) sheds some light
on the definition of utilitarianism:
"Always act so the
balance of good over harm will be maximized for the majority
of society (cost/benefit analysis)."
Today many ethicists subscribe to the science of duty
and moral obligation with emphasis on an ethic of individual
right (deontology).
Becker (1991) points out that
Kohlberg's moral perspective is an example of a deontological approach.
Becker quotes Aron:
Kohlberg follows the Kantian tradition in
defining the morality of an action by its
intent rather than its consequences...The
deontological conception of morality is that
certain acts are intrinsically right or
wrong, irrespective of their consequences,
and that morality is defined by such acts.
(Becker, 1991, p. 21)
With the deontological approach there is frequent conflict
between the general welfare and individual liberty (Moran,
1987, p. 33).
Moran proposes that both uti1itarianizm and deontology
lack a firm basis.
addressed.
What makes good things to be good is not
He maintains that benevolence is central to the
morality of everyday life and that the responsibility of
giving and receiving good is a chief characteristic of
morality (pp. 49, 67).
In addition to responsibility, Moran
describes two other characteristics:
(1) Morality is
51
trans-natural in that it goes beyond without going contrary
to the natural (p. 85), and (2) Morality is both private and
public.
It is public in that it contributes to the welfare
of others and private in that one's personal convictions
need to be the basis for public action (p. 113). Moran's
approach is useful when describing the relationship between
personal and professional values.
Any study of professional
values must of necessity include some discussion of the
personal values which prompt professional value statements
and professional codes and standards of practice.
Standards of Nursing Practice
Professional ethics, codes, and standards of care are
inherent in the "helping" professions.
to be integrated into all studies.
These directives are
A challenge for nursing
educators is to explicate and demonstrate codes and
standards of care in a way that is meaningful to students.
Nursing's Code of Ethics (American Nurses Association, 1985)
consists of eleven items related to human dignity, right to
privacy, competence, accountability, informed judgment,
building up nursing knowledge, implementing standards, work
ambient and public image, integrity, and collaboration to
meet community needs.
State Boards of Nursing elaborate
on standards of care, monitor adherence to professional
codes of conduct, provide state accreditation for schools
of nursing, and regulate RN licensure.
The National
52
League for Nursing (NLN) establishes criteria and provides site visits for professional accreditation of Associate Degree, Bachelor's Degree, and Master's Degree
Programs in Nursing (National League for Nursing, 1991).
In addition to the above code, the American Association
of Colleges of Nursing (1986) identifies seven values
essential for the professional nurse:
esthetics,
freedom,
human dignity,
altruism,
justice,
equality,
and truth.
Each
of these essential values is accompanied by examples of
attitudes and personal qualities as well as professional
behaviors (see Appendix A ) .
AACN Has Established the Conceptual
Framework for Study of Values
in Nursing
Member institutions of the American Association of
Colleges of Nursing (AACN) number 383 baccalaureate schools
of nursing (BSN) programs.
There are approximately 615 BSN
programs in the United States (Johnson, 1987).
The
"Essentials" outlines values, knowledge, and skills considered essential for professional nursing education.
This
researcher is focusing on the values section.
Johnson (1987) describes the two year project for
production of the "Essentials."
AACN received a Pew
Memorial Trust in the amount of $400,000.00 to conduct a
threefold purpose study:
(1) to identify essential knowl-
edge, practice, and values of college and university
53
education for professional nursing; (2) to stimulate
consensus-building about what constitutes professional
nursing education and practice; and (3) to secure commitments from nurse educators and employers to use the essentials.
The "Essentials" study was conducted by an expert
nationally representative panel and three work groups.
The
nursing community was also given opportunities to participate in the definition and verification of the essentials.
The expert panel was selected by the AACN Board of
Directors from nominations by member institutions.
Members
included six nurses and four non-nurses from either health
care or higher education communities.
dent chaired the panel.
A university presi-
The panel directed the project
which was carried out by three work groups along with project staff.
Each of the work groups consisted of six to
seven people, with all but one of each group being a nurse.
Selection of both panel and work group members took into
account geographic regions of the U.S., minority representation, type and size of institutions represented, and the
educational, experiential backgrounds of the members.
Each
of the work groups were assigned a project section:
(1) knowledge, (2) practice, or (3) values.
The process of building the "Essentials" proceeded in
stages.
A preliminary questionnaire was distributed to
faculty of AACN member schools.
Each work group met twice
and submitted a working draft to the panel.
A second
54
questionnaire was developed and sent to AACN institutional
members.
Two-hundred eight individual members representing
120 of the 383 member institutions responded to the second
questionnaire.
printed.
Using the above data, a working document was
Over 26,000 copies were distributed to members of
the nursing, higher education, and health care communities
inviting them to attend a regional hearing and submit a
complete evaluation at the hearing.
Twenty-three regional
hearing sessions provided 75 hours of testimony and
discussion--al1 of which was recorded and transcribed to
identify themes.
hearings.
Five-hundred individuals attended the
Following the hearings, a 180-item questionnaire
was completed by over 1500 individuals with 98% agreement on
90 of the 180 items and 90% agreement on 178 of the 180
items.
Data analysis from the hearings and questionnaire
results were presented to the panel and three work groups.
The data analysis working document formed the basis for
the final report accepted by AACN representatives at the
October, 1986 national meeting.
The process and stages used by AACN to validate the
"Essentials" model are similar to Hensley and Tunstall's
Process
for
Validating
System
Models
(see Appendix C).
However, qualitative, rather than quantitative measures were
used to analyze the data.
The current Task Force for up-
dating the "Essentials" is using a process similar to the
process leading up to the 1986 Final Report.
However, the
55
values section of the 1986 Final Report has not been
considered for revision.
Revision focus is on the knowledge
and skills sections (Acord, June, 1995).
Seminal Research on AACN's Values Model
National studies.
Eddy, Elfrink, Weis, and Schank
(1994) report one of two national "Essentials" studies since
the 1986 study discussed above.
This study provides
nationwide information related to professional values in
nursing education.
It is the most recent study of its kind.
The purpose of their study was to determine if there were
different perceptions about professional nursing values
between senior baccalaureate nursing students and their
faculty.
It was found that faculty had significantly higher
scores than students in the areas of equality, human dignity
and freedom.
This group of researchers also found that
faculty employees in public or private institutions did not
differ significantly in values.
Of special interest in Eddy, Elfrink, Weis, and Schank
(1994) is the use of a Professional Nursing Behavior (PNB)
instrument.
The PNB consists of 22 behaviors identified in
the "Essentials" values section.
The instrument was tested
for internal consistency using Cronbach's coefficient alpha.
Results for the total instrument (.89) indicate strong
reliability.
Subscale reports for each of the seven
56
"essential" values are not as good (.45 to .72). The
authors claim these scores are acceptable given the limited
number of behaviors in each subscale.
Further research on
evaluation methods as a means to enhance the values component of nursing education is recommended.
A second national study was conducted by Elfrink and
Lutz (1991).
These authors report an exploratory descrip-
tive study of faculty perceptions, practices, and plans as
related to AACN essential professional values.
Their
investigator-designed instrument contained both open-ended
questions and fixed-alternative options.
Open-ended
question responses were analyzed in a qualitative fashion.
All 697 participants agreed that the "essentials" seven
values were representative of values nurses need to use in
practice, and that educational opportunities related to
these values should be included in the curriculum.
One
finding of this study was that values are treated through
the informal lesson plan more often than through a formal
plan.
The authors recommend more study on current and
projected values for education practices.
Non-national studies.
Thurston, Flood, Shupe, and
Gerald (1989) developed an instrument to measure beliefs
about the importance of professional values using the
attitudes and personal qualities related to each of the
seven essential professional values.
Their professional
values instrument consisted of ranking the AACN examples of
57
attitudes and personal qualities or characteristics designated for each of the seven essential values to determine
the extent to which these values were important to the
respondent.
An analysis of internal consistency of the new
instrument showed a coefficient alpha of 0.94.
studies were reported.
No validity
The investigators also used a
personal values measurement instrument, the Rokeach Values
Survey (1973), to gather data for their 1988 descriptive
study of professional students in nursing (Shupe, Flood,
Thurston, & Gerald,1988).
The investigators point out that
Rokeach (1979) reported research data to support his
conclusion that values influence behavior.
Thurston et al. (1989) reported findings of their
descriptive study using the above instruments.
They
examined the professional and personal values of nursing
faculty in a large midwestern school of nursing and compared
them with those of generic students entering the program.
Faculty demonstrated a significantly higher commitment to
the AACN's value, human dignity, than to the values of
equality and esthetics.
There was also a higher commitment
to altruism than esthetics.
Results showed that entering
students were more alike on personal values (as measured by
the Rokeach Values Survey) than different from the faculty
who teach them.
The authors recommend longitudinal studies
to determine the impact, if any, of nursing curriculum on
58
values and ethical dilemmas.
Ochsner's Inventory
This researcher's proposed
of Professional
Nursing
Values
could be
used in longitudinal studies.
Schank and Weis (1989) examined how the relationship
between professional values of senior baccalaureate nursing
students and graduate nurses compared to the values
reflected in the 1985 Code for Nurses.
Findings indicated
that values identified most frequently by all respondents
related to patient care issues rather than social issues of
nursing.
Weis and Schank (1991) found that among practi-
tioners of nursing, values identified most frequently were
reflected in the first six statements of the Code for Nurses
document (1978).
These statements deal with patient care
issues while the last five statements deal with social
issues of the profession.
The authors suggest that inter-
nalization of the social issue values are critical in the
interest of nurse empowerment; furthermore, nurse empowerment should play a key in continuing education for nurses.
The Ochsner Inventory
of Professional
Values
could be useful
in continuing nursing education as well as generic nursing
education.
Weis, Schank, Eddy and Elfrink (1993) compared program
objectives of National League for Nursing-accredited
baccalaureate programs with the professional nursing
behaviors that reflect the seven values identified by the
AACN.
Most of these values were represented in program
59
objectives; however, two essential values, truth and
esthetics were rarely found while two values not identified
by the AACN, research and life-long learning, were overwhelmingly identified in nursing program objectives.
Two of the behavior items added to Ochsner's Inventory
Professional
Values
of
address areas of research and life-long
learning (behavior items 10 and 34).
In the above study (Weis, Schank, Eddy & Elfrink,
1993), professional nursing behaviors were also classified
according to the three AACN roles of baccalaureate
graduates:
(1) provider-of-care, (2) member-of-profession
and (3) coordinator-of-care.
As a provider of care (P), the
nurse is expected to utilize critical thinking and clinical
judgement in nursing process activities (assess, plan,
implement, and evaluate/research).
As coordinator of nurs-
ing care (S=System), the nurse is expected to be an effective, efficient case manager.
As member of a profession
(PR), the nurse is expected to exercise ethical/legal judgments related to nursing care.
A panel of five, nurse educator experts determined the
above behavior-role relationships to exist.
Cronbach's
coefficient alpha was calculated on these categories:
(1)
provider-of-care (P) 0.66; (2) coordinator-of-care (S) 0.72;
and (3) member-of-profession
(PR) 0.83.
No other
reliability or validity studies on nurse behavior-nurse role
60
correlations are reported.
Weis, Schank, Eddy, and Elfrink
(1993) suggest that future research needs to examine professional socialization to the AACN values by baccalaureateprepared nurses.
Saarmann, Freitas, Rapps, and Riegel (1992) investigated the relationship of education to critical thinking
ability and values among nurses.
They concluded that the
proposition of professional socialization (as contributing
to moral development) put forth by AACN should be examined
to determine if in fact these are changes to be expected in
professional socialization.
The authors suggest that future
research is needed to determine whether nursing educational
programs have a significant influence on professional
socialization when compared with the work place and preexisting personal characteristics.
Knowledge Base for Construction and
Validation of Ochsner's Inventory
of Professional Nursing Values
The principal knowledge base for construction of the
Inventory of Professional Nursing Values (IPNV) is the
values and professional behaviors statements in the American
Association of Colleges of Nursing's 1986 final report on
Essentials
Professional
of College and University
Nursing
Education
(the "Essentials").
for
Nineteen of the 50
behavior items and 36 of the 50 attitudes and personal
qualities are adapted from the "Essentials."
Five behavior
61
items are direct quotes from the American Nurses Association's Code for
Nursing.
Seven of the activity statements
are adapted from the Pew Health Commission Competencies
(Healthy America:
Practitioners for 2005, 1991).
The
balance of items are new and result from an extensive
literature search, pilot study responses from 90 nurses,
interviews with nurse educators, and personal experience.
These new items were incorporated into the IPNV while
retaining the 1986 "Essentials" value statements as a
philosophical base.
Summary
Chapter II includes a comprehensive literature review
of nursing values, ethics, moral behavior and beliefs.
The
focus is on the inclusion of professional values in nursing
education and nursing practice.
There is also an article on
the teaching of values in higher education and an article on
the philosophical underpinnings of values, ethics, moral
behavior and beliefs.
The literature review spans four
years of research based on extensive computer searches,
review of current journals, and follow-up on citations from
literature articles.
CHAPTER III
RESEARCH METHOD AND PROCEDURES
The Setting
To date, no valid, comprehensive, and useful instrument
for assessing professional values in nursing has been
nationally studied.
Seminal research by the American
Association of Colleges of Nursing (AACN) provides an
initial identification of essential nursing values along
with associated professional behaviors, attitudes, and
personal qualities.
AACN's seminal work served as an
impetus to build nursing value knowledge and to utilize this
knowledge in construction of an Inventory of Professional
Nursing Values (IPNV).
Ochsner's IPNV is designed as a
self-report inventory which addresses professional
behaviors, attitudes and personal qualities identified by
AACN (1986), selected behaviors from the American Nurses
Association's 1985 Code for Nurses, and behavior statements
adapted from the Pew Health Professions Commission Report
(De Tornyay, 1992).
Additional professional behaviors,
attitudes and personal qualities in Ochsner's Inventory
Professional
Nursing
Values
emanate from literature
searches, interviews, and personal experience.
62
of
63
Modes of Inquiry
Two modes of inquiry are chosen for this research:
(1) an expert systems design is used to build up professional nursing values knowledge; and (2) a psychometric
analysis design is used to identify items that best describe
behaviors, attitudes and personal qualities that characterize professional nursing practice.
Expert systems design.
A model validation process for
building essential nursing values knowledge is adapted from
expert systems decision-making theory (Harmon, Maus, &
Morrissey, 1988).
The adaptation used in this study is
taken from a model drawn by Hensley and Tunstall (in press) entitled "A Schematic of the Process for Validating System
Models."
It is noted that AACN's research methods for the
Essentials Report follows a process similar to the HensleyTunstal 1 Model.
This researcher uses the Hensley-Tunstal1
Model to establish how nursing experts rate importance,
usefulness, and comprehensiveness of selected professional
behaviors, attitudes and personal qualities reflective of
nursing values.
Application of this model is explicated in
the following nine stages.
Stage
one asks the question, "Can a structure of knowl-
edge model be created?"
This investigation builds upon
AACN's existing knowledge model of professional nursing
values.
Stage
two involves a shell creation of the model.
In 1994, this writer converted AACN's essential values into
64
an instrument designed to help nursing students identify
ethical problems in community health settings.
Use of this
initial inventory prompted interest in development of an
inventory to be validated by nursing experts.
three,
stage
During
the nursing discipline has been scanned for the pur-
pose of building on T^CN's model of nursing value knowledge.
Methods included both formal and informal interviews, professional journal reviews, and literature searches.
Two
nursing ethics workshops stimulated further investigation
into nursing values.
Participation in the International
Society for Epistecybernetics (ISEE) 1993 annual meeting
provided additional information on an expert systems mode of
inquiry.
An infrastructure for the first draft of a professional
values inventory was formulated using the American Association of Colleges' suggested examples of professional
behaviors, attitudes and personal qualities.
Additional
value-based behaviors identified through scanning the literature and through personal experience were included in this
first draft.
sents stage
The development of the infrastructure reprefour
of the model validation process.
The
refining of this first draft in Fall, 1994, represents
five
stage
(constructs the prototype).
The professional values inventory prototype was ap-
proved by the Texas Tech University Committee for Protection
of Human Subjects (Appendix D) and pilot tested {stage
six)
65
in a 1994 survey of nurse educators and graduate nursing
students from two universities in West Texas.
The survey
was also sent to selected nurse educators at Cuesta Community College, San Luis Obispo, CA and the California State
University nursing program.
Analysis of Pilot Test returns
(90 responses from 135 requests) was used to develop
Ochsner's Inventory
of Professional
Nursing
for field testing and modification {stage
Values
seven).
(IPNV)
In fall,
1995, the IPNV was reviewed by four nurse educator colleagues at the University of Texas El Paso.
Following minor
changes, this modified IPNV was accepted by the Texas Tech
University Committee for the Protection of Human Subjects.
During fall, 1995, the final version of Ochsner's IPNV
was prepared for validation testing {stage
eight).
Using a
published list of 507 National League for Nursing (NLN)
accredited baccalaureate nursing programs (1994), two
schools from each of 45 states and Washington D.C. were
randomly selected to receive ten IPNV inventories for distribution among full-time baccalaureate nursing faculty.
In
addition, ten IPNV inventories were sent to the sole NLN
accredited baccalaureate programs in the states of Alaska,
New Mexico, Vermont, and Wyoming.
From the above selection,
nine schools were randomly picked to receive an initial
mailing in order to avert unforeseen problems (Appendix E
lists all schools--public and private--with one or more
responders).
66
Stage
nine
will consist of adoption, maintenance, and
enhancement of the Professional Nursing Values Model for use
in baccalaureate programs of nursing.
In the future, post-
baccalaureate and continuing education programs in nursing
may find IPNV items to be useful for curriculum building,
clinical evaluation of students, professional self evaluation, and career counseling.
Results of this study were
requested by and will be distributed to 286 of the 413
respondents.
Psychometric analysis design.
A second mode of inquiry
chosen for use in validating Ochsner's IPNV is a psychometric analysis design.
This analysis is appropriate for
development of measurement instruments such as an inventory
scale (Borg & Gall, 1989).
Steps in the process for instru-
ment development as presented by Borg and Gall (1989), Dawis
(1987), and Cohen, Swerdlik, and Smith (1992) are followed
in order to determine which items best describe underlying
dimensions of professional nursing behaviors, attitudes and
personal qualities.
Borg and Gall (1989) discuss eight steps in the
measurement development process (pp. 273-276).
objectives are defined.
In step
one,
An important question to ask is
"What knowledge or skills is the inventory designed to
measure?"
The expert systems model validation process was
used to address this question.
population is defined.
In step
two,
the target
Based on the expert systems design.
67
nurse educator experts compose the defined population.
In step
three,
related measurement instruments are reviewed.
Several well-known instruments which measure personal values
and two newly developed instruments using AACN's model were
reviewed in Chapter II of this research.
six,
and seven
Steps
four,
five,
consist of developing an item pool, preparing
a prototype, evaluating the prototype, and revising the
measurement instrument.
Activities related to these four
steps are addressed in development of the inventory section.
In step
eight,
ability.
data is collected on test validity and reli-
Descriptive and correlational statistics (nurse
educator expert comments, means, confidence limits, itemtotal-score correlations, Cronbach's coefficient alpha, and
factor analysis) were used for reliability, validity, and
revision purposes.
Development of a final form for an instrument such as
the IPNV is a time-consuming process in which a single
research project is rarely sufficient (Borg & Gall, 1989, p.
276).
None the less, initial development and rigorous
validation of a new nursing value instrument promises a
significant contribution to nursing knowledge and practice.
The IPNV has potential for repeated revisions and collection
of data for validity and reliability studies.
68
Sample Characteristics
Participants in the validation of Ochsner's inventory
are drawn from a random cluster sampling of 89 NLN accredited baccalaureate nursing programs representing 47 states
and Washington D.C.
Ten inventories were sent to each
nursing program dean for distribution.
approximately five respondents.
Programs averaged
Of the 89 programs, 35 are
private and 54 are public institutions (Appendix E ) . Eight
hundred and seventy-five inventories with attached cover
letter were distributed to full-time nursing educators.
Four-hundred and thirteen usable responses were returned
(47.2%).
Based on number of students (National League for
Nursing, 1994), the population of NLN baccalaureate program
educators calculated at one per ten students, is 10,079.
This approximation, based on one instructor per 10 students,
is generally required for accreditation purposes.
According
to Krejcie and Morgan (1970), a representative sample size
for a given population of 10,000 should be at least 370.
The SAS Institute (1990, p. 140) recommends five respondents
per item for factor analysis.
Separate factor analysis was
used for 50 behavior items and for 50 attitude and personal
quality items.
A research sample of 413 experts more than
meets (1) sample size recommendations of 370 respondents and
(2) SAS recomendations of 250 respondents.
Eddy, Elfrink, Weis, and Shank (1994) found no significant difference in professional value scores for either
69
student or faculty members of public or private institutions.
For descriptive purposes, analysis of variance
(ANOVA) using the GLM procedure for unbalanced ANOVA (SAS
Institute Inc., 1990, p. 898) was used to determine if
employment in a public or private university affected nurse
educator expert's IPNV item ratings.
F values revealed no
significant difference in ratings.
Subject characteristics summarized in Table 1 on the
following page were used to establish respondent expertise.
This summary reflects a population that is considered expert
in nursing education:
(1) the years of experience in
nursing average 23.5 years with a range of 1-45 years;
(2) the highest degree attained category shows all subjects
at the master's level or above; (3) institutional rank
indicates a majority either hold tenure or are in a tenure
track position; and (4) professional specialty categories
indicate expertise in nursing practice and some investment
in post-graduate studies.
Original type of nursing degree
reflects initial orientation to nursing as a profession.
The bachelor's degree in nursing is most oriented to nursing
as a profession.
Almost 58% of respondents have an initial
bachelor's degree in nursing (BSN).
subject
In addition to these
characteristics described in Table 1, it is of
interest to note that 164 respondents (39.7%) teach in
private colleges or universities while 249 respondents
(60.3%) teach in public institutions.
70
Table 1
Subject characteristics
Frequency
Characterist ic
Gender (N=413)
Female
Male
Age in Years (N=401)
Percent
397
16
96.0
04.0
04
54
195
116
32
01 .0
13.5
48.6
28.9
08.0
26
144
151
63
10
06.7
36.5
38.3
16.0
2.5
Original Type of Nursing Degree (N=399)
Licensed Vocational Nurse
Diploma in Nursing
Associate Degree in Nursing
Bachelor's Degree in Nursing
07
117
44
231
1.8
29.3
11 .0
57.9
Highest Degree
Master of
Doctorate
Doctor of
207
52
149
50.7
12.7
36.5
42
146
87
37
13.5
46.8
27.8
11.9
20-29
30-39
40-49
50-59
60 and Older
Years of Nursing Experience (N=394)
1-10
11-20
21-30
31-40
41-45
Attained (N=408)
Science in Nursing
in Education (EdD)
Philosophy (PhD)
Institutional Rank (N=312)
Lecturer
Assistant Professor
Associate Professor
Professor and/or Dean
Professional Specialty (N=397)
Adult Health
Critical Care
Public Health
Mental Health
Women's Health
Nurse Practitioner
Child Health
Gerontology
Administration
93
56
55
48
40
40
26
26
13
23.4
14.1
13.9
12.1
10. 1
10.1
06.5
06.5
03.3
71
Development of the Inventory
The theoretical basis for construction of the Inventory
of Professional Nursing Values is the values and professional behaviors statement in the American Association of
Colleges of Nursing 1986 final report.
The AACN statement
defines values, attitudes, personal qualities, and professional behaviors.
These definitions (see definition section
in Chapter I) are accepted by this writer.
Description of Pilot Study Inventory
For the stage six 1994 pilot study, a Professional
Nursing Behavior (PNB) instrument developed by Eddy (Eddy,
Elfrink, Weis, & Schank, 1994) was obtained from Eddy with
permission to use her instrument.
This researcher inter-
viewed two expert nurse educators from Texas Tech University
Health Science Center, Lubbock, for feedback on Eddy's
instrument (items came directly from AACN's behavior statements).
As a result of these interviews, literature
searches, and personal experience, six items were added to
the AACN behaviors.
The pilot study items included
(1) Practices and encourages patient/client to practice
positive assertive techniques; (2) Seeks and creates learning experiences for self and others; (3) Seeks opportunities
to offer help, support, and/or positive feedback to colleagues; (4) Maintains and promotes physical and psychological safety for patient/client, self, and staff;
72
(5) Inspires confidence and trust in patients/clients and
staff; and (6) Identifies own strengths and weaknesses and
asks for help in doubtful situations.
Two other additions to Eddy's PNB instrument were
(1) ratings of AACN's word list representing examples of
attitudes and personal qualities pertaining to professional
nursing values and (2) usefulness ratings for clinical evaluation, career advisement, and self assessment.
The pilot
study inventory included space for respondent comments.
This pilot inventory was sent to 135 nurse educators
and graduate nursing students with 94 responses.
For the
pilot study, the overall Cronbach's coefficient alpha
estimate for internal consistency was 0.92.
On a 1 to 4
scale, usefulness mean ratings ranged from 2.93 for clinical
evaluation to 3.37 for self-assessment.
Analysis of pilot
study data (including many written suggestions and comments)
along with continual scanning of the literature contributed
to a revised version of Ochsner's Inventory
Nursing
Values
(IPNV).
of
Professional
This revised version as described in
the following pages was used for IPNV validation studies.
Description of Ochsner's IPNV
Ochsner's IPNV used for validation studies was built on
key research reported in the essential values section of the
American Association of Colleges of Nursing's 1986 Final
73
Report on Essentials
of College
Professional
(the "Essentials").
Nursing
and University
Education
for
Section I of the
IPNV contains 50 nursing behavior statements and Section II
contains 50 attitude and personal quality terms accompanied
by word/phrase definitions.
Both Sections I and II are to
be rated on a 5-point Likert scale ranging from l=not
important to 5=essential.
The one to five-point scale was
chosen so as to be in keeping with the original Likert scale
even though there is disagreement on use of a middle number
such as three
on the Likert scale (Cohen, Swerdlik, & Smith,
1992, pp. 201, 689).
Section III contains four potential use subcategories
for Sections I and II:
(a) nursing curriculum development,
(b) nursing practice/clinical component, (c) professional
self-evaluation, and (d) career counseling.
Section III is
to be rated on a 5-point Likert scale ranging from l=not
useful to 5=100% useful.
Section IV asks for comprehen-
siveness ratings (overall) for Section I and for Section II.
Section IV is to be rated on a 5-point Likert scale ranging
from l=not comprehensive to 5=100% comprehensive.
Section
IV also invites suggestions for addition and/or deletion of
items.
Section V contains identifying data used to estab-
lish expertise of the respondent as well as an area to
request results of the study.
74
Section I of the IPNV.
In Section I of the IPNV, 18 of
the 50 behavior items come from the "Essentials" (1986):
Items
1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 14, 18, 19, 20, 23,
25, 26, and 28.
The remaining items were selected for
Ochsner's IPNV in the following manner:
Five items are
direct quotes from the American Nurses Association (1985)
Code for
Nurses.
39, and 41.
These five items are numbered 15, 24, 37,
Seven items are adapted from De Tornyay's
(1992) analysis of recommendations from Healthy America:
Practitioners for 2005 (1991).
These eight items are
numbered 16, 27, 29, 31, 32, 33, and 36.
Nursing behaviors
number 38 and 40 summarize several statements listed in the
Patient's Bill of Rights (American Hospital Association,
1972).
Nursing behavior items 43, 44, 45, 47, 48, 49, and
50 were adapted from Becker (1991).
Nursing behavior items
10, 13, 17, 21, 22, 30, 42, and 46 were adapted from two
studies in which this writer participated:
1982/83; and Parker, 1981/1982.
Ehrenberg,
Nursing behavior items 6,
34, and 35 are a compilation of readings, interviews, and
personal experience.
Table 2 on the next page summarizes
IPNV Section I items by origin.
Section II of the IPNV.
In Section II of the IPNV, 36
of the 50 nursing attitudes and personal qualities are taken
from the American Association of Colleges of Nursing's 1986
final report.
The remaining 14 items for Section II were
75
Table 2
IPNV Section I items:
IPNV Item Origin
Summary by origin.
Item Number
Behavior
I. Items' origin: AACN (1986) professional nursing behaviors.
1.
2.
3.
4.
5.
7.
8.
9.
11.
12.
14.
18.
19.
20.
23.
25.
26.
28.
II.
Supports the right of other caregivers to suggest
alternatives to the plan of care.
Presents self in a manner that prcmotes a positive image of
nursing.
Alters the environment so it is pleasing to the client
(modified).
Assists other personnel in providing care when they are
unable to do so.
Expresses to key persons/groups ideais about the improvement
of access to nursing and health care (modified).
Provides nursing care based on the individual's needs
irrespective of client's personal characteristics.
Participates in discussions of controversial ethical issues
in nursing (modified).
Honors individual's right to refxise treatment.
Creates an emotionally pleasant workplace environment for
self and others (modified).
Expresses to key persons/groups concern about social trends
and issues that have inplications for health care (modified)
Interacts with other providers in a non-discriminatory
manner.
Maintains confidentiality of clients and staff (modified).
Safeguards the individual's right to privacy.
Addresses stciff/clients as they prefer to be addressed
(modified).
Documents nursing care accurately and honestly.
Gives full attention to the client when giving care.
Treats colleagues and clients with respect regardless of
sociocultural background (modified).
Cfctains sufficient data to make sound judgments before
reporting infractions of organizational policy.
Items' origin—direct quotes:
(ANA, 1995, Code for Nurses).
15. Acts to safeguard the client and the public when health care
and safety are affected by the inccrpetent, unethical or
illegal practice of any person.
24. Participates in the profession's effort to protect the public
from misinformation and misrepresentation and to maintain the
integrity of nursing.
37. Participates in the profession's efforts to inplement and
improve standards of nursing.
76
Table 2.
Continued
IPNV Item (Drigin
39.
41.
III.
Behavior
Participates in the profession's efforts to establish and
maintain conditions of orployment conducive to high quality
nursing care.
Collaborates with the members of the health professions and
other citizens in promoting cormunity and national efforts to
meet health needs of the public.
Items' origin: Healthy America: Practitioners for 2005 (1991).
(Note: These items are adapted from the Pew Corrmission list of
conpetencies for future practitioners.)
16.
27.
29.
31.
32.
33.
36.
IV.
Item Number
Participates in activities to prevent or reduce the inpact of
environmental hazards on the public's health.
Considers cost along with quality care to clients.
Utilizes technological approaches to manage client care
information.
Updates clinical skills to meet client's health care needs.
Promotes health care changes that increase access, quality,
or service for clients.
Works with an interdisciplinary team designed to meet the
public's health care needs.
Coordinates nursing care plans and activities.
Items' origin: Construction based on literature review, exp)ert
interviews and personal experience.
6.
10.
13.
17.
21.
22.
30.
34.
35.
38.
Exerts cultural sensitivity in practice of assertive
techniques.
Creates learning experiences for self and/or others.
Seeks opportunity to offer help, support, and/or positive
feedback to colleagues.
Prcmotes safety for self and others in the work place
environment.
Inspires confidence and trust in clients, colleagues, and
supervisors.
Asks for help in unfamiliar clinical situations.
Identifies own strengths and weaknesses.
Participates in nursing research activities.
Takes an active role when attending professional nursing
organization meetings.
Supports the right of clients to take part in the developinent
of their own care plan.
77
Table 2 .
Continued.
IPNV Item Origin
40.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Item Number
Supports the right of c l i e n t s to be told about care,
procedures, treatments they are to receive, including risks
and benefits.
Introduces self to c l i e n t .
Balances care for others with care for self.
Maintains a sense of control in professional practice.
Maintains a kindly sense of humor in stressful situations.
Acts to relieve pain and suffering.
Makes a moral decision based on loyalty to a c l i e n t .
Makes a moral decision based on loyalty to a health care
organization/institut ion.
Makes a moral decision based on loyalty to a medical doctor.
Makes a moral decision based on loyalty to nursing profession
obiigat ions/dut i e s .
added as f o l l o w s :
(1) Supportiveness
Parker,
1981/1982);
Becker,
1991);
(4) Flexibility
Viens,
1994);
(8) Sanctity
(2) Connectedness
(3) Sense
(6) Common Sense
(Parker,
of Life
(10) Wisdom-,
(13) Discernment;
(Gould & B e v i s ,
1992;
(Gould & B e v i s ,
1992;
of Humor ( P a r i s h ,
and (5) Intuition
(7) Collegiality
1991);
Behavior
1994);
(Gould & B e v i s ,
1992;
(Mohr, 1995, March);
1 9 8 1 / 1 9 8 2 ; Gould & B e v i s ,
(Viens,
1994);
(11) Initiative;
and (14) Spirituality.
(9) Loyalty
(12)
1992);
(Becker,
Attentivenessj
Table 3 on t h e
f o l l o w i n g page summarizes IPNV S e c t i o n I I items by o r i g i n .
78
Table 3
IPNV Section II items:
IPNV Item Origin
I.
Summary by origin.
Item Number
Attitude and Personal Quality
Items' Origin: AACN (1986) professional nursing attitudes and
personal qualities. (Note: All definition phrases were carpi led by
this researcher—AACN does not define these tenns)
1.
Acceptance (favorable regard, approval).
2.
Accountability (legally obligated).
3.
Appreciation (recognition of worth, inportance, or quality).
4.
Assertiveness (courage and self-confidence in expression of
opinion).
6.
Authenticity (genuineness, legitimacy, realness,
truthfulness, validity).
7.
Caring (feeling of conmitment to self and others that
energizes constructive interaction).
9.
Conmitment (duty, course of action demanded by the
profession).
11. Compassion (concerned alleviation of suffering).
12. Confidence (self-assurance).
14. Consideration (concern, regard, solicitude, thoughtfulness).
15. Courage (barvery, fortitude, fearlessness, resolution).
16. Creativity (inventiveness).
18. Eirpathy (a relationship with mutual understanding).
19. Fairness (impartiality, just, and unbiased).
21. Generosity (big-heartedness, magnanimity).
22. Honesty (truth, uprightness).
23. Hope (expectation of success).
24. Humaneness (concern for human welfare).
25. Imagination (creative resourcefulness).
26. Independence (self-reliance, self-determination).
28. Integrity (trustworthiness, moral or ethical strength,
soundness, ccxrpleteness).
29. Inquisitiveness (eagerness to acquire knowledge).
31. Kindness (favor, benevolence).
33. Morality (principle(s) of right or good conduct).
34. Objectivity (free from bias in judgment).
35. Openness (willingness to take a chance with or listen to the
other side).
36. Perseverance (steadfastness).
37. Rationality (logic, valid reasoning).
38. Reflectiveness (thoughtfulness).
39. Respectfulness (regard, attention, consideration).
41. Self-direct ion (self-guidance).
42. Self-discipline (ccnposed, freedom from agitation).
43. Self-esteem (sense of one's own dignity and worth).
45. Sensitivity (awareness of attitudes and feelings).
48. Tolerance (charitableness).
49. Trust (assured reliance on character, ability, strength or
truth of someone or something).
79
Table 3.
Continued.
IPNV Item Origin
II.
Item Number
Attitude and Personal Quality
Items' origin: Identification and definitions based on literature
review, expert interviews, and personal experience.
5.
8.
10.
13.
17.
20.
27.
30.
32.
40.
44.
46.
47.
50.
Attentiveness (being observant, alertness, mindfulness).
Collegiality (caring relationship with peers).
Corrmon Sense (ability to make sensible decisions, gunption).
Connectedness (nurse-client interaction based on an
understanding of the human condition).
Discernment (skill in perceiving, discriminating, or
judging).
Flexibility (adaptiveness, resilience in the face of change).
Initiative (ability to establish a plan or task).
Intuition (ready insight without evident rational thought or
inference).
Loyalty (fidelity to a person, cause, obligation, or duty).
Sanctity of Life (holiness and sacredness of life).
Sense of Humor (ability to kindly laugh at self and/or
situations).
Spirituality (attachment to a belief or value system which
provides meaning to life and death).
Supportiveness (helpfulness).
Wisdom (deep, thorough or mature understanding).
A professional nursing values model.
following page summarizes professional
Figure 1 on the
behavior,
attitude
and personal quality items as envisioned
in a professional
nursing values model.
nursing values
This professional
model serves as a structure of knowledge base for the
development
Values
of Ochsner's Inventory of Professional
(IPNV).
Nursing
80
[CODES, POLICIES, lAWS
CONCEPTS: MORAL PHILOSOPHY
VALUES and MORAL BELIEFS
PROFESSIONAL
BEHAVICES
OCHSNER'S IPNV
(Section I items 1-50)
1-AC
2-PI
3-CE
4-HW
5-AHC
6-AT
7-PC
8-EI
9-RR
10-LE
11-WE
12-SCN
13-CS
14-NDC
15-SP
16-EH
17-WS
18-CCS
19-RP
20-PG
21-IC
22-AH
23-HD
24-PNI
25-FC
Figure 1.
26-RC
27-CQC
28-DD
29-TA
30-ISW
31-US
32-QCA
33-IT
34-NRP
35-AP
36-CNC
37-IINS
38-CP
39-WPC
40-RK
41-CPC
42-IS
43-SOC
44-SC
45-HS
46-RS
47-LC
48-LI
49-LD
50-LN
AITITUDES and
PERSC»iAL QUALITIES
OCHSNER'S IPNV
i(Section II items 1-50)
1-ACCE
2-ACOO
3-APPR
4-ASSE
5-AnE
6-AUTH
7-CARE
8-OOLL
9-COMM
10-COSE
11-OOMP
12-CCM^
13-OONN
14-CONS
15-OOUR
16-CREA
17-DISC
18-E>1PA
19-FAIR
20-FLEX
21-GENE
22-HONE
23-HOP
24-HUMA
25-IMAG
26-INDE
27-INIT
28-INTE
29-INQU
30-INTU
31-KIND
32-LOYA
33-MC3^
34-CBJE
35-OPEN
36-PERS
37-RATI
38-REFL
39-RESP
40-SOL
41-SDI
42-SDS
43-SES
44-SOH
45-SENS
46-SPIR
47-SUPP
48-TOLE
49-TRU
50-WISD
Ochsner's Professional Nursing Values Model, (a) Nursing
ethic's three subcategory labels, (b) Profess ional behavior
and attitudes and personal qualities labels.
Sources: (a) Michael Yeo, Concepts and cases in nursing ethics, 1991
(b) American Association of Colleges of Nursing, The
"Essentials," 1986.
81
Procedures for Analyzing Data
Sections I, II, III, and IV of the IPNV all contain
items that result in interval data (a 5-point Likert scale).
In addition. Section IV contains a section for narrative
comments including an invitation to suggest addition and/or
deletion of items.
Summaries of the narrative comments are
presented in this study.
The research questions posed in Chapter I are as
follows:
The first research question asks if IPNV items
contain behaviors, attitudes and personal qualities
reflective of important values characteristic of professional nursing practice.
It is postulated that nurse
educator experts will rate IPNV items equal to or greater
than 3.50 on a 5-point Likert scale of l=not important to
5=essential.
For each item in sections I and II, mean,
confidence limits, and t-test on the mean are calculated for
validity purposes.
The second research question asks if IPNV items reflect
important underlying value dimensions characteristic of
nursing practice.
It is postulated that nurse educator
expert ratings of IPNV items on a 5-point Likert scale of
l=not important to 5=essential will reflect important
underlying value dimensions characteristic of professional
nursing practice.
Item-total-score correlations, factor
analysis, and coefficient alpha are used (1) to identify
82
value dimensions underlying IPNV items and (2) to identify
IPNV items which best describe the underlying value
dimensions.
Coefficient alpha measures are used to test the
internal consistency of the IPNV.
Item-total-score
correlations, principal factor analysis, and goodness-of-fit
measures are used to test IPNV construct validity.
The SAS
system for statistical analysis, factor analysis, and latent
variable models is utilized (SAS Institute Inc., 1990).
Research question three asks if Ochsner's IPNV contains
behaviors, attitudes and personal qualities useful in the
development of values characteristic of professional
nursing.
It is postulated that nurse educator experts will
rate IPNV items equal to or greater than 3.50 on a 5-point
Likert scale of l=not useful to 5=100% useful for the
following categories:
overall rating and ratings for
curriculum development, nursing practice, professional selfevaluation, and career counseling.
For IPNV sections I and
II, means, confidence limits, and t-tests on the mean are
calculated to estimate usefulness.
Research question four asks if Ochsner's IPNV contains
comprehensive content related to professional nursing
values.
It is postulated that nurse educator experts will
rate IPNV items equal to or greater than 3.50 on a 5-point
Likert scale of l=not comprehensive to 5=100% comprehensive.
For IPNV sections I and II, means, confidence limits.
83
and t-tests on the mean are calculated to estimate
comprehens iveness.
Research question five pertains to the narrative
portion of section IV of the IPNV.
Nurse educator experts
are asked to suggest modifications, deletions, and/or
additions to Ochsner's IPNV.
Suggestions and comments are
summarized in Chapter IV.
Milestones
This project was initiated during the fall of 1993.
Activities consisted primarily of literature review,
interviews, and work projects related to nursing student
clinical evaluations and nursing school curriculum reviews.
By summer of 1994, a first draft prospectus was prepared.
In October, 1994, a prospectus summary and doctoral plan
were approved by the dissertation chair and committee.
By
December, 1994, an inventory prototype had been developed
and pilot-tested.
During fall, 1994 and spring, 1995, the dissertation
proposal was being developed.
accepted in July, 1995.
The proposal presentation was
During fall, 1995, minor revisions
of the IPNV followed a review by four nursing educators at
the University of Texas El Paso.
In October, 1995, 96
National League for Nursing accredited baccalaureate nursing
programs representing 49 states plus Washington, D.C. were
84
randomly selected to receive ten copies of Ochsner's IPNV
with attached cover letter and stconped return envelope.
Initially, ten copies were sent to the Deans of nine
programs.
mailing.
No problems were encountered with this initial
In November, 1995, ten copies were sent to the
Deans of the remaining 87 randomly selected schools.
By
spring, 1996, 413 responses from distribution of 875 IPNV's
were received and analyzed. Of the original 96 schools, 89
were represented with a 47.2% response rate.
CHAPTER IV
PRESENTATION AND ANALYSIS OF DATA
Purpose
The chief objective of this study is to develop and
validate a self-report inventory to assess behaviors,
attitudes and personal qualities reflective of professional
nursing values.
objectives:
From this objective, flow two additional
(1) build the knowledge base of nursing ethics
through expert ratings by nurse educators of the importance,
usefulness, and comprehensiveness of Ochsner's IPNV; and
(2) disseminate this knowledge within major areas of nursing
scholarship.
Chapter IV presents a series of tables that show the
results of Ochsner's Inventory
Values
of Professional
Nursing
(IPNV) ratings by 413 expert nurse educators.
These
educators represent 47 U.S. States plus Washington, D.C.
One or two schools from each state were randomly selected
from a list of National League for Nursing accredited baccalaureate nursing programs to receive ten copies of the IPNV
for rating.
Eighty-nine schools participated in the study.
Eight hundred seventy-five inventories were distributed
resulting in a 47.2% response rate.
The preceding chapter
describes subject characteristics in greater detail.
85
86
Procedures
The development of the Inventory of Professional
Nursing Values has progressed in stages identified in
Chapters I, II, and III.
Model validation research with an
expert systems design is used to build a nursing values
model.
Research with a psychometric analysis design is used
to identify IPNV items which best describe underlying
professional nursing value dimensions.
Statistical Testing
All statistical tests are conducted using the SAS/STAT
system (SAS Institute Inc., 1990).
Confidence limits and
t-tests on the means are calculated by hand.
In Chapter
III, frequency and percentages are used for descriptive
analysis of subjects.
A 5-point Likert scale is used in the
analysis of research questions one through five.
For IPNV
items in Section I and Section II, means, confidence limits,
and t-tests on the means are calculated from nurse educator
expert ratings of degree of importance.
Item-total-score
correlations, coefficient alpha and factor analysis
procedures are used for identification of the best item
combination to describe underlying dimensions of professional nursing values.
For Section III and Section IV
means, confidence limits, and t-tests on the means are
calculated from nurse educator expert ratings on degree of
87
usefulness and degree of comprehensiveness.
Section IV
includes narrative comments from respondents.
Data Analysis
Research Question One (1)
Research question number one asks "Do items in
Ochsner's IPNV contain behaviors, attitudes and personal
qualities reflective of important values characteristic of
professional nursing practice?"
hypotheses were tested:
From this question two null
(la) behavior items from IPNV
Section I and (lb) attitude and personal quality items from
IPNV Section II.
Hypothesis la.
Alternate hypothesis (Ha) la states
"Nurse educator experts will rate IPNV professional behavior
items > 3.50 on a 5-point Likert scale of l=not important to
5=essential (means, confidence limits, t-test, coefficient
alpha)."
Table 4 beginning on the next page presents data
for hypothesis la.
88
Table 4
IPNV Section I:
Item No.
01 .
02 •
03 .
04 .
05 .
06 .
07 .
08 .
09 .
10
11 .
12
13 .
14 .
15
16 .
17 .
18 .
19 .
20 .
21
22 .
23 .
24 .
25
26
27
28.
29
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
Mean ratings for 50 nursing behaviors
Behavior
alternative care
positive iitage
client environment
help workers
access health care
assert ive
personalized care
ethical issues
right to refuse
learning experiences
work environment
social concern
colleague support
nondiscriminatory
safeguard public
environmental hazards
workplace saifety
confidentiality
right to privacy
proper greeting
inspires confidence
asks for help
honest documentation
public nursing image
focus on client
respect client/coll
cost quality care
data for decisions
use technology
know strength weakness
update skills
access quality care
tearrwork
research -participates
active professional
coordinate care
nursing standards
client participation
workplace care
right to know
collaborate
introduce self
self other care
self control
Number
409
413
407
410
411
401
405
413
413
412
412
413
412
413
413
412
411
412
412
412
411
412
412
410
412
412
412
411
409
412
411
411
411
412
409
411
412
412
412
412
411
411
411
404
Mean
SD
SE
4.15
4.64
3.71
3.94
4.19
4.26
4.31
3.94
4.73
4.28
3.91
3.91
4.10
4.49
4.88
3.80
4.36
4.93
4.86
4.09
4.32
4.75
4.83
4.48
4.47
4.64
3.85
4.28
3.58
4.49
4.69
4.15
4.07
3.62
3.42
4.02
4.20
4.54
4.36
4.79
4.13
4.52
4.20
4.05
0.80
0.60
0.82
0.90
0.77
0.78
1.09
0.91
0.49
0.73
0.83
0.86
0.72
0.66
0.35
0.82
0.71
0.28
0.37
0.83
0.72
0.50
0.43
0.67
0.67
0.55
0.74
0.76
0.87
0.63
0.52
0.69
0.80
0.88
0.87
0.85
0.80
0.62
0.70
0.46
0.75
0.72
0.78
0.87
0.04
0.03
0.04
0.04
0.04
0.04
0.05
0.04
0.02
0.36
0.04
0.04
0.04
0.03
0.02
0.04
0.04
0.01
0.02
0.04
0.04
0.03
0.02
0.03
0.03
0.03
0.04
0.04
0.04
0.03
0.03
0.03
0.04
0.04
0.04
0.04
0.04
0.03
0.03
0.02
0.04
0.04
0.04
0.04
Limits (.95)
(4.07 , 4.23)
(4.58 , 4.70)
(3.63 , 3.79)
(3.85 , 4.03)
(4.11 , 4.27)
(4.18 4.34)
(4.20 , 4.42)
(3.86, 4.02)
(4.68 4.78)
(4.21, 4.35)
(3.83. 3.99)
(3.83, 3.99)
(4.03, 4.17)
(4.43, 4.55)
(4.85, 4.91)
(3.72, 3.88)
(4.29, 4.43)
(4.91, 4.95)
(4.83 4.91)
(4.01, 4.17)
(4.25 4.39)
(4.70, 4.80)
(4.79 , 4.87)
(4.41, 4.55)
(4.40 4.54)
(4.59, 4.69)
(3.78 3.92)
(4.20, 4.36)
(3.49, 3.67)
(4.43, 4.55)
(4.64, 4.74)
(4.08, 4.22)
(3.99, 4.15)
(3.53, 3.71)
(3.33, 3.51)
(3.95, 4.10)
(4.12, 4.28)
(4.48, 4.60)
(4.29 4.43)
(4.75 4.83)
(4.06 , 4.20)
(4.45 , 4.59)
(4.12 , 4.28)
(3.96 , 4.14)
89
Table 4.
Continued.
Item No. Behavior
Number
46. relieve suffering
412
47. loyalty to client
402
48. loyalty to institution 404
49. loyalty to doctor
404
50. loyalty to nursing
405
Mean
SD
SE
4.54
3.75
2.33
1.71
3.45
0.67
1.23
1.07
0.91
1.20
0.03
0.06
0.05
0.05
0.06
Limits (.95)
(4.47,
(3.63,
(2.22,
(1.62,
(3.33,
4.61)
3.87)
2.44)
1.80)
3.57)
Note. t-tests: Using a mean > 3.50, all items except 35,
48, 49, and 50 were significant at the .05 level.
Null hypothesis (Ho) la is rejected for all items,
except numbers 48 and 49 IPNV Section I.
Although items 35
and 50 have a mean < 3.50, upper confidence limits exceed a
mean > 3.50.
Coefficient alpha estimates for overall IPNV
Section I items (0.92) indicate internal consistency.
In
general, the means tend toward a positive rating of 4 (very
important) and 5 (essential).
Items 48 and 49 tend toward a
negative rating of 2 (somewhat important) and 1 (not
important).
Subsequent rotated factor patterns reflect a
normal distribution.
Further examination of Table 4 shows that making moral
decisions based on loyalty to institution, and/or to doctor
(items 48 and 49) are the only two nursing behaviors with a
mean below 3.42.
Items 47, 48, 49, and 50 refer to making
moral decisions based on loyalty.
These four items reflect
conclusions from Becker's discussion (1991) on the shift of
nursing's loyalty from physician to client
(p. 12).
The
third and fourth lowest means relate to nursing as a
profession:
Item 35 (mean 3.42) states "Takes an active
90
role when attending professional nursing organization
meetings," and item 50 (mean 3.45) states "Makes a moral
decision based on loyalty to nursing profession obligations
and duties."
However, standard deviations indicate somewhat
widespread opinions on these two items, especially item 50.
The seven items with
highest means center on client
rights and the nurse's responsibility to maintain
competence.
Item 18, "Maintains confidentiality of clients
and staff" received the highest mean rating (4.93).
Item
15, "Acts to safeguard the client and the public when health
care and safety are affected by the incompetent, unethical
or illegal practice of any person" received the second highest mean ratings (4.88).
Other items dealing with client
rights include item 19, right to privacy (mean 4.86), item
40, right to be told about care to be received (mean 4.79),
and item 9, right to refuse treatment (mean 4.73).
Item 22
"Asks for help in unfamiliar clinical situations" (mean
4.75) and item 31 "Updates clinical skills to meet client's
health care needs" (mean 4.69) refer to nurse competency.
Hypothesis lb.
Alternate hypothesis (Ha) lb states
"Nurse educator experts will rate IPNV attitudes and
personal qualities > 3.50 on a 5-point Likert scale of l=not
important to 5=essential (means, confidence limits, t-test
on the mean, coefficient alpha)."
presents data for hypothesis lb.
Table 5 on the next page
91
Table 5
IPNV Section II:
qualities.
Item No.
1
2.
3.
4.
5.
6.
7.
8.
9.
10 .
11 .
12 .
13 .
14 .
15 .
16 .
17 .
18
19
20 .
21
22
23
24
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
Mean ratings for 50 attitudes and personal
Attitude/Quality Number Mean
Acceptance
Accountability
Appreciation
Assert iveness
Attentiveness
Authenticity
Caring
Collegiality
Comnitment
Ccnrnon Sense
Conpeission
Confidence
Connectedness
Consideration
Courage
Creativity
Discernment
Eirpathy
Fairness
Flexibility
Generosity
Honesty
Hope
Humaneness
Imagination
Independence
Initiative
Integrity
Inqui sit iveness
Intuition
Kindness
Loyalty
Morality
Objectivity
Openess
Perserverance
Rationality
Reflectiveness
Respectfulness
Sanctity of Life
Self-Direct ion
Self-Discipline
402
412
404
410
411
411
410
412
410
411
411
412
410
412
412
412
410
411
411
411
412
411
412
412
411
412
412
412
411
411
410
410
410
410
411
411
411
412
410
408
410
410
3.67
4.82
3.73
4.15
4.57
4.60
4.71
4.10
4.45
4.42
4.60
4.19
4.33
4.26
3.76
3.84
4.44
4.51
4.51
4.50
3.07
4.85
3.92
4.53
3.80
4.13
4.36
4.92
4.17
3.72
3.91
3.74
4.54
4.22
4.32
3.97
4.24
4.06
4.36
4.10
4.22
4.16
SD
SE
Limits (.95)
0.99
0.45
0.83
0.74
0.59
0.62
0.53
0.69
0.67
0.70
0.57
0.72
0.69
0.70
0.87
0.81
0.68
0.61
0.61
0.61
0.92
0.42
0.81
0.65
0.81
0.71
0.63
0.32
0.69
0.91
0.90
0.89
0.74
0.85
0.69
0.78
0.76
0.79
0.71
1.01
0.71
0.75
0.05
0.02
0.04
0.04
0.03
0.03
0.03
0.03
0.03
0.03
0.03
0.04
0.03
0.03
0.04
0.04
0.03
0.03
0.03
0.03
0.05
0.02
0.04
0.03
0.04
0.03
0.03
0.02
0.03
0.04
0.04
0.04
0.04
0.04
0.03
0.04
0.04
0.04
0.04
0.05
0.04
0.04
<[3.57,
[4.78,
1[3.65,
1[4.08,
([4.51,
([4.54,
([4.66,
([4.03,
([4.38,
([4.35,
('4.54,
1[4.12,
('4.26,
([4.19,
1[3.67,
([3.77,
([4.37,
([4.45,
([4.45,
([4.44,
1[2.97,
<[4,81,
([3.84,
1[4.47,
1[3.72,
([4.06,
([4.30,
[4.89,
([4.10,
[3.63,
[3.82,
(3.65,
(4.47,
(4.14,
(4.25,
(3.89,
(4.17,
(3.98,
(4.29,
(4.00,
(4.15,
(4.09,
3.77)
4.86)
3.81)
4.22)
4.63)
4.66)
4.76)
4.17)
4.52)
4.49)
4.66)
4.26)
4.40)
4.33)
3.85)
3.93)
4.51)
4.57)
4.57)
4.56)
3.16)
4.89)
4.00)
4.59)
3.88)
4.20)
4.42)
4.95)
4.24)
3.81)
4.00)
3.83)
4.61)
4.30)
4.39)
4.05)
4.31)
4.14)
4.43)
4.20)
4.29)
4.23)
92
Table 5. Continued.
Item No. Attitude/Quality
Number Mean
SD
SE
Limits (.95)
43.
44.
45.
46.
47.
48.
49.
50.
412
412
411
412
412
412
410
411
0.68
0.80
0.65
0.92
0.74
0.80
0.72
0.79
0.03
0.04
0.03
0.05
0.04
0.04
0.04
0.04
(4.17,
(3.91,
(4.30,
(3.94,
(3.98,
(3.90,
(4.37,
(4.01,
Self-Esteem
Sense of humor
Sensitivity
Spirituality
Support iveness
Tolerance
Trust
Wisdom
Note.
4.24
3.99
4.36
4.03
4.05
3.99
4.44
4.09
4.31)
4.07)
4.42)
4.12)
4.12)
4.06)
4.51)
4.17)
*t-tests based on > 3. 50 for all items , except
number 21, were significant at the .05 level.
Null hypothesis (Ho) lb is rejected for all items,
except number 21, IPNV Section II.
Coefficient alpha
estimates for overall IPNV Section II items (0.96) indicate
internal consistency.
Means for items range from 3.07 to
4.92 (important to essential).
The qualities of generosity
and loyalty along with the attitudes of acceptance and
appreciation have the lowest means (from 3.07 for generosity
to 3.74 for loyalty).
The qualities of integrity, honesty,
and accountability along with the attitude of caring have
the highest means (from 4.71 for caring to 4.92 for
integrity).
Research Question Two (2)
Research question number two asks "Do items in
Ochsner's IPNV reflect important underlying value dimensions
characteristic of professional nursing practice?"
93
From this second question two null hypotheses were considered:
(2a) behavior items from IPNV Section I and (2b)
attitude and personal quality items from IPNV Section II.
Hypothesis 2a.
Alternate hypothesis (Ha) 2a states
"Nurse educator expert ratings of IPNV behavior items on a
5-point Likert scale of l=not important to 5=essential will
reflect important underlying value dimensions characteristic
of professional nursing practice."
Procedures used to
address hypothesis 2a began with principal exploratory
factor analysis.
Confirmatory factor analysis procedures
were used to construct a valid IPNV measurement model.
Item-total-score correlations and coefficient alpha were
calculated for each underlying dimension of the final IPNV
measurement model.
Factor analysis is closely associated with construct
validity and is considered a very good validity measure,
especially of psychological constructs (Thompson & Daniel,
1996).
Cohen, Swerdlik, and Smith (1992) define factor
analysis as "a set of mathmatical techniques used to identify dimensions underlying a set of empirical measurements"
(p. 746).
These three co-authors present examples (p. 752)
of what one may do with factor analysis.
One example
"Finding the dimensions that people use when judging social
behaviors" fits nicely with the IPNV.
In factor analysis, correlations are computed among
items chosen to represent underlying dimensions.
94
The computer program factors a matrix of intercorrelations
to produce factor coefficients that are like coefficients
between the item and the underlying factor.
For this study,
a 0.40 factor coefficient was chosen as a significant or
salient
coefficient (Cohen, Swerdlik, & Smith, 1992,
p. 750).
In determining the number of meaningful factors to
retain for IPNV Section I, guidelines suggested by Hatcher
(1994) were utilized.
The Initial factor analysis (princi-
pal axis method) of IPNV behavior items revealed 12 underlying factors with eigenvalues (relative strength of
importance of each factor) of 1 or more.
These twelve
factors accounted for 60% of the total variance of items.
A scree plot of the Eigenvalues demonstrated a large break
between factor 1 and factor 2
factors 3, 4, and 5.
breaks.
with smaller breaks between
The remaining factors show minimal
These first five factors account for 42.79% of the
total variance:
Factor 1 (24.56%), Factor 2 (6.42%), Factor
3 (4.71 % ) , Factor 4 (3.88%), and Factor 5 (3.22%).
Large
breaks between factors indicate relatively important
factors.
Based on the scree test and proportion of variance
accounted for, it would appear that there are at least three
and no more than five salient factors.
Exploratory factor analysis (maximum likelihood method)
was used to force Section I items into three, four, and five
factors.
A promax (oblique) rotated factor pattern with
95
standardized regression coefficients was examined for forced
factors of three, four, and five.
Hatcher's (1994, pp.
85-86) interpretability criteria were used for analysis of
the above three factor patterns.
The retention of four
factors (underlying dimensions) best fit Hatcher's four
criteria:
(1) there were at least three items with salient
factor coefficients on each
retained factor; (2) the items
on each given factor shared some conceptual meaning; (3) the
items on different factors seemed to be measuring different
constructs; and (4a) the rotated factor pattern showed most
items with relatively high coefficients on only one factor
with near-zero coefficients for other factors, as well as
(4b) most factors had relatively high coefficients for some
items and near-zero coefficients for the remaining items.
Every effort to confirm the validity of a model is
important.
Confirmatory factor analysis is one method that
can be used to identify and establish validity for a best
model.
Confirmatory factor analysis (CFA) is, in a sense,
a disconfirmation process; rival models can be disconfirmed
and model parsimony can be evaluated.
Ideally, CFA fits
parameters from one study to independent data.
When data
comes from the same sample (as in this IPNV study), invariance over saimples cannot be tested (Thompson & Daniel,
1996) .
96
In this study, a measurement model to test goodness-offit between latent factors (suggested by exploratory
factor analysis) and manifest variables (in this case, IPNV
Section I items) is constructed (Hatcher, 1994, p. 256). No
structural (causal) model will be tested.
Data from IPNV's
50 behavior items were analyzed using the SAS System's CALIS
procedure (SAS Institute Inc., 1989).
Confirmatory factor
analysis was used to develop a measurement model that demonstrated an acceptable fit to the data.
The Section I model
in this study consisted of four latent variables corresponding to the four underlying dimensions extracted from
exploratory factor analysis.
The four dimensions were named
by this writer as (1) health advocacy, (2) competency,
(3) human rights, and (4) autonomy.
Although the fourth
dimension items were directed toward moral decision-making
based on loyalty, mean scores plus numerous respondent
comments clearly favored loyalty to one's own values
(autonomy) over loyalty to institution, physician, client,
or nursing duty.
The CFA measurement model identifies latent variables
with the letter F (for Factor) and labels manifest variables
with V (for Variables).
In this study the 50 behavior items
in IPNV Section I were all potential manifest variables.
The initial measurement model was estimated using the
maximum likelihood estimation for covariance structure
97
analysis.
The results indicated a problem with the initial
model fit.
The initial measurement model was revised by reviewing
(1) item-total-score correlations for each of the four
dimensions, (2) rank order of the ten largest asymptotically
standardized residuals, and (3) rank order of the ten
largest Lagrange multiplier:
PHI and GAMMA matrices to
identify items loading highly on more than one factor
(Hatcher, p. 308).
Items with low correlations-to-total-
score for each dimension were deleted.
Items shown to
relate strongly to more that one dimension were deleted.
The revised measurement model goodness-of-fit indexes were
generated by individually testing the four underlying
dimensions--health advocacy, competency, human rights, and
autonomy--of IPNV behavior items.
These indexes demon-
strated a better fit between the four dimensions (latent
factors) and selected behavior items (manifest variables).
There are many indexes available to evaluate CFA model
fit, and there are many unsettled issues regarding CFA fit
statistics.
Thompson and Daniel(1996) suggest some
consensus on the following points:
(1) chi-square-to-
degrees-of-freedom ratios are problematic since large sample
sizes inflate these values; (2) even though problematic,
chi-square and the df should be reported in order to help
the reader determine- how the model was specified; and
98
(3) comparative fit indexes (CFI) and adjusted goodness of
fit indexes (AGFI) take into account sample size and are
preferred over normed and unadjusted GFI (p. 204).
Table 6 summarizes five goodness-of-fit indexes for
each dimension of the revised measurement model for IPNV
Section I.
Table 6
IPNV S e c t i o n I :
f i t indexes.
Confirmatory f a c t o r a n a l y s i s .
Dimension
Goodness-of
Chi-square
df
AGFI
NNFI
CFI
RMR RMSEA
81.53
20
.90
.91
.94
.05
.09
I.
Health Advocacy
II.
Corpetency
114.86
54
.93
.93
.94
.04
.06
III.
Human Rights
155.19
20
.83
.69
.78
.07
.14
IV.
Autonomy
15.75
2
.90
.89
.96
.05
.14
Note.
N=413. AGFI=Adjusted Goodness of F i t ;
NNFI=Bentler
& B o n e t t ' s Non-normed Index; C F I = B e n t l e r ' s Comparative F i t
I n d e x ; RMR=Root Mean Square R e s i d u a l ;
RMSEA=Root Mean
Square R e s i d u a l A d j u s t e d .
Table 6 r e v e a l s c h i - s q u a r e - t o - d e g r e e s - o f - f r e e d o m
ratio
l a r g e r than t h e d e s i r e d < 2 f o r h e a l t h a d v o c a c y , human
rights,
and autonomy d i m e n s i o n s .
has a r a t i o of 2 . 1 3
acceptable
(Hatcher,
(114.86/54)
Dimension I I ,
competency,
and c o u l d be c o n s i d e r e d
1994, p . 2 9 0 ) .
This study d e a l s with a
99
fairly large sample.
As has been noted, the chi-square
statistic is "...very sensitive to sample size... and will
very often result in the rejection of a well fitting model"
(Hatcher, 1994, p. 415). For this reason, additional
indexes such as those suggested by Thompson and Daniel
(1996) are evaluated.
In addition to chi-square per degrees of freedom, other
goodness-of-fit indexes for the IPNV Section I revised
measurement model are presented in Table 6.
The AGFI
indexes for health advocacy, competency, human rights, and
autonomy dimensions are .90, .93, .83, and .90, respectively.
The only dimension to fall below the suggested .90 -
is dimension III, human rights.
However, an AGFI of .83 may
still be considered acceptable (Sodowsky, Taffe, Gutkin, &
Wise, 1994, p. 144). The CFI indexes for health advocacy,
competency, human rights, and autonomy dimensions are .94,
.94, .78, and .96, respectively.
Again, dimension III,
human rights, falls below the desired >.90.
Gierl and Rogers (1996) define the RMR as "...the root
mean of squared discrepancies between the observed covariances fitted and hypothesized covariances..." (p. 319).
Gierl and Rogers go on to say a small RMR indicates a good
fit.
The RMR indexes for health advocacy, competency, human
rights, and autonomy dimensions are .05, .04, .07, and .05,
respectively.
These all fall within an acceptable range.
100
The adjusted RMR residuals (RMSEA) assess discrepancy per
degree of freedom in the model and are intended to measure
parsimony.
RMSEA measures are preferably <.10 (Gierl &
Rogers, 1996, p. 319). The RMSEA indexes for health
advocacy, competency, human rights, and autonomy dimensions
are .09, .06, .14, and .14, respectively.
Dimensions III
and IV, human rights and autonomy are >.10 and thus somewhat
higher than desired.
Overall, the revised IPNV measurement model's four
dimensions and 33 behavioral item variables appear to
provide a reasonable final measurement model fit for IPNV
Section I.
Consequently, validity and reliability tests
were conducted.
On the following page. Table 7 presents standardized
coefficients (factor loadings) with their error variances
for retained behavior items.
This table summarizes the
final measurement model for IPNV Section I.
101
Table 7
IPNV Section I:
Final measurement model, decimals omitted.
Item Number and Abbreviation
Factor
Loading
(Error
Variance)
Dimension I: Health Advocacy (Coefficient hlpha = 0.85)
41.
12.
35.
5.
16.
32.
24.
33.
(CPC)
(SCN)
(AP)
(AHC)
(EH)
(QCA)
(PNI)
(IT)
Collaboration for health
Social concern for health
Active as a professional
Access to health care
Environmental hazard control
Promote quality, access, service
Protect public, promote nursing image
Teamwork to meet public health needs
702
715
649
590
665
724
554
602
(.712)
(.700)
(.761)
(.807)
(.747)
(.690)
(.832)
(.800)
Dimension II: Competency (Coefficient Alpha = 0.85)
45.
20.
25.
21.
42.
13.
46.
4.
22.
30.
31.
17.
(HS) Humor in stress
(PG) Proper greetings
(FC) Focus on client
(IC) Inspires confidence
(IS) Introduces self
(CS) Colleague support
(RS) Relieve suffering
(HW) Helps other workers
(AH) Asks for help when needed
(ISW) Identifies own strengths, weaJcnesses
(US) Updates skills
(WS) Promotes workplace safety
634
660
569
666
557
615
487
522
521
558
482
531
(.773)
(.752)
(.822)
(.746)
(.830)
(.789)
(.873)
(.853)
(.853)
(.830)
(.876)
(.848)
Dimension III: Human Rights (Coefficient Alpha = 0.75)
40.
19.
38.
15.
9.
18.
36.
23.
(RK)
(RP)
(CP)
(SP)
(RR)
(CCS)
(CNC)
(HD)
Supports right to know
Safeguards right to privacy
Encourages client participation
Safeguards client/public
Honors right to refuse treatment
Maintains confidentiality
Coordinates care plans
Honest documentation
611
626
626
410
511
509
591
362
(.791)
(.780)
(.780)
(.912)
(.860)
(.861)
(.807)
(.932)
Dimension IV: Autonomy (Coefficient Alpha = 0.73)
48.
49.
47.
50.
(LI)
(LD)
(LC)
(LN)
Decision-making,
Decision-making,
Decision-making,
Decision-making,
loyalty
loyalty
loyalty
loyalty
to institution
to physician
to client
to nursing duty
939
736
455
420
(.343)
(.677)
(.891)
(.908)
102
Standardized coefficients (or factor loadings) for each one
of the four dimensions depicted in Table 7 represent the
portion which each item variable shares in common with other
item variables in the same dimension.
The error variance
for each item variable represents the portion which is not
shared in common by other item variables in the same
dimension.
All but one factor loading (honest documentation
under factor III, human rights) is above the level of .40
which was chosen as the salient (valid) cut-off point for
loadings.
The item variable, honest documentation (.362),
was retained by this researcher in view of a high mean
rating by the nurse experts (4.83) and logical importance in
relation to moral and legal principles.
The SAS system's Calls procedure allows for large
sample t-tests of the null hypothesis that the standardized
coefficients (loadings) are equal to 0 in the population.
These tests are significant if the t value is greater than
1.96.
Significance supports convergent validity (Hatcher,
1994, p. 416).
The range of item variable t values for
health advocacy, competency, human rights, and autonomy are
all well above 1.96:
Dimension I--health advocacy [10.78 to
15.133; Dimension II--competency [9.14 to 13.51];
Dimension III--human rights [6.33 to 11.73]; and Dimension
IV--autonomy [7.76 to 17.69].
These values provide evidence
supporting convergent validity of the IPNV Section I final
103
measurement model.
In other words, there is evidence that
the final selection of behavior items are effectively
measuring their respective dimensions.
The SAS systems's CORR procedure for Cronbach's coefficient alpha was used as an index of internal consistency
for each of IPNV Section I's four dimensions.
For domain
sampling, coefficient alpha is an appropriate measure of
internal consistency (Cohen, Swerdlik, & Smith, 1992, p.
151).
Furthermore, coefficient alpha is proposed not only
as a measure of reliability but also as an external
generalizabi1ity measure closely connected to construct
validity.
Moss (1992) quotes Cronbach as insisting the two
measures of generalizability and construct validity are
inseparable (p. 237). Thus, coefficient alpha reliability
may also be considered as a measure of construct validity.
All four IPNV Section I dimensions demonstrated acceptable
alpha levels with coefficients in excess of .70.
Health
advocacy, competency, human rights, and autonomy dimensions
weire .85, .85, .75, and .73, respectively.
In summary, confirmatory factor analysis findings and
Cronbach's coefficient alpha indexes of internal consistency
generally support the reliability and construct validity of
the final IPNV Section I measurement model.
Null hypothesis
2a which states "Nurse educator expert ratings of IPNV
behavior items on a ^-point Likert scale of l=not important
104
to 5=essential will not reflect important underlying value
dimensions characteristic of professional nursing practice"
is rejected, and the alternate hypothesis is accepted.
Hypothesis 2b.
Alternate hypothesis (Ha) 2b states
"Nurse educator expert ratings of IPNV attitude and personal
quality items on a 5-point Likert scale of l=not important
to 5=essential will reflect important underlying value
dimensions characteristic of professional nursing practice."
Procedures used to address hypothesis 2b consisted of
principal exploratory factor analysis, item-total-score
correlations, and Cronbach's coefficient alpha.
SAS proce-
dures indicated that the IPNV Section II (attitude and
personal quality items) sample covariance or correlation
matrix is not positive definite which prohibits computation
of maximum likelihood and confirmatory factor analysis.
In determining the number of meaningful factors to
retain for IPNV Section II, guidelines suggested by Hatcher
(1994) were utilized.
The initial factor analysis
(principal axis method) of IPNV attitude and personal
quality items revealed 10 underlying factors with eigenvalues of 1 or more.
A scree plot of the eigenvalues
demonstrates a large break between factor 1 and factor 2
with smaller breaks between 2, 3, and 4.
The first four
factors account for 46.95% of the total variance:
Factor 1
(34.46%), Factor 2 (4.92%), Factor 3 (4.06%), and Factor 4
(3.51%).
Based on the scree test and proportion of variance
105
accounted for, it would appear that there are least three
and no more than four salient factors.
Exploratory factor analysis (principal axis method) was
used to force IPNV Section II items into three and four
factors.
A promax (oblique) rotated factor pattern with
standardized regression coefficients for each item was
examined.
Hatcher's interpretabi1ity criteria (1994, p. 85-
86) were used for forced three and four factor patterns.
The four factor pattern appeared to best represent a shared
conceptual meaning for each factor.
In addition, relation-
ships between coefficients for the four factor solution were
somewhat more distinct than those of the three factor
solution.
The four factors for IPNV Section II were
identified and named (1) freedom, (2) altruism, (3) caring,
and (4) character.
On the following page, Table 8 presents standardized
regression coefficients (factor loadings) for the initial
Section II 50-item model.
106
Table 8
IPNV S e c t i o n I I :
Standardized r e g r e s s i o n c o e f f i c i e n t s .
Rotated factor pattern:
Promax ( O b l i q u e ) method.
Decimals
omitted.
Inventory Item Statement
Factor I
25.
41.
27.
16.
26.
4.
12.
42.
20.
43.
29.
37.
44.
38.
35.
9.
17.
45.
Four Factor Solution
I
II
III
IV
(Freedom)
Imagination
Self-direction
Initiative
Creativity
Independence
Assert iveness
Confidence
Self-discipline
Flexibility
Self-esteem
Inquisitiveness
Rationality
Sense of Humor
Reflect iveness
Openness
Collegiality
Discernment
Sensitivity
75
73
71
69
69
65
57
57
55
54
53
52
52
48
45
36
35
34
21
9
-11
22
14
-22
-2
18
-17
19
8
7
17
15
0
3
14
7
-5
-10
3
-3
-13
12
-2
-16
22
1
13
0
12
17
15
20
24
30
-30
5
7
31
-5
6
18
19
0
0
1
29
-10
8
33
14
5
12
1
-7
7
11
10
28
36
31
28
18
40
21
74
67
62
62
56
53
52
48
47
45
45
36
9
-8
4
13
41
11
-5
-5
7
21
-8
19
-10
24
-10
25
5
-15
-5
3
-12
13
18
18
Factor II (Altruism)
21.
40.
46.
32.
31.
23.
15.
50.
30.
47.
36.
48.
Generosity
Sanctity of Life
Spirituality
Loyalty
Kindness
Hope
Courage
Wisdom
Intuition
Support iveness
Perseverance
Tolerance
107
Table 8.
Continued.
Four Factor Solution
I
II
III
Inventory Item Statement
Factor III
18.
19.
24.
11.
7.
13.
14.
1.
3.
39.
22.
28.
2.
33.
34.
9.
5.
49.
6.
10.
(Caring)
Btpathy
Fairness
Hunaneness
Compassion
Caring
Connectedness
Cons iderat ion
Acceptance
Appreciation
Respectfulness
Factor IV
IV
1
1
-8
3
14
38
20
18
3
5
-2
4
14
11
35
10
35
-5
19
26
3
3
5
-7
2
11
34
27
28
92
92
49
47
47
42
39
38
34
30
-17
-17
17
32
17
-4
21
-7
2
28
-1
-9
0
38
-9
28
-19
32
-5
17
-7
1
3
-15
2
-9
27
13
29
6
65
61
56
52
44
43
38
37
27
25
21
(Character)
Honesty
Integrity
T^countability
Morality
Objectivity
Conmitment
Attentiveness
Trust
Authenticity
Conrmon Sense
From Table 8, it can be seen that Factor I (freedom) has 18
items.
All but the last three items (9, 17, and 45) have
standardized regression coefficients that meet the 0.40
"loading" criteria.
Factor II (altruism) has 12 items.
All
but the last item (48) have standardized regression
coefficients that meet the 0.40 "loading" criteria.
III (caring) has 10 items.
Factor
All but the last four items
108
(14, 1, 3, and 39) have standardized regression coefficients
that meet the 0.40 "loading" criteria.
(character) has 10 items.
Factor IV
All but the last four items (5,
49, 6, and 10) have standardized regression coefficients
that meet the 0.40 "Loading" criteria.
Rotated pattern coefficients derived from exploratory
factor analysis as represented in Table 8 were further
analyzed using item-total-score correlations within each of
the four identified factors and alpha coefficients for trial
models.
These analyses were used to achieve a final
parsimonious configuration for Section II attitude and
personal quality items.
On the following page, Table 9 presents IPNV Section
II's final four-factor model with item-total-score
correlations and Cronbach's coefficient alpha.
109
Table 9
IPNV Section II:
Final four-factor model.
Item Number, Abbreviation, Name
Factor I
41.
27.
16.
26.
4.
42.
12.
20.
43.
29.
44.
37.
38.
(Freedon)
(SDI)
(INIT)
(CREA)
(INDE)
(ASSE)
(SDS)
(OC^IF)
(FLEX)
(SES)
(INQU)
(SOH)
(RATI)
(REEL)
Factor II
21.
46.
32.
23.
15.
50.
30.
47.
(GENE)
(SPIR)
(LOYA)
(HOP)
(OOUR)
(WISD)
(INTU)
(SUPP)
Fact or III
18.
19.
24.
11.
7.
13.
Correlation
with Total
(EMPA)
(FAIR)
(HUMA)
(OOMP)
(CARE)
(CONN)
Self-direction
Initiative
Creativity
Independence
Assert iveness
Self-discipline
Confidence
Flexibility
Self-esteem
Inquisitiveness
Sense of Humor
Rationality
Reflectiveness
0.90
0.71
0.64
0.56
0.64
0.55
0.62
0.60
0.51
0.64
0.60
0.55
0.64
0.63
(Altruism)
Generosity
Spirituality
Loyalty
Hope
Courage
Wisdom
Intuition
Supportiveness
0.86
0.64
0.52
0.60
0.63
0.64
0.59
0.56
0.63
(Caring)
Eirpathy
Fairness
Humaneness
Compassion
Caring
Connectedness
Coefficient
Alpha
0.84
0.77
0.77
0.57
0.59
0.48
0.52
no
Table 9.
Continued.
Item Number, Abbreviation, Name
Factor IV
22.
28.
2.
33.
34.
9.
5.
Correlation
with Total
(Character)
(HONE)
(INTE)
(ACOO)
(MORA)
(OBJE)
(OOMM)
(ATTE)
Coefficient
Alpha
0.71
Honesty
Integrity
Accountability
Morality
Objectivity
Corrmitment
Attentiveness
0.40
0.39
0.35
0.43
0.42
0.45
0.45
Overall, the final IPNV Section II four-factor model
with 34 attitude and personal quality items appears to
provide a reasonable companion model to IPNV Section I's
final measurement model.
Factor I (freedom) may
IPNV Section I's competency dimension.
relate to
Factor II (altruism)
may relate to IPNV Section I's health advocacy dimension.
Factor III (caring) may relate to IPNV Section I's human
rights dimension.
Factor IV (character) may relate to IPNV
Section I's autonomy dimension.
All four IPNV Section II factors demonstrated
acceptable alpha levels with coefficients in excess of .70.
Freedom, altruism, caring, and character factors were .90,
.86, .84, and .71, respectively.
These indexes provide
support for reliability and possibly construct validity
(see
Moss, 1992, p. 237) of the final IPNV Section II four-factor
model.
In conclusion, null hypothesis 2b which states
Ill
"Nurse educator expert ratings of IPNV attitude and personal
quality items on a 5-point Likert scale of l=not important
to 5=essential will not reflect important underlying value
dimensions characteristic of professional nursing practice"
is rejected and the alternate hypothesis is accepted.
Research Question Three (3)
Research question number three asks "Does Ochsner's
IPNV contain behaviors, attitudes and personal qualities
useful in development of professional nursing values?"
this question, two null hypotheses were tested:
From
(3a)
usefulness of behavior items from IPNV Section I and (3b)
usefulness of attitude and personal quality items from IPNV
Section II.
Hypothesis 3a.
Alternate hypothesis (Ha) 3a states
"Nurse educator experts will rate IPNV behavior items > 3.50
on a 5-point Likert scale of l=not useful to 5=100% useful
for the following categories:
Overall rating and ratings
for curriculum development, nursing practice, professional
self-evaluation, and career counseling (means, confidence
limits, t-tests)."
On the following page. Table 10 presents
data for hypothesis 3a.
112
T a b l e 10
I n v e n t o r y of P r o f e s s i o n a l Nursing V a l u e s (IPNV).
r a t i n g s for Section I:
Behaviors.
SE
Usefulness
Variable
N
Mean
SD
Limits ( . 9 5 )
Overall Usefulness
251
4.24
0.716
0.045
( 4 . 1 5 , 4.33)
Nursing Curriculum
Development
401
4.39
0.744
0.037
(4.32, 4.46)
Nursing Practice/
Clinical Component
400
3.46
1.013
0.051
(3.36, 3.56)
Professional
Self-evaluation
400
3.93
0.987
0.049
(3.83, 4.03)
Career Counseling
400
4.18
0.835
0.042
(4.10, 4.26)
Note.
t - t e s t : Using a mean > 3 . 5 0 , a l l c a t e g o r i e s e x c e p t
n u r s i n g p r a c t i c e / c l i n i c a l component a r e s i g n i f i c a n t a t both
.01 and .05 l e v e l s .
Null h y p o t h e s i s
will
(Ho) 3a s t a t e s
"Nurse e d u c a t o r
r a t e IPNV b e h a v i o r item < 3 . 5 0 on a 5 - p o i n t
s c a l e of
1-not u s e f u l
t o 5=100% u s e f u l
for the
experts
Likert
following
categories:
O v e r a l l r a t i n g and r a t i n g s f o r
curriculum
development,
nursing p r a c t i c e ,
self-evaluation,
and c a r e e r c o u n s e l i n g . "
professional
This n u l l h y p o t h e s i s i s
rejected
f o r IPNV, S e c t i o n I o v e r a l l u s e f u l n e s s c a t e g o r y and f o r
specific
u s e f u l n e s s c a t e g o r i e s e x c e p t the n u r s i n g
and c l i n i c a l
component a r e a .
r e c e i v e d the highest
all
practice
Nursing c u r r i c u l u m development
IPNV S e c t i o n I u s e f u l n e s s
f o l l o w e d by c a r e e r c o u n s e l i n g and p r o f e s s i o n a l
rating
evaluation.
113
Hypothesis 3b.
Alternate hypothesis (Ha) 3b states
"Nurse educator experts will rate IPNV attitude and personal
quality items > 3.50 on a 5-point Likert scale of l=not
useful to 5-100% useful for the following categories:
Overall rating and ratings for curriculum development,
nursing practice, professional self-evaluation, and career
counseling (means, confidence limits, t-tests)."
Table 11
presents data for hypothesis 3b.
Table 11
I n v e n t o r y of P r o f e s s i o n a l N u r s i n g V a l u e s (IPNV).
Usefulness
r a t i n g s for Section I I :
Attitudes & personal q u a l i t i e s .
Variable
N
Mean
SD
SE
L i m i t s (.95)
Overall Usefulness
402
4.09
0.866
0.043
(4.02, 4.16)
Nursing Curriculum
Development
401
4.18
0.784
0.039
(4.10, 4.26)
Nursing P r a c t i c e /
Clinical Component
218
4.23
0.747
0.051
(4.14, 4.34)
Professional
Self-evaluation
400
4.23
0.892
0.045
(4.14, 4.32)
Career Counseling
399
3.49
1.075
0.054
(3.38, 3.60)
Note.
t - t e s t s : U s i n g a mean > 3 . 5 0 , a l l c a t e g o r i e s e x c e p t
c a r e e r c o u n s e l i n g a r e s i g n i f i c a n t a t b o t h . 0 1 and .05
levels.
Null h y p o t h e s i s
will
(Ho) 3b s t a t e s
"Nurse e d u c a t o r
r a t e IPNV a t t i t u d e and p e r s o n a l q u a l i t y
a 5-point
Likert
s c a l e of
l=not useful
experts
i t e m s < 3.50 on
t o 5=100% u s e f u l
for
114
the following categories:
Overall rating and ratings for
curriculum development, nursing practice, professional selfevaluation, and career counseling."
This null hypothesis is
rejected for IPNV Section II overall usefulness category and
for all specific usefulness categories except the career
counseling area.
Nursing practice/clinical component
received the highest IPNV Section II usefulness rating and
is closely followed by professional self-evaluation and
nursing curriculum development categories.
Research Question Four (4)
Research question four asks "Does Ochsner's IPNV
contain comprehensive content related to professional
nursing values?"
were tested:
From this question two null hypotheses
(4a) comprehensiveness of IPNV Section I
behavior items and (4b) comprehensiveness of IPNV Section II
attitude and personal quality items.
Hypothesis 4a.
Alternate hypothesis (Ha) 4a states
"Nurse educator experts will rate IPNV behavior items > 3.50
on a 5-point Likert scale of l=not comprehensive to 5=100%
comprehensive (mean, confidence limits, t-test)."
On the
following page. Table 12 presents data for hypothesis 4a.
115
Table 12
Inventory of Professional Nursing Values (IPNV).
hensiveness ratings for Section I: Behaviors.
Compre-
Variable
N
Mean
SD
SE
Limits (.95)
Overall
Conprehensiveness
371
4.24
0.755
0.039
(4.16, 4.32)
Note. t-test: Using a mean > 3.50, the comprehensiveness
rating is significant at the .01 level.
Null hypothesis (Ho) 4a states "Nurse educator experts
will rate IPNV attitude and personal quality items < 3.50 on
a 5-point Likert scale of l=not comprehensive to 5-100%
comprehensive."
This null hypothesis is rejected for IPNV
Section I overalll comprehensiveness ratings.
Hypothesis 4b.
alternate hypothesis (Ha) 4b states
"Nurse educator experts will rate IPNV attitude and personal
quality items > 3.50 on a 5-point Likert scale of l=not
comprehensive to 5=100% comprehensive (mean, conficence
limits, t-test)."
On the following page. Table 13 presents
data for hypothesis 4b.
116
Table 13
Inventory of Professional Nursing Values (IPNV). Comprehensiveness ratings for Section II: Attitudes and personal
qualities.
Variable
N
Mean
SD
O/eral 1
Conprehens iveness
368
4.28
0.816
SE
0.43
Limits (.95)
(4.19, 4.37)
Note. t-test: Using a mean > 3.50, the comprehensiveness
rating is significant at the .01 level.
Null hypothesis (Ho) 4b states "Nurse educator experts
will rate IPNV attitude and personal quality items < 3.50 on
a 5-point Likert scale of l=not comprehensive to 5=100%
comprehensive."
This null hypothesis is rejected for IPNV
Section II overall comprehensiveness rating.
It is noted
that nurse expert comprehensiveness mean ratings for both
IPNV Sections I and II, 4.24 and 4.28, respectively, are
well above the hypothesized > 3.50 mean.
Research Question Five (5)
Research question number five asks "Will nurse educator
experts suggest modifications, deletions, or additions of
any behaviors, attitudes and personal qualities included in
Ochsners's IPNV?
(Answers to an open-ended question will be
considered by this researcher on an individual item basis)."
One hundred thirty-six of 413 (32.9%) individual respondents
117
made one or more written comments.
sumarized under two headings:
These comments are
(1) suggested deletions,
changes, and/or additions to the IPNV, and (2) suggested
structural modifications.
Suggested deletions, changes, and/or additions.
Sug-
gested deletions, changes, and/or additions to the IPNV are
summarized as follows:
Twenty-eight comments called for more clarity in IPNV
Section I items 6, 7, 29, and 44.
Twenty-one comments
related to IPNV Section I items 47, 48, 49, and 50.
These
items address making a moral decision based on loyalty to an
institution, to the client, to physicians, and to the
nursing profession.
A number of respondents suggested
addition of an item on moral decisions based on a personal
code of ethics.
Some respondents noted that moral decisions
involve much more than loyalty.
There were fewer comments related to attitude and personal quality items (IPNV Section II).
Three respondents
note that item 1, "acceptance (favorable regard, approval)"
depends on the situation.
The same comments were made about
item 3, "appreciation (recognition of worth, importance, or
quality)."
Seven comments were on item 40, "sanctity of
life (holiness and sacredness of life)."
One individual
summed up what most respondents had to say:
"Does this mean
the nurse cannot support issues of choice even if it means
death"?
One respondent commented on IPNV Section II:
118
"The qualities are extremely subjective and may have
cultural overtones."
Another respondent asked "What
specifically is different in attitudes and qualities of a
'good nurse' versus a 'good person'?"
Most of the comments on Section III, Inventory
Usefulness, and Section IV, Inventory Comprehensiveness,
related to lack of understanding of what was being asked.
Several individuals noted that nothing is 100% useful or
100% comprehensive.
On the other hand, a few individuals
noted that since most items were positive ideals, they would
be difficult to dispute.
One respondent noted that
usefulness and comprehensiveness depend on purpose.
Five
respondents did not believe that attitudes and qualities are
things that can be taught.
Inclusion of the following areas were suggested:
(1) leadership and management, (2) autonomy, (3) advances
formal education, (4) sees conflict as an opportunity for
growth, (5) more fiscal responsibility, (6) cultural
differences in demonstrating caring behaviors, (7) cultural
interpretation of expressed attitudes, (8) dependability and
responsibility, (9) effective communication, (10) selfawareness as mandatory for growth, (11) political activity
and awareness, (12) commitment to lifelong learning,
(13) resourcefulness, (14) use of knowledge, (15) continuity
of care, (16) providing counseling/education, (17) how to
handle mistakes, (18) critical thinking, (19) use of theory
119
and research in practice, (20) advocate, (21) holistic
principles, (22) community building, (23) transcultural
issues, and (24) priority setting.
Suggested structural modifications. Only four respondents remarked that the IPNV was perhaps too comprehensive.
A few individuals remarked that the IPNV was too global.
One respondent classified only about 50% of the items as
specific to the profession of nursing.
Many of the items
were marked "could apply to any profession" or "could apply
to any person."
The writer gave an example:
"Caring is
essential to nursing, but not to professionalism."
Nine respondents remarked on how quickly the inventory
became boring.
Several individuals suggested that some
negative items would have helped get their attention.
For
example, one person asks "How about including more passive,
coercive, or less redeemable attitudes"?
One respondent
said that grouping items according to topic (like items 47
through 50, Section I) would make the IPNV more interesting
to complete.
Another suggestion was to form the items into
groups for ranking (least to most important).
The remainder of comments were, by and large, positive.
Several respondents suggested that IPNV Section I would
serve as a more objective guide than IPNV Section II.
Three
respondents made a comment about the importance of a nurse
being "human."
One remarked:
"While self-discipline and
120
bravery are important factors, I feel it's OK at times (more
often than not) to be human and afraid."
Summary of Chapter IV
This chapter presents an analysis of the five research
questions posed in the first chapter.
Under discussion of
the first research question. Tables 4 and 5 summarize means,
confidence limits, and t-test for IPNV Sections I and II
respectively.
Under discussion of the second research
question, a short presentation of exploratory and confirmatory factor analysis precedes Table 6 (confirmatory factor
analysis goodness-of-fit indexes for IPNV Section I) and
Table 8 (exploratory factor analysis standardized regression
coefficients for IPNV Section II). Table 7 presents the
IPNV Section I final measurement model, and Table 9 presents
the IPNV Section II final four-factor model.
Under discussion of research question three, Tables 10
and 11 summarize nurse educator expert usefulness rating for
IPNV Section I and II.
Under discussion of research
question four. Tables 12 and 13 summarize nurse educator
expert comprehensiveness rating for IPNV Section I and II.
Overall usefulness and comprehensiveness mean rating were
4.24 and 4.28 respectively.
These ratings are well above
the hypothesized mean > 3.50 on a 5-point Likert scale.
The last section summarizes comments generated from the
open-ended research question number five related to
121
suggested changes in the IPNV.
Individual comments from 136
of the 413 respondesnts were summarized under two headings:
(1) suggested deletions, changes, and/or additions to the
IPNV, and (2) suggested structural modifications.
In the next chapter, a final measurement model for
Ochsner's Inventory of Professional Values (IPNV) is
presented.
Construction of the final IPNV measurement model
will be based on this study's five research question results
and analysis.
The study concludes with discussion and
recommendations for inclusion of values and beliefs in
nursing curriculum studies and for appropriate use of
Ochsner's IPNV.
CHAPTER V
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Summary
This national study has been conducted for the purpose
Inventory
of validating a self-report inventory:
Ochsner's
of Professional
Four-hundred and
Nursing
Values
(IPNV).
thirteen (47.2 %) nurse educator experts representing 89 NLN
accredited baccalaureate nursing programs have rated the
importance, usefulness, and comprehensiveness of the IPNV
inventory.
Data has been analyzed using SAS/STAT procedures
(SAS Institute Inc., 1990).
Descriptive statistics,
Cronbach's coefficient alpha estimates, and factor analyses
were utilized in study of the data.
Professional Nursing Values Model
A professional nursing values model, as depicted in
Tables 2 and 3 and Figure 1, was constructed for the purpose
of building up valid nursing knowledge in the field of
nursing ethics.
Field testing, modification and validation
of this model were conducted using an expert system mode of
inquiry.
This mode of inquiry is transfered from the field
of computer technology and is based on human expert problemsolving patterns through use of a heuristic inductive
approach (Harmon, Maus, & Morrissey, 1988).
Technology
transfer has been proposed by Hensley and Jauch (1988) as
122
123
part of a new classification of research called technology
innovation.
Validation of Ochsner's Professional Nursing Values
Model was based on data obtained from nurse educator
experts.
The experts were asked to rate importance, use-
fulness, and comprehensiveness of 50 professional behavior
items and 50 attitude and personal quality items contained
in Ochsner's Inventory
(IPNV).
of Professional
Nursing
Values
Levels of importance were rated on a 5-point Likert
scale (l=not important to 5=essential).
Levels of useful-
ness and comprehensiveness were also rated on a 5-point
Likert scale.
In addition to overall usefulness, four
potential usefulness categories were rated:
(1) nursing
curriculum development, (2) nursing practice/clincal
component, (3) professional self-evaluation, and (4) career
counseling.
Nurse educator experts were also invited to
write suggestions and comments related to the IPNV.
Based on respondent ratings and comments, all but two
behavior items were considered very important
upper limits exceeded a mean of 3.50).
(confidence
The two rejected
behavior items concerned moral decision-making based on
either loyalty to an institution or loyalty to a physician.
A number of respondents suggested that loyalty to personal
values and beliefs would be a very important element in
moral decision-making.
Ratings for attitude and personal
124
quality items revealed that all but number 21, generosity,
were considered very important.
Ratings and comments from nurse educator experts supported a very high level of comprehensiveness.
Respondents
rated behavior, attitude and personal quality items very
useful for nursing curriculum development and for professional self-evaluation.
Behavior items were rated very
useful for career counseling.
Attitude and personal quality
items were rated very useful for nursing practice.
Inventory of Professional Nursing Values
A second mode of inquiry, a psychometric analysis
research design, was used to develop and validate a final
measurement model for Ochsner's Inventory
Nursing
Values
(IPNV).
of
Professional
This research design is appropriate
for developing instrument measures such as self-report
inventories (Borg & Gall, 1989).
The second mode of inquiry
was used to determine which IPNV behavior, attitude and
personal quality items best describe underlying professional
value dimensions.
During the instrument development
process, value dimensions were identified and named.
Principal exploratory factor analysis, confirmatory
factor analysis, item-total-score correlations, and
Cronbach's coefficient alpha were used for validity and
internal consistency reliability examination of IPNV
behavior item ratings.
Statistical calculations were
125
generated through SAS/STAT procedures (SAS Institute, Inc.,
1990).
Four underlying behavior dimensions were identified
and named:
(1) health advocacy, (2) competency, (3) human
rights, and (4) autonomy.
A total of 33 items were retained
as best descriptors for Section I behavior dimensions.
Principal exploratory factor analysis, item-total-score
correlations, and Cronbach's coefficient alpha were used for
validity and internal consistency reliability examination of
IPNV attitude and personal quality item ratings.
Four
underlying attitude and personal quality factors were identified and named:
and (4) character.
(1) freedom, (2) altruism, (3) caring,
A total of 34 attitude and personal
quality items were retained as best descriptors for the four
attitude and personal quality factors.
The four behavior dimensions appear to be related to
the four attitude and personal quality factors:
(1) Health
advocacy with altruism, (2) Competency with both freedom and
caring, (3) Human rights with caring, and (4) Autonomy with
both character and freedom.
The possible relationship of
attitudes and personal qualities with professional behaviors
would seem to support interlocking of personal and professional values as described in review of literature.
Figure 2 summarizes Ochsner's final IPNV measurement
model.
126
VALUES and MORAL BELIEFS
PROFESSIONAL
BEHAVIORS
ATTITUDES and
PERSCWAL QUALITIES
]
Ochsner's IPNV
(Section I)
HEALTH ADVOCACY
Collaborate
Social Concern
Professional
Care Access
Environment
Quality
Nurse Image
Teamwork
COMPETENCY
Humor—Stress
Greeting
Client Focus
Inspire Trust
Introduce Self
Peer Support
Relieve Suffering
Help Care-givers
Ask for Help
See Strenth/Weakness
Update Skills
Safe Workplace
Ochsner's IPNV
(Section II)
ALTRUISM I
Generosity
Spirituality
Loyalty
Hope
Courage
Wisdom
Intuition
Support ive
FREEDOM
Self-Direct ion Confidence
Initiative
Flexibility
Creativity
Self-Esteem
Independent
Inquisitive
Assert ive
Humor
Rationality
Reflection
Self-Di scipline
L
HUMAN RIGHTS
Right to Know
Right: Privacy
Client Involved
Safeguard Public
I
Right to Refuse
Confidentiality
Coordinate Care
Honest Documentation
AUTONOMY
Loyalty:
Loyalty:
Loyalty:
Loyalty:
Loyalty:
to
to
to
to
to
Institution/Organization
Physician
Client
Nursing Duty/Obligations
Personal Values/Beliefs
CARING
Eirpathy
Fairness
Connectedness
CHARACTE
Compassion
Caring
HunHne
3
Honesty
Integrity
Accountable
hioral
Attentive
Objective
Corrmitment
F i g u r e 2. F i n a l Measurement Model for O c h s n e r ' s
of P r o f e s s i o n a l Nursing Values (IPNV).
Inventory
127
The final IPNV measurement model as depicted in Figure 2
provides a guide for structural revision of Ochsner's
Inventory of Professional Nursing Values.
Seventeen behav-
ior items and 16 attitude and personal quality items
contained in the professional nursing values model as
described in Chapter III were deleted from the IPNV final
measurement model.
Item deletion criteria was based on
(1) item-total-score correlations, (2) factor analysis,
(3) nurse educator expert's suggestions and comments, and
(4) literature review.
At least two of the four criteria
were used in item deletion decisions.
Three items with less important mean ratings were shown
to function as good descriptors and were retained under two
The personal quality item generosity
value dimensions.
was
found to be a good descriptor of the dimension "Altruism."
Behavior items related to moral decision-making based on
loyalty
to doctor
and loyalty
important" ratings.
to institution
received "not
These negative ratings contributed
greatly to defining the positive value dimension "Autonomy."
The four identified behavior dimensions and four
identified attitude and personal quality factors provide a
proposed measurement structure to reflect an individual's
commitment to values identified by the American Association
of Colleges of Nursing (1986) as essential to college and
university education for professional nursing.
Aspects of
all seven AACN identified values may be functioning in any
128
one dimension of the final measurement model for Ochsner's
Inventory of Professional Nursing Values (IPNV).
Two of the
attitude and personal quality factors were named altruism
and freedom.
Altruism and freedom, along with esthetics,
equality, justice, human dignity, and truth are named as
AACN professional values.
The AACN "Essentials" document
proposes that "Adoption of the essential values leads the
nurse to a sense of commitment and social responsibility, a
sensitivity and responsiveness to the needs of others, and a
responsibility for oneself and one's actions" (p. 5).
Ochsner's IPNV final measurement model is presented as a
valid measure of professional behaviors, attitudes and
personal qualities reflective of professional nursing
values.
The IPNV final measurement form, derived from data
produced through exploratory and confirmatory analysis, is
ready to be subjected to further validity and reliability
test ing.
Conclusions
Validation of a discipline model and a self-report
inventory such as the IPNV should be an ongoing process.
Stage nine of the Hensley-Tunstal1 Schematic of the Process
for Validating System Models includes adoption, maintenance,
and enhancement of the model.
This step implies ongoing
promotion and revision of a model.
Likewise, Borg and Gall
(1989) point out that since data on earlier inventory forms
129
cannot be applied to the final form, the most important
inventory validity and reliability data will be obtained
after the instrument is in its final form (p. 276).
The constuct validation of a self-report inventory
represents a broader concept than that of a test measuring
what it is supposed to measure (Moss, 1992, p. 232). The
purpose of construct validity is to justify measurement
interpretations by explaining the behavior(s) that a specific score measures.
Thus, interpretation and use of these
measures must include consideration of personal and social
consequences resulting from measurement application.
Implications for Nursing Education
and Nursing Practice
Nurse educator expert ratings of IPNV item importance,
overall comprehensiveness, and usefulness indicate ways in
which both Ochsner's professional value model and Ochsner's
final measurement IPNV may be applied in nursing education
and in nursing practice.
IPNV comprehensiveness ratings.
The overall compre-
hensiveness ratings for behavior items (mean 4.24) and
attitude and personal quality items (mean 4.28) suggest that
respondents found Ochsner's IPNV to be very comprehensive.
Respondent comments as summarized in Chapter IV reveal
consensus of opinion on the deficiency of IPNV section I
items 47-50 (moral decisions based on loyalty to client,
institution, medical doctor, and professional obligations).
130
At the same time, comments would seem to indicate this is an
area of extreme importance.
Several respondents suggested
inclusion of an item on loyalty to one's own beliefs and
values.
The recommended item has been added to the IPNV
final measurement model.
Answers on the "loyalty" items
confirmed a historical trend in the basis for nurses'
decision-making:
away from loyalty to physicians and insti-
tutions toward loyalty to client, to professional obligations and to one's own beliefs and values.
This trend moves
from belief in an underlying value of obedience toward a
belief in an underlying value of autonomy.
One respondent
suggested "autonomy" as an important item to add to Section
II.
IPNV Section I and II importance ratings.
All items
(with exception of those items referring to moral decisions
based on loyalty to physician and to institutions) tended
toward a positive response mean average of three or above on
a 5-point Likert scale.
These positive ratings would
suggest IPNV Section I and II items are generally considered
important by expert nurse educators.
Mean rankings on items
in IPNV Section I reveal that the highest ranked items
center on client rights and nurses' responsibility to maintain competence.
Mean rankings on items in IPNV Section II
reveal that the highest ranked items were integrity, honesty
and accountability.
Nurse educator expert importance
of
131
item
ratings suggest that Ochsner's model of professional
nursing values provides a structure of nursing value knowledge which is valid.
IPNV usefulness ratings.
Overall usefulness ratings
suggest that Ochsner's IPNV is considered by nurse educator
experts to be very useful.
Comparison of the four useful-
ness subcategories for Section I shows that behavior items
are rated most useful for nursing curiculum development
followed by career counseling, professional self-evaluation
and nursing practice/clinical component.
Comparison of the
four usefulness categories for Section II shows that
attitude and personal quality items are rated most useful
for professional self-evaluation and for nursing
practice/clinical component.
The third and fourth ranked
Section II subcategories are rated very useful for nursing
curriculum development and career counseling.
cator expert usefulness
Nurse edu-
ratings suggest areas in which
Ochsner's IPNV content can be effectively used in both
nursing education and nursing practice.
Recommendat ions
Recommendations for use of Ochsner's two models
(professional nursing values model--Figure 1 and final
measurement model--Figure 2) in nursing education and
practice are as follows:
132
1.
It is recommended that colleges of nursing use the
professional nursing values model depicted in Figure 1 as a
springboard to initiate formal inclusion of values in
nursing curricula.
Faculty could discuss ways in which
values may be taught.
Active student participation along
with faculty role-modeling is vital.
There is need to dis-
cover innovative ways to teach values.
2.
It is recommended that colleges of nursing consider
how Ochsner's Inventory of Professional Nursing Values final
measurement model depicted in Figure 2 may be used for
teaching and for evaluation of clinical nursing practice.
Since initial uses would probably involve validity studies,
it is of utmost importance to protect students from any
adverse personal or social consequences that could result
from IPNV testing.
3.
It is recommended that continuing education
programs for nurses include an offering on the topic of
professional nursing values.
Ochsner's IPNV final
measurement model depicted in Figure 2 could serve as a
professional self-evaluation tool.
This model could also be
used to initiate discussion of values and ethical practice
in nursing.
4.
It is recommended that Ochsner's IPNV final
measurement model be used at some future point in time to
ascertain level of congruence between nurse and consumer
respondents.
133
A note of caution.
A note of caution on using experi-
mental self-report inventories such as the IPNV for grading,
hiring, firing and like purposes.
There needs to be
multiple testing of an inventory before it is used as a
criterion.
In addition, decisions of such great importance
to the individual should be based on several criteria.
Speculat ions
This research study demonstrates the process of transfering an expert systems mode of inquiry from the discipline
of computer science to the discipline of nursing.
The tech-
nology transfer model of research as described by Hensley
and Jauch (1988) proved to be a useful way to build professional nursing values knowledge.
In turn, this values
knowledge structure was used as the basis for a psychometric
analysis research design in which a professional values
measurement model was developed and tested for construct
validity and internal consistency reliability.
Future Uses of Research Data
Descriptive data for subjects (age, sex, nursing experience, highest degree obtained, nursing specialty, and
faculty rank) form an accurate profile of nurse educators in
undergraduate baccalaureate programs.
Further analysis of
data might suggest future directions for nursing education
134
and nursing practice in the United States.
Nurse educators
have great influence on the way future nurses identify
professional functions and roles.
Thirty-three percent of respondents wrote comments,
suggestions and questions related to the IPNV and to professional nursing values.
One might use a more sophisticated
qualitative mode of inquiry to further study nurse educator
experts' views on professional nursing values.
Response scores on Ochsner's IPNV behavior, attitude
and personal quality items may be further analyzed through
additional confirmatory analysis procedures for more definitive validity testing.
Also, multiple testing and analysis
of the IPNV final measurement model will be necessary before
the inventory is used for predictive purposes.
A great deal
more field testing and analysis of the final measurement
model will be required.
Health care delivery patterns and nurse practice roles
are in flux.
The time is opportune for professional nursing
values to be identified and used as a moral force in health
care delivery.
Ochsner's Inventory of Professional Nursing
Values can contribute to this moral force in two ways:
(1) nursing's professional values and moral beliefs knowledge base will be increased, and (2) Ochsner's IPNV can be
used by nurses and nursing students for personal and
professional reflection on basic values that guide nursing
pract ice.
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APPENDIX A
AMERICAN ASSOCIATION OF COLLEGES OF NURSING
"ESSENTIALS" VALUES, ATTITUDES,
AND PROFESSIONAL BEHAVIORS
145
146
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APPENDIX B
SURVEY COVER LETTER AND OCHSNER'S INVENTORY OF
PROFESSIONAL NURSING VALUES (IPNV)
147
148
9506 Beals Drive
El Paso, Texas 79924
Oaober, 1995
Dear Colleague,
I invite you to participate in my doaoraj study, the purpose of u-hich is to develop and validate a selfrepon inventory to zssess the imporunce of professional values in nursing: The Inventor)- of Professional Nursing Values (IPN\^. Approval to implement this study xK-as obtained from the Texas Tech
University Committee for Proteaion of Human Subjects.
The contribution of this study is two fold: 1) the kno-c^'ledge base for nursing's professional values
and mora] beliefs will be increased; and 2) the IPNV can be used by nurses, nursing students, and nurse
educators for self-evaluation, career counseling, curriculum building, and refleaion on the ^•alues that
guide nursing praaice and influence nursing education.
This study builds on key research reported in the essentia! values seaion of the American Association of
Colleges of Nursing's 1986 Final Report on Essentials of College and University Education for Professional
Nursing (the 'Essentials"). Nineteen of the 50 behavior items and 36 of the 50 auirude/qualit)- terms come from
The 'Essentials'. Five behavior items are direa quotes from the American Nurses Association Code of Nurses.
The balance of items are new and result from an extensive literature search, pilot study responses from 9D nurses,
interviews with nurse educators, and personal experience. These new items were incorporated into the IPNV
while retaining the 1986 'Essentials' value statements as a philosophical base.
Health care delivery panems and nurse praaice roles are in flux. This is an opportune time to develop an
instrument that can aid in the clarification of professional nurse values thereby enhancing role and functions of
nurses.
Please read instuaions at the top of each section of the IPNV. If you believe items should be added or deleted,
please so indicate in Section IV on the last page. The data will be colleaed and recorded in such a manner that all
information will be held confidential. Demographic data will be reported as collective descriptive data. If you
desire a copy of the results of this study, check 'Results Requested" blank in Seaion V, and I will send you an
executive summary of this study.
Place the completed inventory in the attached stamped pre-addressed envelope and mail it. Thank you f c
your assistance. Your participation is most appreciated.
Sincerely,
Anita K. Ochsner, MSN, MA, RN
Doaoral Candidate in Higher Education, Texas Tech Universitv, Lubbock
Coordinator, Primary Care Nursing, University of Texas at El Paso
(915) 747-7228
149
Inventory of Professional Nursing Values
Section I: Nursing Behaviors
Directions: For the behaviors listed below, indicate which ones you think represent important
professional nursing values. If you think the behavior is not important, circle I. If you think it is
somewhat important, important, or very important, circle 2, 3 or 4. If you think it is an essential
professional nursing behavior, circle 5.
Note: Client = Individual, family, community
I
Not lmp>ortant
1.
2
Somewhat Important
3
Important
5
Essential
Very Important
Supports the right of other caregivers to suggest alternatives to
the plan of care.
2
3
5
2.
Presents self In a n^nner that promotes a posttrve image of nursing.
2
3
5
3.
Alters the environment so It ts pleasing to the client.
2
3
5
4.
Assists other personnel in providing care v/hen they are unable to
do so.
5.
Expresses to key persons/groups ideas about the improvement of
access to nursing and health care.
2
3
5
6.
Exerts cultural sensrtrvity in practice of assertive "techniques".
2
3
5
7.
Provides nursing care based on the individual's needs irrespective of
client's personal characteristics.
2
3
5
8.
Participates in discussions of controversial ethical issues in nursing.
2
3
5
9.
Honors individual'srightto refuse treatment.
2
3
5
10.
Creates learning experiences for self and/or others.
2
3
5
11.
Creates an emotionally pleasant workplace environment for self and
others.
12.
Expresses to key persons/groups concern about social trends and
issues that have Implications for health care.
13.
Seeks opportunrty to offer help, support, and/or positive feedback
to colleagues.
2
3
5
14.
Interacts with other providers in a non-discriminatory manner.
2
3
5
15.
Acts to safeguard the client and the public v/hen health care and
safety are affected by the incompetent, unethical or illegal practice
of any person. •
150
Section I: Nursing Behaviors (cont.)
I
Not Important
16.
2
Somev/hat Important
3
Important
Very Important
S
Essential
Participates in activities to prevent or reduce the impact of
environmental hazards on the public's health.
2
5
17.
Promotes safety for self and others in the work place environment.
2
5
18.
Maintains confidentiality of clients and staff.
2
5
19.
Safeguards the individual's right to privacy.
2
5
20.
Addresses staff/clients as they prefer to be addressed.
2
5
21.
Inspires confidence and trust in clients, colleagues, and supervisors.
2
5
22.
Asks for help in unfamiliar clinical situations.
2
5
23.
Documents nursing care accurately and honestly.
2
5
24.
Participates in the profession's effort to protect the public from
misinformation and misrepresentation and to maintain the integrity
of nursing.*
2
5
25.
Gives full attention to the client when giving care.
2
5
26.
Treats colleagues and clients v»Tth respect regardless of sociocultural
background.
2
5
27.
Considers cost along with quality care to clients.
2
5
28.
Obtains sufficient data to make sound judgments before reporting
infractions of organizational policy.
2
5
29.
Utilizes technological approaches to manage client care information.
2
5
30.
Identifies own strengths and weaknesses.
2
5
31.
Updates clinical skills to n>eet client's health care needs.
2
5
32.
Promotes health care changes that increase access, quality, or
service for clients.
33.
Works v>Tth an interdisciplinary team designed to meet the public's
2
5
2
5
health care needs.
34.
Participates in nursing research aalvlties.
35.
Takes an active role v»^n attending professional nursing organization
meetings.
2
5
36.
Coordinates nursing care plans' and activities.
2
5
151
Section I: Nursing Behaviors (cont.)
I
Not Important
2
Somewhat Important
3
Important
Very Important
37.
Participates in the profession's efforts to implement and improve
standards of nursing.*
38.
Supports the right of clients to take pari in the development of
their own care plan.
39.
Participates In the profession's efforts to establish and maintain
conditions of employment conducive to high quality nursing care *
40.
Supports the right of clients to be told about care, procedures,
treatments they are to receive, including risks and benefits.
41.
Collaborates with the members of the health professions and
other citizens in promoting community and national efforts to
meet health needs of the public*
42.
Introduces self to client
43.
Balances care for others with care for self.
44.
Maintains a sense of control in professional practice.
45.
Maintains a kindly sense of humor in stressful situations.
46.
Acts to relieve pain and suffering.
47.
Makes a moral decision based on loyalty to a client.
48.
Makes a moral decision based on loyalty to a health care
organization/institution.
49.
Makes a moral decision based on loyalty to a nr>edical doctor.
50.
Makes a moral decision based on loyalty to nursing profession
obligations/duties.
• From Code for Nurses, American Nurses Association. 1985.
5
Essential
152
Section I I: Nursing Attitudes and/or Qualities
Direaions: For the attitudes and/or qualities listed below, indicate which ones you think represent
important professional nursing values. If you think the attitude/quality is not important, circle I. If you
think it is somev»,+iat important, important, or very important, circle 2, 3 or 4. If you think it is an essential
professional nursing attitude/quality, circle 5.
I
N o t Important
2
Somev/hat Important
Note: Client = Individual, family, community
3
Important
S
Essential
Wery Important
1.
Acceptance (favorable regard, approval).
2
3
4
5
2.
Accountability (legally obligated).
2
3
4
5
3.
Appreciation (recognltkjn of worth, importance, or quality).
2
3
4
5
4.
Assertiveness (courage and self-confidence in expression of opinion).
2
3
4
5
5.
Attentiveness (being observant, alertness,mindfulness).
2
3
4
5
6.
Authenticity (genuineness, legitimacy, realness. truthfulness, validity).
2
3
4
5
7.
Caring (feeling of commitment to self and others that energizes
constructive Interaction).
2
3
4
5
8.
Collegiality (caring relationship vmh peers).
2
3
4
5
9.
Commitment (duty, course of action demanded by the profession).
2
3
4
5
10.
Common Sense (ability to make sensible decisions, gumption).
2
3
4
5
I I.
Compassion (concerned alleviation of suffering).
2
3
4
5
12.
Confidence (self-assuranee).
2
3
4
5
13.
Connectedness (nurse-dient interaction based on an understanding
of the human condition).
2
3
4
5
14.
ConsWeration (concern, regard, solicitude, thoughtfulness).
2
3
4
5
15.
Courage (bravery, fortitude, fearlessness, resolution).
2
3
4
5
16.
Creativity (inventiveness).
2
3
4
5
17.
Discernment (skill in perceiving, discriminating, or judging).
2
3
4
5
18
Empathy (a relationship with mutual understanding).
2
3
4
5
19.
Fairness (impartiality, just, and unbiased).
2
3
4
5
20.
Flexibility (adaptiveness, resilience in the face of change).
2
3
4
5
153
Section 11: Nursing Attitudes and/or Quatities (cont.)
1
N o t Important
2
Somev^^at Important
3
Important
4
Very Important
5
Essential
21.
Generosity (big-heartedness, magnanimity).
2
5
22.
Honesty (truth, uprighmess).
2
5
23.
Hope (expectation of success).
2
5
24.
Humaneness (concern for human v<elfare).
2
5
25.
Imagination (creative resourcefulness).
2
5
26.
Independence (self-reliance, self-determination).
2
5
27.
Initiative (ability to establish a plan or task).
2
5
28.
Integrity (trustworthiness, moral or ethical strength, soundness,
completeness).
2
5
29.
Inquisltlveness (eagerness to acquire knov^^ledge).
2
5
30.
Intuition (ready insight v>rlthout evident rational thought or
inference).
2
5
31.
Kindness (favor, benevolence).
2
5
32.
Loyallty (fidelity to a person, cause, obligation, or duty).
2
5
33.
Morality (princlple(s) of right or good conduct).
2
5
34.
Objectivity (free from bias in judgment).
2
5
35.
Openness (willingness to take a chance with or listen to the other side).
2
5
36.
Perseverance (steadfasmess).
2
5
37.
Rationality (logic, valki reasoning).
2
5
38.
Reflectiveness (thoughtfulness).
2
5
39.
Respectfulness (regard, attention. conskJeration).
2
5
40.
Sanctity of Life (holiness and sacredness of life).
2
5
41.
Self-direction (self-guidance).
2
5
42.
Self-discipline (composed, freedom from agitation).
2
5
154
Section I I: Nursing Attitudes and/or Qualities (cont.)
1
N o t Important
2
Somewhat Important
3
Important
43.
Self-esteem (sense of one's own dignity and worth).
44.
Sense of Humor (ability to kindly laugh at self and/or situations).
45.
Sensitivity (av/areness of attitudes and feelings).
46.
Spirituality (attachment to a belief or value system v/hich provides
meaning to life and death).
47.
Supportlveness (helpfulness).
48.
Tolerance (charitableness).
49.
Trust (assured reliance on character, ability, strength or truth
of someone or something).
50.
Wisdom (deep, thorough or mature understanding).
4
Very Important
Essential
Section I I I : Inventory Usefulness
Directions: Please rate each of the following Inventory Sections according t o the extent t o which
you believe the section w o u l d be useful in development of professional nursing values. Circle I if you
believe it w o u l d n o t be useful. Circle 5 if you believe it w o u l d be 1 0 0 % useful.
I = N o t Useful
Section I:
Section I I:
5 = 100% Useful
Nursing Behaviors (Overall)
Subcategories:
a) Nursing Curriculum Development
2
3
4
5
b) Nursing Practice / Clinical Component
2
3
4
5
c) Professional Self-evaluation
2
3
4
5
d) Career counseling
2
3
4
5
a) Nursing Curriculum Development
2
3
4
5
b) Nursing Practice / Clinical Component
2
•3
4
5
c) Professional Self-evaluation
2
3
A
5
d) Career counseling
2
3
4
5
Nursing Attitudes and/or Qualities (Overall)
Subcategories;
155
Section IV: Inventory Comprehensiveness
Directions: Please rate each of the following inventory Sections according to the extent you believe that section to contain comprehensive content related to professional Nursing Values. Mark I
if you believe it is not content comprehensive. Mark 5 if you believe it is 100% content comprehensive.
Comments: Please comment on both Section I and Section I I of the Inventory. Include suggestions for addition of Items and/or deletion of items.
I = Not Comprehensive
5 = 100% Comprehensive
Section I: Nursing Behaviors (Overall)
1 2
3
4
5
Comments:
Section I I: Nursing Attitudes and/or Qualities (Overall)
Comments:
Section V: Identifying Data
Name (Rank/Titie):
Institution:
Address:
State:.
Age in Years: (Check One)
D 20-29
Years of Experience:
D 30-39
D 40-49
Gender: D Female
Zip Code:
D 50-59
D 60 & over
D Male
Specialty Area and/or Certification:
Original degree/diploma for entry into nursing:
Highest Educational Degree:
Results Requested?
D Yes
D No
Copyright; Antta K. Ochsner
Oaober 12, 1995
APPENDIX C
A SCHEMATIC OF THE PROCESS FOR
VALIDATING SYSTEM MODELS
156
157
STAGE 3
Scanning
the
Discipline
STAGE 4
Model
Infrastructure
Identification
STAGE 5
Prototype
Construction
STAGE 6
Pilot Testing
The Model
STAGE 7
Field Testing
& Modification
STAGE 8
Validation of
the Model
STAGE 9
Adoption
Maintenance
& Enhancement,
of the Model
Figure 3. A Schematic of the Process for Validating System Models
APPENDIX D
TEXAS TECH PROTECTION OF HUMAN SUBJECTS
APPROVAL FOR PROFESSIONAL
NURSING VALUES SURVEY
158
159
<S?tii.
• > .
f TEXAS TECH UNIVERSITY
Oflicf of Research SCTVKCS
203 Ha}dCT\ Hall
Lubbock, Texas 79409 1035
(806) 742 38&^ FAX (806) 742 3892
htovcmba 18, 1994
M Tallent Runnels
Education, 1071
Re:
94-1752-X
Professional Nursing Values (Survey)
Dear Dr. Runnels:
The Texas Tech University Osmminee fw the Protection of Human Subjects has approved
your proposal rcfererx«l above. The approN-al is effective from _11/17/94^ to _11/30/95 . You
^NoU be reminded of the pending e>q3iration one month before your approval expires so that you may
request an extension if you wish.
The best of luck on your projects.
Sincerely,.
Jamd L Smith, Chairman
Hidan Subjects Use Qnnmittee
xc:
An Ajjrrmaftve Action Inaaulkm
APPENDIX E
INSTITUTIONS INCLUDED IN SAMPLE
160
Table 15
Institutions included in sample
State
(Number of respondents)
ALABAMA (8)
University of Alabama at Birmingham
Auburn University at Montgmery
ALASKA (1)
University of Alaska, Anchorage
ARIZONA (15)
Northern Arizona University, Flagstaff
University of Arizona, Tucson
ARKANSAS (7)
Arkansas State University, State University
Henderson State University, Arkadelphia
Public
X
X
X
X
X
X
X
CALIFORNIA (14)
Azusa Pacific University, Azusa
California State University, Chico
X
COLORADO (11)
Mesa State College, Grand Junction
University of Northern Colorado, Greeley
X
X
DELAWARE (13)
Delaware State College, Dover
University of Delaware, Newark
X
X
X
D.C. WASHINGTON (5)
Catholic University of America
Howard University
X
X
FLORIDA (11)
Florida A & M University, Tallahassee
Florida Atlantic University, Boca Raton
X
X
GEORGIA (6)
Georgia Southern University, Statesboro
X
HAWAII (9)
Hawaii Pacific University, Kaneohe
University of Hawaii, Honolulu
ILLINOIS (9)
Bradley University, Peoria
Northern Illinois University, DeKalb
161
Private
X
X
X
X
162
Table 15.
State
Continued
(Number of respondents)
Public
INDIANA ( 9 )
Indiana Wesleyan University, Marion
University of Southern Indiana, Evansville
IOWA (9)
Allen College of Nursing, Waterloo
Luther College, Decorah
KANSAS (9)
Mid-America Nazarene College, Olathe
University of Kansas, Kansas City
KENTUCKY (14)
Spalding University, Louisville
University of Louisville, Louisville
LOUISIANA (12)
Our Lady of Holy Cross College, New Orleans
Southeastern Louisiana University, Hammond
X
X
X
X
X
X
X
X
X
X
MAINE (10)
Husson College-Eastern Maine Medical Center,
Bangor
Saint Joseph's College, North Windham
MARYLAND (9)
Coppin State College, Baltimore
Towson State University, Towson
X
X
X
X
MASSACHUSETTS (7)
Curry College, Milton
Simmons College, Boston
MICHIGAN (7)
Northern Michigan University, Marquette
Saginaw Valley State Univ., University Center
MINNESOTA (11)
College of St. Catherine, St Paul
Winona State University, Winona
MISSISSIPPI (13)
Univ. of Southern Mississippi, Hattiesburg
William Carey College, Gulfport
MISSOURI (5)
Maryville University of St Louis, St Louis
Private
X
X
X
X
X
X
X
X
X
163
Table 15.
State
Continued
(Number of respondents)
Public
MONTANA (6)
Carroll College, Helena
Montana State University, Bozeman
X
NEBRASKA (15)
Clarkson College, Omaha
University of Nebraska, Omaha
X
NEVADA (14)
University of Nevada, Las Vegas
University of Nevada, Reno
X
X
X
NEW HAMPSHIRE (11)
Saint Anselm College, Manchester
University of New Hampshire, Durham
X
NEW JERSEY (3)
Trenton State College, Trenton
William Paterson College, Wayne
X
X
NEW MEXICO (3)
University of New Mexico, Albuquerque
X
NEW YORK (6)
City College School of Nsg of CUNY, New York
Pace University, Pleasantvi1le
X
NORTH CAROLINA (6)
University of North Carolina at Charlotte
NORTH DAKOTA (5)
Jamestown College, Jamestown
Tri College Univ.-North Dakota State, Fargo
OHIO (8)
Cleveland State University, Cleveland
Youngstown State University, Youngstown
OKLAHOMA (3)
University at Central Oklahoma, Edmond
OREGON (15)
Linfield College-Good Samaritan, Portland
Oregon Health Sciences University, School of
Nursing, Portland
Private
X
X
X
X
X
X
X
X
X
X
164
Table 15.
State
Continued.
(Number of respondents)
Public
PENNSYLVANIA (12)
Temple University, Philadelphia
Thomas Jefferson University, Philadelphia
X
RHODE ISLAND (5)
Rhode Island College, Providence
Salve Regina University, Newport
X
SOUTH CAROLINA (4)
Clemson University, Clemson
Lander University, Greenwood
X
X
X
X
SOUTH DAKOTA (12)
Mount Mary College, Yankton
South Dakota State University, Brookings
X
TENNESSEE (12)
Austin Peay State University, Clarksville
Middle Tennessee State Univ., Murfreesboro
X
X
TEXAS (8)
Lamar University, Beaumont
Texas Women's University, Denton
X
X
UTAH (9)
Brigham Young University, Provo
University of Utah, Salt Lake City
VIRGINIA (6)
Eastern Mennonite College, Harrisonburg
Radford University, Radford
WASHINGTON (8)
Pacific Lutheran University, Tacoma
Seattle University, Seattle
WEST VIRGINIA (6)
Marshall University, Huntington
University of Charleston, Charleston
X
X
X
X
X
X
X
X
X
WISCONSIN (7)
Cardinal Stritch College, Milwaukee
Edgewood College, Madison
WYOMING (5)
University of Wyoming, Laramie
Private
X
X
X