ABSTRACT Given the significant and widespread changes in the health
care system, generational diversity and the resulting differences in
values present a challenge for the nursing profession. A three-group
comparative design was used to compare the professional nursing values
held by nursing students, new graduates, and seasoned practitioners,
utilizing the Nursing Professional Values Scale (Weis & Schank,
2000) developed from the American Nurses Association Code of Ethics.
Findings revealed greater similarities than differences across the three
groups; the notion that experience is necessary to develop professional
values was not supported. Significant differences were seen across
groups related to their knowledge regarding the code of ethics and its
relevance to practice. Strategies to bridge the gap in value orientation
between education and practice are offered as a means to strengthen
professional commitment and maintain the viability of the profession.
Values that are likely to influence behavior are a legitimate
concern of those who educate and employ nurses. As a result of new
technologies, scientific advances, and changes in the health care
environment, today's nurses are confronted with uncertainty,
unknown boundaries, and new practice questions. Despite our best
intentions, we take new graduates, who are full of hope and excitement,
and throw them into often-impossible situations. It is imperative that
nursing students clearly understand their own values and those of their
chosen profession so that they may realize the rewards of nursing as a
caring profession (Thorpe & Loo, 2003).
Today's workforce is made up of individuals from different
generational cohorts. Zemke, Raines, and Filipczak tell us that
"there is a problem in the workplace ... not derived from
downsizing, rightsizing, or change. It is a problem of values, views,
mindsets, demographics, and generations in conflict" (2000, p. 9).
The challenge for both nursing education and practice is to view these
differences as potential strengths and maximize the contributions of all
nurses. It takes time to understand the differences between the
The successful leader will try various strategies to bridge the
generational gap and use the expertise of each group to facilitate
patient care. For example, the energy, techno-literacy, and commitment
of Generation X and Millennials will complement the wisdom and nursing
experience of the Baby Boom generation. Recognizing differences and
appreciating the expertise that each nurse brings to the workplace will
create an environment that embraces generational diversity (Gibson,
In discussions with colleagues, we often find ourselves comparing
today's students with ourselves, when we were students and new
graduates. We hear comments such as: "Students/new graduates have
no sense of professional values or professional behavior."
"Students/new graduates are not aware of nursing traditions,
nursing culture, or what it means to be a nurse. Have they not been
taught the Code of Ethics?" "New graduates are not committed
to the organization but are working to pay for their next
vacation." The authors of this article contend that generational
gaps are not new or insurmountable and that recognizing shared values in
the workplace is essential to establish commitment to the nursing
profession (Laschinger, Finegan, Shamian, & Casier, 2003; Swearingen
& Lieberman, 2004).
Translating generational differences into workplace initiatives
requires research into what each group sees as important, but little
research has been done on whether professional values differ by age,
experience, or generation. This research examined the value orientation
of students, new graduates, and seasoned practitioners with regard to
the fundamental values of professional nursing as delineated in the
American Nurses Association (ANA) Code of Ethics (2001). This code is a
succinct statement of the ethical obligations and duties of every
individual who enters the profession. It serves as an expression of
rules, goals, and nonnegotiable ethical standards. Moreover, the code is
an expression of nursing's understanding of its commitment to
society. The values that direct the priorities outlined in the code are
a reflection of the professional commitment necessary for socialization
into our profession.
The study explored the values held by nursing students and compared
findings with new graduates (practicing less than one year) and seasoned
practitioners (practicing at least five years). Three research questions
were generated in response to anecdotal concerns by faculty and staff
regarding value incongruence at the study institution:
* Are there differences in the values of student nurses, new
graduates, and seasoned nurses?
* What is the relationship between professional nursing values and
years of nursing experience?
* Are nursing students and staff nurses aware of the professional
values outlined in the ANA Code of Ethics?
Literature Review The definitions of three terms guided the
literature review: values (attitudes, beliefs, and priorities that bind
individuals together around a common theme and guide behavior);
generational diversity (differences in attitudes, values, work habits,
and expectations); and code of ethics (an explicit statement of the
primary goals, values, and obligations of the profession). The existence
of a code is considered a hallmark of professionalism and is a benchmark
for the profession of nursing (ANA, 2001, p. 26).
In their work on developing a tool to measure professional values
as outlined by the ANA Code of Ethics, Schank and Weis reviewed a number
of studies measuring values. They found that few generalizations could
be drawn from their review because of the diversity of instruments
utilized and the types of values studied. They reiterated the importance
of incorporating values into education and practice in several articles
(Schank & Weis, 1989, 2000, 2001; Schank, Weis, & Ancona, 1996;
Weis, Schank, Eddy, & Elfrink, 1993).
Other authors described the current manner of addressing values
within nursing curricula and identified gaps leading to inadequate
values development (Calhoun, 2005; Daly, 2002; Leners, Roehrs, &
Piccone, 2006; McNeese-Smith & Crook, 2003; Secrest, Norwood, &
Keatley, 2003; Thorpe & Loo, 2003). Recommendations from these
researchers suggest that there is a continuing role for educators,
service, and the profession in helping to maintain professional
excellence, with professional values a requisite component of this
excellence. Alterations in nursing education must recognize the
importance of incorporating generational core values as well as
professional values into nursing preparation.
The challenge for all faculty and practice settings is to try to
engage students in valuable work. Students need to hear about the value
in becoming a nurse, despite a current health care system that raises
serious concerns about the commitment to values. Faculty and staff need
to model professional behaviors and values for students while setting
clear expectations and enforcing appropriate consequences for failure to
meet those expectations (Anderson, 2000).
In their work on managing generational conflicts in the workplace,
Zemke et al. (2000) provide relevant insight into today's nursing
workforce. There is a lack of value congruence that must be addressed in
order to meet the demands of the current health care system (Curtin,
2001; McLeod & Spee, 2003). The preservation of the professional
value systems held by different generations direct and nurture
professional practice and therefore becomes a priority of those who
educate and employ nurses.
Methodology DESIGN/SAMPLE A three-group, cross-sectional design was
used to describe and compare the professional nursing values held by
students, new graduates, and seasoned practitioners. Having obtained
institutional review board approval for the study, a convenience sample
of junior and senior baccalaureate nursing students from three state
university programs were asked to participate, along with two groups of
nurses practicing at the affiliated children's hospital. Practicing
nurses were divided into groups based on years of experience: new
graduates (practicing up to one year) and seasoned practitioners
(practicing five years or more). The students were recruited during
their pediatric rotation at the affiliated institution. They represent a
homogenous group in terms of curricula, clinical experiences, and
PROCEDURE Students were informed about the nature of the study,
that completion of the survey was voluntary, and that participation or
nonparticipation would not affect their course evaluation. The
co-investigator, who had no formal affiliation with the students,
presented the study, answered questions, and requested that students
return the completed survey in the envelope provided if they chose to
participate. Willingness to complete and return the survey implied
Practicing clinical nurses were randomly selected from a list
provided by the human resources department of the hospital. Nurses in
advanced practice roles, administration, and management were excluded.
Surveys were mailed (via interoffice mail) along with a return envelope
and a cover letter requesting participation. A $2.00 spending
certificate for the cafeteria was attached to the survey packet for all
groups as a "thank you" for participating.
DATA COLLECTION INSTRUMENT The Nursing Professional Values Scale
(NPVS), developed by Weis and Schank (2000), was used for this research.
The NPVS is the only standardized instrument that measures professional
nursing values based on the ANA Code of Ethics for Nurses (2001), a
document used in all levels of American nursing programs that prepare
registered nurses, as well as by agencies that employ RNs. The survey is
a 44-item, norm-referenced instrument with a Likert-scale format;
responses range from 5 (most important) to 1 (not important). Each item
on the NPVS is a short, descriptive phrase reflecting a specific code
statement and its interpretive commentary. The 44 items are divided into
11 subscales based on the 11 ANA code value statements. (See Figure.)
The investigators also constructed a demographic survey. Questions
pertained to the subject's age, length of time as an RN, and length
of time at the institution. Other questions were designed to identify
variables of interest, including awareness of the ANA code, its
assimilation into practice, and course presentations of the code.
FINDINGS A total of 384 surveys were distributed among the three
groups. Responses were received from 97 students (return rate 96
percent, 97/101); 46 new graduates (return rate 46 percent, 46/100); and
84 seasoned nurses (return rate 46 percent, 84/183). The overall
response rate was 59 percent. See Table 1 for sample characteristics.
THE NPVS No statistically significant differences were found in
responses among the three groups on any of the 11 NPVS subscales
corresponding to the 11 code statements. All groups thought that each
code statement was important, very important, or most important and
ranked all statements at least 3.5 or higher; more than half (7/11) of
the statements scored as very important or most important. (See Table 2
on the following page for mean subscale scores by group.)
Question 44 on the NPVS, "Use the Code of Ethics as a guide
for practice," was considered by the investigators to be an
important overall question in determining the integration of the code
into daily practice. Analysis of this item revealed the following mean
scores: students, 4.17; new graduates, 3.91; and seasoned nurses, 3.91.
The overall average score (4.02) suggested that all participants thought
the code was a very important guide for their clinical practice.
GENERATIONAL RELATIONSHIP: VALUES AND EXPERIENCE Pearson
correlations were done to determine if there was a relationship between
years of experience as an RN and scores on the NPVS. No statistically
significant relationship was found between years of experience and any
of the individual statements, indicating that nurses who had been
practicing for many years viewed the code as important a guide for
practice as the nursing students and new graduates. The results
confirmed a congruence of values among the three groups.
AWARENESS OF THE CODE OF ETHICS Statistically significant
differences were found among the groups regarding the impact of two
variables of interest on two items: awareness of and course presentation
of the code. Significantly more new graduates responded that they were
aware of the existence of the code than seasoned nurses or students.
Significantly, more students than seasoned nurses were aware of the
code. The same findings held true for whether the code was presented in
a course; that is, there were significant differences across the three
groups, with a higher percentage of new graduates answering
affirmatively compared to seasoned nurses or students. No significant
difference was seen comparing only the seasoned nurses and students.
(See Table 3.)
Limitations of the Study This study used a convenience sample of
nursing students enrolled in three local universities and staff nurses
from one institution. Applicability of the findings cannot be
generalized to other populations. In addition, faculty from the
affiliated universities were not surveyed; their responses might have
provided insight into student value orientation.
Another limitation of the study was that no statistically
significant differences were found among the three groups on the 11 NPVS
subscales. In addition, there was no statistically significant
relationship between years of nursing experience and scores on the NPVS.
Future research could include longitudinal examination of specific
curricula that address professional values as outlined in the ANA Code
of Ethics for Nurses. To identify changes in value orientation, students
could be surveyed as they progress in professional socialization from
new graduates to seasoned practitioners.
Discussion The findings from this study support the long-held
premise that nurses within this organization hold high levels of
professional values. There were greater similarities than differences
across the three groups studied. The study did not validate the
supposition that experience as an RN is necessary to develop
professional values. In addition, due to the mean age of the student
sample (26 years vs the typical 18 to 22 years), generational
incongruence related to value orientation was not found.
It was interesting to note that respondents attached greater
importance to the code statements related to professional issues than
those addressing societal issues. The first three code statements focus
on professional issues pertaining to client rights (patient-focused code
statements, mean score = 4.2, SD = 0.12). The code statements 4 to 6
address the boundaries of duty and loyalty (nurse responsibilities, mean
score = 4.16, SD = 0.05). The final statements, 7 to 11, address aspects
of duties beyond individual patient encounters (societal statements,
mean score = 3.78, SD = 0.22). The professional issues identified as
most important included competence, collaboration, and peer evaluation.
The societal issues identified as important included patient advocacy,
health promotion, and client safety. These findings differ slightly from
the findings reported by the authors of the NPVS, but coincide with the
generational characteristics of today's nursing workforce.
This study provided useful information about the importance of
professional values held by students and staff at the study institution.
The impact of the high level of value congruence was not unexpected, as
one of the objectives of this teaching organization is to help students
become socialized into the profession through value acquisition. For
example, values are communicated through policies, procedures, job
descriptions, competency evaluations, and through unit-based standards
of care that reinforce professional role development. Operationalizing
professional values through self-assessment exercises, mentoring
experiences, skills training, and role modeling by staff has led to an
emphasis on how personal and professional values are integrated into
organizational values. These strategies have served the purpose of
bridging the gap between education and practice, recognizing the
importance of relevant clinical experiences that incorporate both
professional values and generational core values.
Implications for Nursing Education Strategies to enhance value
orientation in education and practice will strengthen the
interrelationship between organizational commitment and employee
retention. Both are critical to sustaining a strong nursing workforce
for the future. In assessing each of the generations represented by the
current workforce, it is important to create work environments that will
attract and retain students and nurses of all ages. Capitalizing on the
strengths of each generation, and finding a means of accommodating all
individuals in the workplace, is one way of maintaining the viability of
the profession and ensuring that an organization has sufficient
employees to prosper (McNamara, 2005; Stewart, 2006).
To meet this challenge, educators, administrators, and
practitioners must recognize and integrate the ANA Code of Ethics as a
framework for value orientation in both the academic and practice
arenas. In addition, those who educate and employ nurses need to be
aware of the rich diversity of generational perspectives and incorporate
this foundation into educational preparation and practice expectations.
The result will be a more creative and adaptable work environment where
nurse educators and practicing nurses are true partners in the future of
the profession (Apostolidis & Polifroni, 2006; Hart, 2006; Iwaisiw,
Andrusyszyn, & Goldenberg, 2007; Swearingen & Lieberman, 2004;
Weston, 2006). The challenge for nurse educators and practitioners is to
review the essence of nursing within the context of current work
settings and alter practice expectations so nurses may achieve balance
and harmony within their professional development and value orientation.
Key Words Values--Generational Diversity--Nursing Code of
Ethics--Nursing Education--Nursing Practice--Nursing Student Values
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Karen LeDuc, MS, APN-BC, CNS, CPN, CNE, is a clinical nurse
specialist at the Children's Hospital, Aurora, Colorado, and an
assistant professor at Regis University, School for Health Care
Professions. Anne Marie Kotzer, PhD, RN, CPN, FAAN, is a nurse
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Table 1. Sample Characteristics
Age (years) Length of time Length of time
as RN (years) at institution
RANGE MEAN RANGE MEAN RANGE MEAN RANGE
(n = 97) 20-52 26
(n = 46) 22-50 26 .08-1.0 .5 .08-1.0 .5
(n = 84) 30-57 43 5-38 19.5 4-31 15.3
Table 2. Nursing Professional Values Subscale (NPVS)
Mean Subscale Scores by Group
NEW GRADUATES SEASONED STUDENTS
Subscale M SD M SD M SD Overall
1 4.24 .57 4.16 .63 4.28 .48 .35
2 4.33 .61 4.22 .58 4.35 .46 .23
3 4.09 .55 4.04 .54 4.06 .49 .87
4 4.14 .67 4.13 .60 4.20 .52 .68
5 4.27 .52 4.14 .50 4.16 .44 .32
6 4.13 .56 4.17 .54 4.10 .48 .67
7 3.64 .69 3.54 .69 3.69 .67 .36
8 3.88 .69 3.94 .60 3.88 .57 .73
9 4.08 .60 4.17 .54 4.05 .51 .19
10 3.92 ,72 3.90 .63 3.92 .60 .59
11 3.49 .76 3.57 .63 3.52 .59 .72
Table 3. Variables of Interest t p Values
VARIABLES SEASONED VS SEASONED VS NEW GRAD VS
NEW GRAD STUDENT STUDENT
Awareness p = <0.001 p = <0.001 p = <0.001
Instruction p = <0.001 p = <0.01 p = <0.001
Relevance N.S. N.S. N.S.
Framework N.S. N.S. N.S.
Figure. ANA Cede Statements and Corresponding
Nursing Professional Values Scale (NPVS) Subscales
ANA CODE STATEMENT NPVS
The nurse provides services with respect
for human dignity and the uniqueness of
the client, unrestricted by
considerations of social or economic
status, personal attributes, or the
nature of health problems. 1
The nurse safeguards the client's right
to privacy by judiciously protecting
information of a confidential nature. 2
The nurse acts to safeguard the client
and the public when health care and
safety are affected by the incompetent,
unethical, or illegal practice of any
The nurse assumes responsibility and
accountability for individual nursing
judgments and actions. 4
The nurse maintains competence in
The nurse exercises informed judgment
and uses individual competence and
qualifications as criteria in seeking
responsibilities, and delegating nursing
activities to others. 6
The nurse participates in activities
that contribute to the ongoing
development of the profession's body of
The nurse participates in the
profession's efforts to implement and
improve standards of nursing. 8
The nurse participates in the
profession's efforts to establish and
maintain conditions of employment
conducive to high quality nursing care. 9
The nurse participates in the
profession's efforts to protect the
public from misinformation and
misrepresentation and to maintain the
integrity of nursing. 10
The nurse collaborates with members of
the health professions and other
citizens in promoting community and
national efforts to meet the health
needs of the public. 11