Research Design

This study used a mixed design carried out in two stages to examine the professional values of nurses. A mixed methods approach was used to collect, analyze, and mix or integrate quantitative and qualitative data throughout the study. When combined, quantitative and qualitative methods complement each other and provide a complete picture of the research problem. The first stage of this research was data collection, which began with quantitatively collecting data on nurses' professional values using a questionnaire. Then proceed to the second stage, namely collecting qualitative data by conducting semi-structured interviews to explore items of professional values that are the priority of nurses.

Samples and Data Collection

The total size of nursing population was 1554 nurses and up to 517 nurses in all inpatient rooms completed online questionnaires that already got permission from Weis and Schank⁽¹⁰⁾. Samples were taken using a simple random sampling method. Data collection took place from December 2018 to January 2019. The inclusion criteria in this study were (1) Nurses with a minimum level of education of Diploma in Nursing; (2) have a minimum of one year of work experience; and (3) be willing to complete the questionnaire.

A total of 25 nurse managers and 12 nurses met the inclusion criteria, but only 10 nurses agreed to be interviewed. This process is carried out to ensure participant representation and data saturation. The respondent's inclusion criteria were nurse managers who provided nursing care and were recommended by the head of the nursing field. Exclusion criteria were nurse managers who were not recommended by the head of nursing. Sample selection was done by purposive sampling.

The data were taken from general referral center hospitals in Indonesia, carried out between April and May 2019. Data collection was carried out in 2 stages. In the first stage, the researcher collected quantitative data using the Nursing Professional Value Scale Revised (NPVS-R) questionnaire. The NPVS-R is a well-known instrument that has been evaluated on its psychometric properties for measuring professional values in nursing⁽¹¹⁾. The NPVS-R consists of 26 items in Likert scale format ranging from 1 to 5. The participants determined the importance of each item on the Likert scale with the conditions 1 = not important, 2 = somewhat important, 3 = important, 4 = very important, and 5 = most important. The higher the score, the stronger the nurse professional value orientation. To indicate the degree of importance, the total mean scores were divided into low (< 43), medium (43-86), and high (> 86)⁽⁹⁾. Higher scores indicate that professional values are fundamental, and nurses are more orientated towards more professional solid values.

The reliability and validity of the Nursing Professional Value Scale Revised (NPVS-R) instrument has been established in previous studies⁽¹²⁾. The test-retest reliability coefficient was 0.87, with a Cronbach's alpha value of 0.72 and 0.77, indicating sufficient internal homogeneity. The questionnaire consists of 3 dimensions of professional values of nurses, namely 1) Caring: 15 statement items; 2) Professionalism: 8 statement items; 3) Trust: 3 statement items. The trust dimension reflects the nurse's duty (truth value) to the patient. The professionalism dimension reflects nursing competence, self-evaluation, and reflection, and seeking professional development. The caring dimension reflects respect for patients and the protection of patient rights.

The second stage was carried out after the quantitative data was collected and analyzed. Researchers collected qualitative data through semi-structured interview guidelines developed by researchers and validated by senior researchers. The interview guide consists of 3 open questions to explore the professional values of nurses in providing nursing services, namely (1) what do you know about nurse professional values, (2) why professional values are essential for nurses, (3) how do you apply these nurse's professional values? In-depth interviews were conducted for about 40-60 minutes for each respondent. Probing questions were used to encourage participants to provide more information. Bracketing is done during the interview process because it is essential to reduce bias that could affect research objectives. Interviews were conducted face-to-face at a general hospital, a referral center, which guaranteed participants' privacy and avoided distractions such as noise.

Data Analysis

Quantitative analysis was performed using IBM SPSS 26 to analyze the nurse's demographic data and professional values. For the effectiveness and efficiency of qualitative data, the number of participants was adjusted according to saturation at the time of the interview, namely approximately 15 people. Both researchers, in around ten interviews, agreed-upon data saturation. The data were analyzed using thematic analysis, which aims to understand the patterns of meaning from the descriptions of the participant's life experiences⁽¹³⁾. The researcher transcribed the interview verbatim into text and then read it several times.

Furthermore, a search for meaning and identification of themes is carried out, and finally, these themes are arranged into a meaningful whole⁽¹³⁾. The final theme is defined based on the process description and presented as a thematic tree. The thematic tree can represent and connect all possible errors (theme and final sub-theme)⁽¹⁴⁾.

Trustworthiness/ Rigor

The validity test results of r table 0.361 indicate a significance level of 5%. All statement items have a value exceeding the r table, meaning all statement items are valid. The reliability test for the NPVS-R instrument, which consisted of 26 statement items, was 0,639 demonstrating good ability and validity⁽¹⁵⁾. The Cronbach alpha coefficient of 0,94 was reported⁽¹⁶⁾, but this study showed a Cronbach alpha coefficient of 0,91.

Semi-structured interviews with informants were conducted at different times and in different rooms to facilitate qualitative data collection. To increase the reliability of the research, a peer review was conducted involving all members of the research team at each step during the eight months of the study. In addition, researchers use WhatsApp to check members with participants. The results of the member check to validate that the research results follow the experiences expressed by the participants.

Ethical Considerations

This research followed an ethical review process, and ethical approval was obtained from the Health Research Ethics Committee, Faculty of Nursing, University of Indonesia (ethical approval number: 91/UN2.F12. D/HKP.02.04/2019 dated March 14th, 2019). In addition, all participants filled out an online research consent form.

Qualitative data was collected after the participants received information about research consent. It was explained that the participants were volunteers and could choose not to complete the interview without any consequences. Furthermore, the participants were informed about the anonymity of the participants and that the data to be provided would be kept confidential. Participant names are coded from P1-P10.

Descriptive characteristics

Table 1shows the sociodemographic characteristics of the participants. Most participants were female (84.5%), aged 21 to 58 years, and some were 26-30 years old (31.7%). For years of work, approximately 35.4% had worked for less than five years, and 64,6% had worked for more than five years. Most participants were practicing nurses (85.3%), with career paths mostly in PK 2 (39.3%). For educational level, there were mainly nursing diplomas (81.8%), referring to a three-year nursing program at the academy/university level.

Table 1. Respondent Characteristic Demographic Data (n = 517). 

Nurse Professional Values

The results of the Mann Witney Post Hoc test showed that there was a significant difference between the caring dimension and the level of education (p value 0.001 <0.05) and the trust dimension with clinical nurse work experience (p value 0.003 <0.05). Nurses with a Nursing Education level have the highest average score on the caring dimension (58.95 ± 6.98). Nurses with Diploma and Bachelor of Nursing Education levels have an average value of the caring dimension (56.06 ± 8.20) and an average value of the caring dimension at the SPK Education level (53.10 ± 6.77). In addition, the results indicated that Cronbach alpha coefficient was 0,91.

Table 3shows that Nurses perceived caring as the most critical professional value dimension (56.55 ± 8.19). Most clinical nurses perceived professional value at a high level (74.3%) and moderate professional value (25.7%).

Table 3. Average Score for the Nurses Professional Values Scale-Revised (NPVS-R) Subscale (n = 517). 

Apart from quantitative analysis, this study also used a qualitative approach. The results of the interview obtained the following explanation.

Three categories emerged from the data qualitative analysis: “How nurses' professional values are applied by nurse managers”. Figure 1illustrates the organization of categories and subthemes formed from keywords.

Figure 1. Overview of the thematic tree analysis. 

Theme 1: Caring

The essential primary professional value displayed by nurses is caring. According to the participants, the crucial caring behavior is respecting human rights and applying evidence-based practice (EBP). Nurses understand the importance of respecting human rights to be a nurse and apply EBP in nursing practice. Here are some illustrative quotes from the participants:

Theme 2: Professionalism

Nurses state that professionalism is essential in nursing services. Professionalism can have an impact on patient safety. According to the participants, professionalism manifests as being active in professional organizations, practicing based on competence, and practicing based on the latest knowledge.

Theme 3: Trust

The form of trust nurses showing is Collaboration, justice, and patient safety. Nurses collaborate with other care providers to foster a sense of trust from patients to nurses. Collaboration can facilitate the exchange of views or ideas for solving patient health problems from various perspectives according to the field of collaborators.

Implication and Limitations

The results of this study state that clinical nurses need to be trained to take patients’ perspectives in the interaction process, which can make them feel trusted by patients and can consequently be motivated to deliver better nursing services. This research has limitations. The tendency of respondents to choose answers with higher scores on the Likert scale can make respondents' answers inaccurate. Researchers try to minimize this impact by informing respondents about the purpose of the research and reassuring respondents about confidentiality and anonymity. In addition, a proportion of eligible nurses (10%) refused to participate in the interview in this study. This may reduce the diversity of data obtained from the interview results. To reduce this impact, researchers added respondents to be involved in interviews according to recommendations from the head of nursing.