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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.23 no.73 Murcia ene. 2024  Epub 23-Feb-2024 


The Importance of Professional Values from Clinical Nurses' Perspective

Rutmauli Hutagaol1  , Enie Novieastari2  ,  Suharmanto3  , Savitri Kurnia Widya Sari4 

1Banjarmasin Health Polytechnic of the South Kalimantan Ministry of Health. Indonesia

2Doctor in Nursing. Department of Basic Sciences and Fundamental Nursing. Faculty of Nursing. University of Indonesia. Indonesia

3Doctor in Public Health. School of Medicine. Lampung University. Indonesia

4Nurse at Santa Clotilde Hospital. Santander. Spain



Values become necessary to direct nurses' professional behavior as a dignified profession.


This research aimed to identify Indonesian nurses' professional values and explore essential professional value items based on clinical nurses' perceptions.


This research used mixed method research. As many as 517 nurses filled out the Nursing Professional Value Scale Revised (NPVS-R) questionnaire from April to May 2019 and ten clinical nurses were included in the semi-structured interview.


The professional values of nurses were 97.30 ± 14.15. As many as 74.3% of nurses perceived the professional values of nurses at a high level. There was a significant difference between education level and nurse caring (P value 0.001 <0.05). The most dominant dimension of nurse professional values was the caring dimension of 56.55 ± 8.19. Three themes were obtained from the qualitative research, namely: Caring, Professionalism and Trust.


As the findings suggest, we need to pay more attention to professional values, especially professionalism and trust for the nurses to work in today's complex healthcare context.

Keywords: Professional Values; Clinical Nurse; Caring Dimension


Nurses are often faced with challenges and dilemmas in various nursing services. The psychological challenges nurses face is related to the condition of the patients being treated, concerns about exposure to work and duties as health workers(1), and worries about being infected with the disease and infecting others(2). The ethical dilemmas faced by nurses as health workers are related to the domain of human life, related to end-of-life care issues (such as making decisions related to respect for organizational dilemmas (such as quality of care and cost management)(3).The nurse understands that the patient has the right to know the truth regarding his health condition, but on the other hand, the patient's family asks not to provide information to the patient. Dilemma due to a lack of teamwork among medical care providers (such as doctors who are unresponsive when treating patients with deteriorating conditions)(4,5). In dealing with challenging conditions and ethical dilemmas, nurses need a guide in directing their behavior.

Every professional organization adheres to fundamental principles known as professional values. Nurses apply their professional values in their daily duties(6)because professional values can provide a philosophical framework for nursing practice(7). Values become the need to direct the professional behavior of nurses as a profession in establishing relationships with patients and other caregiving teams(8). As one of the pillars of the health care system, nurses must truly realize the importance of professional values to carry out their complex duties effectively.

Values are acquired, which implies that they are either directly or indirectly learned by observing the behavior of others. After receiving academic education, the cultivation of professional values in nurses is predominantly shaped by experts in the field, fellow colleagues, patient care experiences, and the values upheld by the organization(9). However, it is necessary to explore what items of professional value are the priority of nurses in nursing practice. Therefore, it is proposed to answer the following research question: What are the professional values of clinical nurses?

Thus, this study aimed to: analyze the perspectives of clinical nurses and nurse managers about the importance of professional values and how to apply them in clinical practice.


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:

Subtheme 1.1: Respect others completely

"Everyone has the same competence; we just need to train the nurses in tricks regarding human rights and human relations."(P1, Nurse Manager)

"We have to care for the patient because he is human, he has dignity, he is a living being who needs to be respected, who has integrity, has a heart, and he will return to society, return to his environment."(P7, Nurse Manager)

Subtheme 1.2: Evidence-based practice

“…. Most of the new scientific developments are based on evidence-based practice”.(P2, Nurse Manager)

“… developing research and education in hospital yet Nursing Training Center”.(P3, Nurse Manager)

“Research is always evolving, so we must be able to learn”.(P4, Nurse Manager)

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.

Subtheme 2.1: Active in professional organizations

“I joined in the organization and made nurse competency levels, such as PK I, PK II, PK III according to their competence”.(P2, Nurse Manager)

“We have an association called the Association of Infertility Nurses in Indonesia. So, I was included in the working group …”.(P4, Nurse Manager)

“…I can develop my potential, one of which is in the organization”.(P6, Nurse Manager)

“Participating in scientific meetings, because it's crucial to update, sometimes in theory, the implementation is also different, so the nurses are also involved in scientific meeting events”.(P8, Nurse Manager)

Subtheme 2.2: Practice based on competency according to SOP

“…but with SOPs and rules so how to keep patients safe”.(P2, Nurse Manager)

“Of course, we act according to the SOP; there are rules, for example, there is a stone, we take it out by stepping on it or something, but with SOP and rules so that the patient stays safe”.(P9, Nurse Manager)

“Making improvements from the start of entering the Yasmin Room, until now there have been improvements, starting from the nursing staffing, or competence in general”.(P10, Nurse Manager)

Subtheme 2.3: Professional enhancement

“….so, it is from our own will to learn as well, continue to update and upgrade knowledge”.(P1, Nurse Manager)

“I have to keep abreast of scientific developments, both from literature, training or seminars such as Asian gastroenterology, and so on.”(P2, Nurse Manager)

“The nurses have to keep updating their knowledge, if it is possible, they may continue their education or take part in training courses”.(P6, Nurse Manager)

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.

Subtheme 3.1: Collaboration

“…But like it or not, we have to be able to partner with them (other caregiving professionals) by learning, of course”.(P1, Nurse Manager)

“….in the transplant room, we work a lot with people (caregiving professionals) as a team”.(P5, Nurse Manager)

Subtheme 3.2: Truth

“We have to be able to provide correct information through science. We have to be honest too, in the sense that we cannot say A to patients when things are B”.(P1, Nurse Manager)

“…The patient did not go wrong; he felt that he was being accompanied by his nurse” .(P4, Nurse Manager)

“…. for example, in providing nursing actions, we must comply with the competence we have; by rules and policies, we do not discriminate between patients A and B”.(P10, Nurse Manager)

Subtheme 3.3: Caring regardless of the patient's cultural background

“…. especially if treating patients from a different culture”.(P1, Nurse Manager)

“Treating foreign patients, the approach to patients is not always religious, for example, if he is a gentleman, I talk to about his family or his job, there are various approaches”.(P7, Nurse Manager)


Generally, the professional value perceived by nurses was very important (74.3%), which is similar to findings in previous studies(9,16,17). This may be due to the nursing educational background, most of whom have diplomas and Bachelor's degrees, and most of them have more than 5 years of experience. Some factors can influence nurses' professional values like Individual determinants, level of education, and experience(15,18).

Based on the results, the caring dimension was the highest perceived by clinical nurses in central referral hospitals. This finding is in line with other study(19). Caring is a fundamental value of nursing that has unique characteristics and is inseparable from nursing, therefore caring is inherent in the nursing profession(20). The primary duty of nurses is to deliver safe, ethical, and high-quality care, a goal attainable when patients are treated with dignity, respect, and compassion(19). In this research, nurses received high ratings for this aspect. This may be due to the level of education of nurses with the majority having a diploma and bachelor of science in nursing. Previous research stated that the level of education influences the professional values of nurses(21). The higher the education level, the greater awareness and application of professional values of nurses with lower levels of academic or non-academic education(22).

According to this study findings, there was a significant difference between the caring dimension and the level of education also the trust dimension with clinical nurse work experience. The previous result stated that education level is related to nurses' caring behavior(23). Based on Indonesian National Qualifications Framework(24)of diploma education is at level 5, whereas vocational nurse, nurses can know the basic principles of knowledge in nursing practice and are able to carry out all forms of action in nursing practice and are responsible for the actions taken. Caring is included in the nursing education curriculum in Indonesia because the nursing profession deals directly with humans and has a paradigm that humans are viewed holistically, biologically, psychosocially, and spiritually(25), where these are human needs.

Furthermore, within the various dimensions, nurses' professional values exhibited an uneven distribution. The study results showed that the trust dimension was the second priority, which suggested that clinical nurses garnered patients' respect and comprehension through their expertise in medicine and their professional abilities. However, there were differences with the study findings by Xie et al(14), which found that the dimension “trust” was the highest. This could be clarified by the influence of tension in the nurse-patient relationship on the expectations of clinical nurses concerning patient and healthcare professional trust. Another study(26)also found that trust was the nurse's priority among other dimensions of professional values in Iran nurses. This difference may be related to higher facilities, the nurse’s own competence, and better private hospitals’ work conditions than state ones(27). The location of this research was carried out in educational and government hospitals where various health professions carry out clinical practice in these hospitals such as nursing, medical, radiology, nutritionist, and midwifery students. This may cause patients to assume that they are being treated by health students who are still in the educational process.

Trust is an important element and greatly influences the quality of a relationship, including the relationship between nurses and patients(28). Establishing a relationship of mutual trust can be a medium in developing a relationship between the nurse and the client or family to carry out an act of care that is comfortable for the client. A trusting relationship is a process of interaction between nurses and clients to express needs and solve problems faced by patients. The nurse builds trust in the client through a practical behavioral approach with an attitude of acceptance and respect for the uniqueness of each individual, a climate in which patients feel safe, and an attitude of sharing understanding opinions and thoughts creates warmth, sincerity, understanding empathy, and unconditional positive concern(29).

These results suggest that clinical nursing managers can enhance clinical nurses’ professional values by focusing on the relationship between nurses and patients. They could also focus on enhancing nurses' educational attainment and implementing specific measures to provide relevant training, thereby effectively enhancing nurses' professional values for the advancement of clinical nursing.

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.


It is clear that professional values are in a constant state of evolution, influenced by various factors that can be personal, related to one's experiences, education, and individual perspectives on significance. A deeper understanding of values and their formation can provide fresh guidance for the field of nursing and reinvigorate the nursing profession. The broad scope of these implications underscores the fact that values lie at the core of nursing practice.


The authors would like to thank the hospital and participants involved in this study and the Banjarmasin Health Polytechnic which funded the publication of this research.


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Received: June 05, 2023; Accepted: October 13, 2023

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