Correlation Descriptive Study on Nurses’ Professional Values and Job Satisfaction and the Ethical Climate of the Hospital

Introduction

The healthcare environment presents nurses with many challenges, requiring them to be professional, empathetic, and ethical. Nurses’ professional values underpin their practice and are crucial to the quality of health care and the patient experience [1].

The ethical climate of a hospital, in turn, refers to the norms, values, and behaviors present in the workplace, influencing ethical decision-making, the quality of relationships among medical staff members, and the quality of care [2,3]. Understanding this concept can help promote ethical behavior and cultivate a positive ethical culture in hospitals [3].

A favorable ethical climate not only shapes a sense of moral responsibility among nurses but also translates into overall job satisfaction and well-being for those in the profession [4]. In addition, nurses’ adherence to the organization’s values and ethics translates into higher levels of job satisfaction and a sense of recognition and appreciation for their commitment to providing quality care [4].

Professional values refer to deeply held beliefs, norms, and attitudes that shape the way nurses make decisions and conduct their practice [5]. Nurses’ professional values of caring, activism, and professionalism form the foundation of their practice and influence the way nurses engage in patient care. Caring includes concern, empathy, and kindness toward patients, caring for their well-being, and meeting their needs [6]. Activism refers to nurses’ commitment to improving healthcare conditions and promoting justice and equality [7]. Professionalism, on the other hand, refers to behaving according to high ethical standards, developing professional competence, and maintaining autonomy in practice [8].

Nurses’ professional values not only shape nurses’ individual behavior but also influence their relationships with patients, families, and other members of the healthcare team [9]. They are the foundation of a nurse’s ethical and empathetic approach to patient care and form the basis for an ethical climate in the work environment [10,11].

Nurses who show caring and empathy toward patients have a significant impact on creating an ethical climate and quality of care [12]. Their emotional commitment and ability to understand the patient translate into greater patient satisfaction, better health outcomes, and greater trust in the nurse patient relationship [13,14]. These values are also important for patient safety, as nurses care about the well-being of patients, adhere to ethical standards, and are responsible for providing safe care [15]. They also enhance interactions with medical teams through professionalism, cooperation, and respect [15,16]. In addition, nurses’ professional values are a source of professional satisfaction, motivation, and professional development [17]. They are key to quality health care, patient safety, and creating a positive work atmosphere in the medical community [18,19].

Fostering an ethical climate, nurturing job satisfaction, and upholding professional values can contribute to a sense of professional fulfilment among nurses and a thriving profession [4,18].

There is much scientific evidence available showing the impact of the ethical climate of hospitals on nurses’ job satisfaction [20–23]. There are also studies on the relationship between ethical climate and nurses’ professional values [18,24,25]. Previous research on the ethical climate in hospitals has several limitations, especially in terms of geographic coverage and consideration of cultural diversity. Most of the available studies focus mainly on countries in the Middle East or Asia [34,36,37,41,57], which can limit their universality and ability to directly address other contexts, such as Poland. To the best of our knowledge, there is no available research showing the intercorrelations among these 3 important phenomena in groups of nurses working in hospitals. The aim of study is to examine nurses’ levels of professional nursing values, their job satisfaction, and the hospital ethical climate and the relationships between them.

Material and Methods

ETHICS STATEMENT:

The research was initiated following approval from the Bioethics Committee at the Medical University of Lublin (ref. no.: KE-0254/17/2021). The study was performed in accordance with the ethical standards of the Declaration of Helsinki. Enrollment in the research was voluntary and anonymous. Before participating in the study, each participant had to carefully read and understand the informed consent form, which explained the purpose and nature of the study and the procedures involved in participation, as well as their rights as participants. Moreover, respondents’ IP addresses were not collected, because the Google Forms platform that was used to conduct the survey does not provide the researcher with this information. In addition, all collected data in the Excel file were secured by coding, and each respondent was assigned a unique identification number. The data are stored on the first researcher’s computer, which is password-protected to ensure full security against unauthorized access.

STUDY DESIGN:

A descriptive, correlational, cross-sectional study among 388 nurses was conducted from March 2021 to February 2023 in Poland.

STUDY PARTICIPANTS AND SETTINGS:

The Raosoft calculator was used to determine the sample size [26]. Data from the 2022 report of the National Council of Nurses and Midwives shows that there were 15 226 nurses working in Lublin Voivodeship [27]. Assuming a confidence level of 0.95, a margin of error of 0.05, and a response distribution of 0.50, the calculator indicated that the required sample size was 375 people.

A convenience sampling method was used to select the study group. The criteria for inclusion in the study were as follows: (1) consent to participate in the study, (2) possession of a licence to practice as a nurse, (3) current place of work: hospital in the eastern part of Poland, (4) having a minimum of 2 years of professional practice, and (5) access to the internet. The exclusion criteria were opposite to the inclusion criteria.

RESEARCH INSTRUMENTS:

Four research tools were used to conduct this study.

The Nurses’ Professional Values Scale-3 (NPVS-3) is a tool for measuring nurses’ professional values. The scale was developed by Weis and Schank in 2017 based on the earlier Nurses Professional Values Scale (NPVS) and Nurses Professional Values Scale-Revised (NPVS-R) [28]. The NPVS-3 consists of 28 items, which are divided into 3 subscales: caring, activism, and professionalism. The caring subscale refers to nurses’ commitment to caring for patients by showing concern, empathy, and kindness toward them. The activism subscale focuses on nurses’ involvement in efforts to improve healthcare conditions, promote equity and equality, and influence public health and health policy. The professionalism subscale includes nurses’ behavior in accordance with high ethical and professional standards, encompassing responsibility for the work environment, professional and personal development, and having authority as a professional nurse. The respondents rated their responses to the questions on a 5-point Likert scale, where 1 meant “not important” and 5 meant “very important”. The possible range of scores was 28 to 140, where a higher score indicated a greater focus of nurses on professional values. The original version of the NPVS-3 has a high Cronbach alpha coefficient of 0.94 [28], and for the Polish version of the scale, the coefficient is 0.95 [29]. The NPVS-3 was validated in Italy [9], Poland [29], Indonesia [30], Brazil [31], and Austria [32].

The Hospital Ethical Climate Survey (HECS) scale was developed to survey medical personnel’s perceptions about various aspects of ethical workplace climate. The survey tool, developed by Olson in the 1990s in the United States, consists of 26 questions rated by respondents on a 5-point Likert scale, where 1 means “almost never true” and 5 means “almost always true” [2,3]. The Polish version consists of 21 items, and 5 items (Q1, Q2, Q4, Q8, and Q9) that did not meet psychometric criteria were removed [33]. The HECS includes 5 subscales that examine respondents’ relationships with peers, patients, managers, the hospital, and physicians. A higher total score indicates a more positive ethical climate in the surveyed organization. The original version of the NPVS-3 has a high Cronbach alpha coefficient of 0.91 [2,3], and for the Polish version of the scale, the coefficient is 0.93 [33]. The HECS tool was validated and used in many cultures, in Poland [33], Iran [34], Persia [35], Greece [36], and Sweden [37].

The Minnesota Satisfaction Questionnaire-Short Form (MSQ-SF) tool is used to assess the level of intrinsic and extrinsic job satisfaction [38]. Intrinsic job satisfaction is how individuals perceive the nature of the job duties themselves, while extrinsic job satisfaction refers to how people evaluate elements of the work situation that go beyond the specifics of job tasks or the job itself. It assesses 20 job characteristics, such as achievement, independence, coworkers, recognition, and working conditions, using a Likert scale, in which 1 indicates “I am not satisfied”, and 5 indicates “I am extremely satisfied” [38]. The Cronbach alpha coefficient for the variables included in the MSQ in Polish was 0.86 [39]. The MSQ-SF was validated, for example, in Poland [39], Greece [40], and Vietnam [41].

A self-designed survey questionnaire containing questions on the sociodemographic data and professional characteristics of respondents, as well as selected aspects of their work environment, such as age, sex, education, work experience, salary satisfaction, question about re-entering the nursing profession, job position, and working time, was used.

DATA COLLECTION PROCESS:

The survey took place between March 2021 and February 2023 in Poland. In response to the need to avoid face-to-face contact during the coronavirus pandemic, it was decided to conduct the survey remotely. The method used was computer-assisted interviews conducted using a website. An online questionnaire was used, which was created using the “Google Forms” platform. Recruitment of participants was conducted by sending invitations via email to hospitals located in the eastern part of Poland. In addition, the opportunity was taken to make information about the study available on health science and nursing blogs, discussion platforms, and social media that nurses working in this part of Poland use. To join the study, participants were asked to click on a link to the survey questionnaire along with the research instruments. To prevent the same person from completing the survey more than once, the form was made available to respondents as a link that could be used only once. The questionnaire was completed by 586 respondents, from which 388 (66%) were correctly completed and returned. In accordance with the Computer-Assisted Web Interview guidelines, the survey invitation included information for respondents on the purpose and method of the step-by-step survey, clear inclusion criteria, informed and voluntary consent to participate in the survey, and contact information for the researcher in case of questions related to the survey.

STATISTICAL ANALYSIS:

IBM SPSS Statistics software, version 29, was used for statistical analysis. Descriptive analysis of variables was performed, calculating mean values, medians, and standard deviations. Normality of the distribution was analyzed using Shapiro-Wilk tests. Correlations between NPVS-3, HECS, and MSQ-SF were assessed using the Pearson correlation coefficient for variables with normal distribution and the Spearman rho coefficient for non-normal variables.

Mediation analysis was performed using the PROCESS macro in SPSS, following Preacher and Hayes’ guidelines. To assess the significance of mediation effects, a bootstrapping procedure was used, calculating unscaled mediation effects for 5000 samples and 95% confidence intervals. Mediation effects were considered significant when the mean of the estimated indirect effect fell within a 95% confidence interval that did not include zero. Figure 1 illustrates a simple mediation model with a single mediator. Path c shows the overall effect of hospital ethical climate (HECS) on job satisfaction (MSQ). Path c’, in turn, shows both the direct effect of the hospital’s ethical climate (HECS) on job satisfaction (MSQ) and the indirect effect of this climate via the nurses’ professional values (NPVS-3) acting as mediator. The indirect effect is the product of pathways a and b (a×b).

Results

STUDY PARTICIPANTS:

A total of 388 nurses participated in the study. Most respondents were women (95.4%), with an average age of 41.6 years (SD=11.52). More than half of the nurses lived in urban areas (52.3%). Most respondents (83.8%) had higher education (Bachelor of Nursing and Master of Nursing), with an average work experience of 20.6 years (SD=11.52). The detailed characteristics of the respondents are presented in Table 1.

PROFESSIONAL VALUES AND JOB SATISFACTION AMONG NURSES AND THE ETHICAL HOSPITAL CLIMATE:

The overall average NPVS-3 score was 84.47 (SD=7.46), while the minimum score was 65.00 and the maximum score was 101.00. The highest mean score among the 3 dimensions was for activism (39.17; SD=5.14), followed by caring (24.23; SD=4.07) and professionalism (21.07; SD=3.68) (Table 2).

The overall score of the MSQ-SF questionnaire was 60.37, with a minimum score of 44.00 and maximum score of 78.00. Extrinsic job satisfaction among the nurses surveyed was 35.95 (SD=5.05), while intrinsic job satisfaction was 24.42 (SD=3.78) (Table 2).

The total score on the HECS was 77.66 (SD=7.27), with a minimum score of 59.00 and maximum score of 101.00. The highest mean score was recorded for the “managers” subscale at 17.93 (SD=3.69), and the lowest was recorded for the “peers” subscale at 11.82 (SD=2.74; Table 2).

RELATIONSHIP BETWEEN NURSES’ PROFESSIONAL VALUES, JOB SATISFACTIONA AND THE ETHICAL CLIMATE OF THE HOSPITAL:

This study revealed a positive correlation between extrinsic job satisfaction among nurses’ overall MSQ-SF score (rho=0.799; P<0.001) and HECS score (rho=0.140; P=0.006; Table 3).

In turn, intrinsic job satisfaction correlated positively with overall MSQ-SF (rho=0.596; P<0.001) and HECS scale scores (rho=0.170; P<0.001), as well as with HECS subscale scores “peers” (rho=0.102; P=0.045) and “patients” (rho=0.148; P=0.003).

A positive correlation was observed between the overall scores of the MSQ-SF and HECS (rho=0.169; P<0.001; Table 3).

The HECS subscale “managers” correlated negatively with internal job satisfaction (rho=−0.173; P<0.001) and the overall MSQ-SF score (rho=−0.162; P=0.001; Table 3).

There was also a positive correlation between the overall ethical climate in the hospital and all subscales of the tool, namely, “peers” (rho=0.399; P<0.001), “patients” (rho=0.350; P<0.001), “managers” (rho=0.557; P<0.001), “hospital” (rho=0.395; P<0.001) and “physicians” (rho=0.505; P<0.001; Table 3).

The “professionalism” dimension of the NPVS-3 correlated positively with each of its subscales, with the strongest correlation noted with the activism dimension (rho=0.700; P<0.001; Table 3).

Figure 2 shows significant direct associations between hospital ethical climate (HECS) and nurses’ professional values (NPVS-3) (β=0.12, SE=0.04, P<0.05), and between hospital ethical climate (HECS) and job satisfaction (MSQ) (β=0.17, SE=0.04, P<0.001). The direct effect of the mediating variable (nurses’ professional values; NPVS-3) on job satisfaction (MSQ) was also significant (β=0.77, SE=0.04, P<0.001). The direct effect of hospital ethical climate (HECS) on job satisfaction (MSQ) decreased after adding nurses’ professional values (NPVS-3) as a mediator (β=0.07, SE=0.03, P<0.05). The results of the bootstrapping analysis confirmed the mediating role of nurses’ professional values (NPVS-3; IE=0.09; SE=0.04; LLCI=0.02; ULCI=0.17.)

Discussion

The purpose of this study was to examine the relationships between nurses’ professional values, nurses’ job satisfaction, and hospitals’ ethical climate, and their mutual correlations. No study has been found in the literature that uses a compilation of such research tools investigating the correlation between these 3 important phenomena of the nursing profession and the mediation model with these 3 variables. Investigating the relationship between professional values, hospital climate ethics, and nurses’ job satisfaction is crucial due to its significant impact on the organizational commitment, turnover, and well-being of healthcare workers [18,42].

Our study revealed that nurses had the highest mean score in the activism dimension of the NPVS-3. In the case of job satisfaction measured by the MSQ-SF, external job satisfaction was scored higher than internal job satisfaction. Considering the ethical climate of hospital, the highest average score was detected on the “managers” subscale of the HECS. The study showed that external job satisfaction was positively correlated with overall MSQ-SF score and HECS score. Internal job satisfaction correlated positively with the overall MSQ-SF score, HECS score, and “peers” and “patients” subscales of the HECS. The overall MSQ-SF and HECS scores were positively correlated. The NPVS-3 “professionalism” dimension correlated positively with all its subscales, with the strongest correlation with activism. What is more, the direct effect of hospital ethical climate (HECS) on job satisfaction (MSQ) decreased after adding nurses’ professional values (NPVS-3) as a mediator.

Similar studies to ours have focused only on the relationship between a hospital’s ethical climate and either job satisfaction [14] or professional values [18,24,25]. In the study by Özden et al, as in ours, satisfaction was at a moderate level; moreover, the ethical climate had a positive effect on job satisfaction among the nurses surveyed. Tehranineshat et al [18], Elewa [25] and Allari [24] found a positive effect of ethical climate on nurses’ professional values, while in our study, professional values were a “brake” between ethical hospital climate and job satisfaction.

The overall score of professional values among nurses of our study was at a low level (84.47) compared with that of studies conducted by other researchers from, for example, Brazil (124.93) [7] and Iran (121.07) [43]. This may be because nurses can have relatively low knowledge and a relatively low degree of awareness of professional values based on their personal experiences or assumptions of organizational culture and not necessarily the professional values that should guide their ethical decision-making and action [43,44].

Our study shows the hierarchy of professional values among nurses as follows: activism first, followed by caring, and then professionalism. According to the study by Machul et al in 2022, in which they surveyed Polish nursing students, the students’ heirarchy of professional values were different, where caring came first, activism second, and professionalism third [45]. Clinical experience can play a significant role in shaping nurses’ professional values, influencing their application in nursing practice, as in a study by Sibandze and Scafide, which suggested that older nurses with more experience in clinical practice can show greater awareness and application of professional values in nursing care, regardless of their level of education [10]. Managing professional values among nurses is critical to ensuring quality patient care and ethical practice. Nursing ethics play a significant role in guiding nurses’ professional behavior and facilitating ethical reasoning [46]. It is essential to guide nurses’ professional behavior in accordance with established standards of nursing professionalism, such as those recommended by Florence Nightingale, to improve the degree of nurses’ professionalism [47]. Moreover, organizational and individual support for nurses’ ethical competence is crucial to ensure that nurses are well prepared to deal with ethical challenges and make ethical decisions in their practice [48]. In addition, head nurses’ adherence to ethical guidelines is essential to setting a positive example and ensuring ethical behavior among nursing staff [49].

The present study revealed that the average HECS score was 77.66, which can indicate a neutral hospital climate; similar results were obtained by researchers from the United States [50]. A neutral climate can be interpreted as an atmosphere that is not particularly conducive to either positive or negative workplace phenomena; however, according to Linda Olson’s concept, a positive ethical climate is necessary to support professional nursing practice [2,3]. In the present study, the highest rated category on the HECS was relationships with managers, as confirmed by many studies focusing on this topic [23,51,52]. The role of nurse managers as ethical leaders is crucial in shaping the ethical climate in hospitals. Ethical leadership sets the tone for ethical behavior, decision-making, and organizational culture, influencing the overall work environment and experience of nurses [53]. Moreover, ethical leadership is essential for fostering a culture of integrity, transparency, and accountability, which are key to promoting ethical behavior and decision-making among nurses [54,55].

In the present study, the lowest scores in the “peers” category of the HECS among nurses can indicate challenges in the ethical climate related to peer interactions in the hospital environment. This finding suggests that there may be ethical climate issues that affect peer relationships and interactions. Several potential factors can influence this assessment, including communication challenges, lack of support, and perceived ethical dilemmas in peer interactions [56,57]. To address this issue and improve the ethical climate in hospitals, interventions that promote open communication, mutual respect, and ethical decision-making among nursing peers should be considered [58]. Strategies such as team-building activities, conflict resolution training, and fostering a culture of cooperation and support can help improve the ethical climate associated with peer interactions [59]. In addition, providing opportunities for ethical discussions and promoting a shared understanding of ethical principles and values can contribute to a more positive ethical climate among nursing peers [60]. Moreover, supporting leadership and establishing clear ethical guidelines can help create a supportive environment that fosters ethical behavior and positive interactions with peers [61,62].

The positive correlation between the overall ethical climate in the hospital and all subscales of the tool, including “peers”, “patients”, “managers”, “hospital”, and “doctors”, signifies the comprehensive impact of ethical climate on various aspects of the work environment. This correlation indicates that a neutral ethical climate in the hospital environment is associated with positive perceptions along various dimensions. The impact of the ethical climate on nurses also affects their interactions with patients. There is evidence that the ethical climate in hospitals influences nurses’ behavior, which translates into the quality of patient care [63,64].

In the present study, the overall score of the MSQ-SF questionnaire was 60.37, indicating a moderate score. The average job satisfaction among nurses can be attributed to a variety of factors. Studies have shown that job satisfaction among nurses is influenced by several factors, such as job burnout, professional relationships, work climate, age, job position, experience, professional education, social support, control, role clarity, and quality requirements [65,66]. In addition, factors such as salary, job stress, ethical climate, compliance with professional ethics, and turnover intention have been identified as significant factors affecting nurses’ job satisfaction [67–69]. Interestingly, aspects of a nurse’s job, such as procedures to ensure patient safety, significantly affect their perception of job satisfaction [70].

The negative correlation between managers’ and nurses’ intrinsic job satisfaction, as well as overall job satisfaction, can be the result of a variety of factors affecting the work environment in the healthcare system. First and foremost, work overload, which is common in the nursing profession, can lead to fatigue and burnout, especially if managers do not take steps to alleviate this burden [71]. In addition, inadequate staffing and resources can affect job performance, which can lead to frustration and lower satisfaction with duties. A lack of support and communication from managers can create an atmosphere of distrust and isolation within the nursing team [72]. In addition, if managers do not engage in employees’ professional development, offer training, or consider nurses’ individual needs, this can lead to stagnation and a lack of motivation [73]. Notably, nurses’ job satisfaction is often closely linked to the quality of patient care, which further underscores the importance of effective management in the context of the healthcare system [74].

The positive correlations among external job satisfaction among nurses, the overall MSQ-SF scale score, and the “physicians” subscale of the HECS indicate the interplay of job satisfaction, organizational climate, and interprofessional relationships in healthcare facilities. The strong positive correlation between extrinsic job satisfaction among nurses and overall MSQ-SF scale score (rho=0.799; P<0.001) suggested that factors such as salary and other rewards significantly affect overall job satisfaction among nurses [22].

The mediation analysis examined the relationships among nurses’ professional values and job satisfaction and an ethical hospital climate. Introducing the NPVS-3 variable into the analysis reduced the strength of the direct relationship between ethical climate and job satisfaction. This means that professional values act as a mediator between the ethical climate of the hospital and job satisfaction. In other words, the ethical climate has an impact on value formation [18], which ultimately leads to job satisfaction [75].

There may be some tension or conflict between nurses’ professional values and the reality of working in a hospital. Excessive responsibilities can lead to difficulties in realizing nurses’ professional values, resulting in frustration and reduced job satisfaction [18]. A lack of support from staff and a lack of adequate resources can make nurses feel isolated and unable to realize their values, which can negatively affect their motivation and job satisfaction. Conflicts with other staff or supervisors due to incompatibility in values can lead to interpersonal tensions and disruption of the work atmosphere, which can further lower morale and job satisfaction [76]. A lack of congruence between nurses’ values and hospital policies can exacerbate the problem, leading to further conflicts and lowered trust in the institution, which can consequently negatively affect overall job satisfaction [77].

This study has several limitations. Due to the onset of the coronavirus pandemic, it was necessary to conduct the survey remotely, via an online platform. Remote questionnaire-based surveys limited the ability to directly observe behaviors or situations, which made it difficult to assess the context of nurses’ work. Additionally, in data collection, we used questionnaires for nurses’ self-assessment of professional values, job satisfaction, ethical climate of the hospital, which resulted with partial picture of variables measured showing only nurses’ perspective. Supplementing questionnaire-based surveys with qualitative approaches, such as interviews or observations, will allow a better understanding of nurses’ work context and identify subtle aspects that may affect their professional values, their job satisfaction, and the ethical hospital climate.

It is also worth noting that this study was cross-sectional, meaning that it was conducted at a single point in time, making it impossible to draw causal conclusions. In addition, the sampling method used in the study was convenient, which is a limitation, and the conclusions should be interpreted with caution, especially in the context of the nursing population as a whole. It is also significant that the survey covered only the eastern region of Poland. Such a geographic limitation can lead to a lack of representativeness for the entire country, as working conditions and cultural factors can differ in different regions.

In addition, long-term studies can provide more precise information about changes in nurses’ professional values and job satisfaction over time. Tracking these variables over time will provide a better understanding of the evolution and influence of various factors.

The strengths of this study are the isolation of the role of the nurse manager and its importance in the context of job satisfaction, as well as in the ethical climate of the hospital. Focusing on the role of managers in shaping nurses’ professional values and job satisfaction and the ethical climate can provide important insights into effective healthcare management practices.

Conclusions

Our study revealed numerous strong correlations between nurses’ professional values, their job satisfaction, and the ethical climate in hospitals, which can provide important information for managerial personnel working on strategies to increase nurses’ job satisfaction. Effective management of the professional values and ethical climate of hospitals has become a key pillar in building a healthy work environment and influencing job satisfaction, which in turn is capable of improving the well-being of nurses and the quality of patient care. Moreover, the ethical climate of the hospital has an impact on patient satisfaction, through the professional values of nurses (mediators). This result highlights the importance of investment in nurses’ professional value development during professional lifespans, starting from undergraduate education. Additionally, the mediating role of professional values between the ethical climate of hospitals and job satisfaction underlines the importance of actions that protect and strengthen the professional values of nursing staff in the work environment.