THE VALUE OF NURSING: A

LITERATURE REVIEW

Khim Horton, Verena Tschudin and Armorel Forget

Key words: globalization; professional identity; recruitment and retention; value of
nursing

This article is part of a wider study entitled Value of Nursing, and contains the literature
search from electronic databases. Key words for the search included ‘values of nursing’,
‘values in nursing’, ‘organisational values’ and ‘professional identity’. Thirty-two primary
reports published in English between 2000 and 2006 were identified. The findings
highlight the importance of understanding values and their relevance in nursing and how
values are constructed. The value of nursing is seen to be influenced by cultural change,
globalization, and advancement in technology and medicine. These factors are crucial in
providing a more structured and measured view of what nursing is, which will result in
greater job satisfaction among nurses, better nurse retention and enhanced patient care
within a supportive and harmonious organization. The findings of this review have
implications for policy makers in recruitment and retention in determining the global
value of nursing.

Introduction
Much attention by governments is given to health care. Within nursing, the focus on
recruitment and retention has often been on economic and demographic factors, such
as terms and conditions of employment. The inadequate attention to the cultural,
organizational and professional values that may underlie such factors demonstrates a
lack of understanding of these values and their importance. To have a map of various
perceptions, whether positive or negative, of the values and meanings of, and in,
nursing as a social/work/professional role would assist policy making in health care
and health care education. For example, it is well recognized that salary levels are not
always critical factors in choice of profession and subsequent job satisfaction.
Demographic developments, especially population ageing and the decline in
fertility, as well as a variety of medical and biotechnological developments, have
served to accentuate the attention given to care, raising political, financial and ethical
issues and dilemmas that seem to reach into every corner of modern life.1 In the UK,
values in the National Health Service have received significant attention, culminating

Address for correspondence: Khim Horton, Faculty of Health and Medical Sciences, University
of Surrey, Guildford GU2 7TE, UK. Tel:  44 (0)1483 68 4555; Fax:  44 (0)1483 68 6711; E-mail:
[email protected]

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in three major reports.2
4 Hewison argued that National Health Service values are ‘not
fixed and the predominance of particular values change over time’ (p. 253).5 Adapting
to the dynamic nature of health care is a challenge for nursing and represents a value
that is often not recognized by lay people, health professionals and governments.
Malone6 argues that effective patient care requires a valued and rewarded nursing
workforce.
With the continuing change in the status and role of nurses, the profession needs to
question the direction in which it is heading,7 decipher its core values and reach some
agreement about the moral nursing values of practice.8 It is of profound interest to the
profession as a whole to continue to examine the ways in which values in nursing
are portrayed, and whether these are subject to change globally. This article provides
background understanding of the current knowledge of the value of nursing. An
integrative review has been undertaken to assess the current research available.
As the broadest type of review method, an integrative review allows its findings
simultaneously to include experimental and non-experimental research in order to
understand a phenomenon of concern, and incorporates a wide range of purposes: to
define concepts, to review theories and evidence, and to analyse methodological issues
of a particular topic.9,10

Aims and objectives

The literature review was part of the second stage of the Value of Nursing study that
has been ongoing for some years at the International Centre for Nursing Ethics at the
University of Surrey, UK. This is an international study considering aspects of the
value of nursing as well as values in nursing.
The aim of the review was to establish whether the global value of nursing had
changed in the previous five years, and, if so, in what way. Change(s) in the value of
nursing can impact on the social identity of nurses and nursing, as well as on the
perceived satisfaction in the occupation chosen and factors that will affect recruitment
and retention.
Our review questions were:
. What is the value of nursing?
. How has this changed in the last five years?
. What factors influence the value of nursing?
. What are the implications for nursing in a global context?

Conceptualizing value
We wanted to know about the value of nursing, thus we need to know what the word
‘value’ means. Value indicates what is important, worth while and worth striving for.
It has often been suggested that individual achievement and materialism are major
values in western industrial society. Like norms, values vary from society to society.
Haralambos and Holborn11 give examples of western society’s values placed on
human life as expressed in terms of the norms associated with hygiene (in the home),
settling arguments or disputes without violence, protecting life and limb, and the

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many safety regulations in the work-place. Lawton12 suggests that values are also
beliefs that are considered to be socially and personally desirable and therefore are
recognized as being important in organizations. Hewison5 adds that societal,
organizational and personal values all influence the way people operate in large
institutions.
At an early meeting of the working group of the Value of Nursing research team,
group members brainstormed what is meant by ‘value of nursing’. Examples given
were the estimation of nursing as a social and/or work and/or professional role in the
minds of various stakeholders such as nurses, health care managers, physicians and
other professionals, citizens, policy makers, current patients and nurse educators.
‘Value’ could be explicated in terms of degrees between polar opposites such as,
for example, socially useful/useless, prestigious/low status, fulfilling/unfulfilling,
skilful/unskilled, respected/disrespected, opportunities for advancement/dead-end,
requiring certain (named) virtues/not requiring certain (named) virtues, supported/
unsupported, autonomous/dependent and so forth.
The research study itself was therefore conducted by interview, in order to decrease
the potential for the researchers’ own preconceptions to influence the outcome. The
findings will be published in due course.

Method
In order to be included in the literature review, studies had to:
. Have a focus on the value(s) of nursing, value in nursing, organizational value or
professional identity;
. Be published during the period 2000
/2006;
. Be in English;
. Be randomized controlled trials, observational studies, evaluation studies, or
inductive studies;
. Be written by nurse authors from all branches, trained or student nurses;
. Be inclusive of any setting (hospital, primary care and care homes);
. Measure or self-report on the value of nursing, organizational value, or professional
identity.

Identification of studies
We searched for all potentially relevant literature, both published and unpublished,
and included relevant evidence regardless of the country of origin. The search was
carried out using the research databases MEDLINE, Cumulative Index of Nursing
and Allied Health Literature (CINAHL), PsycINFO, Psychological and Behavioural
Sciences Collection, Internurse and British Nursing Index. The search was restricted to
English language items for pragmatic purposes, and publication during the period
2000
/2006 to ensure currency. Key words used to identify relevant sources were:
. Value of nursing;
. Values in nursing;
. Professional identity;
. Organizational values.

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In addition, the reference lists of papers, reports and review articles were checked to
see if they cited references not identified by the electronic searches, and we contacted
researchers and experts in the field to identify unpublished or grey literature. Using
these criteria, a total of 121 articles were retrieved. Although titles and abstracts
seemed to indicate that the retrieved articles were relevant, after reading it was found
that 89 were not pertinent to this study. Appendix 1 details the 32 relevant articles,
their design and their methodologies.

Study selection and data extraction

All citations identified were downloaded and printed. Two authors indepen-
dently screened the titles and abstracts of the citations identified by the electronic
searches, applied the selection criteria to potentially relevant articles and extracted
data from the full articles. Disagreements were resolved by discussion with the third
author.
Further work was then undertaken to select items where the title or abstract (where
available) indicated that it related to the key terms. Having retrieved the original
articles, we scanned the bibliographies for references that also related to the value(s) of
nursing. The search was halted when ‘saturation point’ was reached, that is, no new
references appeared in the bibliographies of the most recent items. In a number of
areas, especially in commentaries, it was evident from the search of bibliographies that
a limited number of articles existed relating to our key words. In these cases, a
representative sample, judged by the first two authors, was obtained. This review does
not therefore claim to be exhaustive. However, the authors felt confident, given
the number of times selected articles were cited in bibliographies, that all the key
articles in the field were included. Items selected for review included empirical
research. No item was excluded for methodological limitations, although these are
discussed below.

Procedure
Each article was briefly read by one of the authors to identify the main points before
assigning key words. As advocated by Cooper,13 we reviewed, categorized and
critiqued each item. To facilitate this process a code sheet was constructed to record
pertinent information about each study.
The snowball method was used to identify additional literature by means of the
reference lists of research reports accessed through the databases. Relevant articles
were then identified using the same process of database searching, first by title, then
abstract and conclusion, followed by full text. These methods follow the recommenda-
tions of Conn et al.14
After this initial review, the articles were read in more detail and assessed by all
three authors. This was supplemented by discussion regarding review findings
and emerging themes. Our findings are presented below using the main themes.
The country of origin of the individual studies cited below is indicated where
appropriate.
Information on study design and some comments are given in Appendix 1, and a
summary of the findings is shown in Tables 1 and 2.

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Table 1 Country of origin of identified articles

Country No.

Australia 4
Belgium 1
Canada 2
Greece 1
Hong Kong 2
Israel 1
Italy 1
Japan/USA 3
Norway 3
Sweden 2
Taiwan 2
UK 7
USA 2
USA/Canada 1
Total 32

Table 2 Research/design methods used in identified articles

Research design/method No.

Applied philosophical 1
Correlational 2
Cross-sectional 2
Ethnographic 5
Grounded theory 2
Historical 2
Phenomenological 6
Qualitative interview 4
Secondary analysis 2
Survey 6
Total 32

Summary of results
The articles retrieved highlighted moral values as an integral part of society and of
nursing. The literature also showed that this is an area of interest to researchers world-
wide.
The research conducted in the 32 reviewed articles was based on data from 14
countries. A range of methods have been identified, including ethnography,
phenomenology, qualitative interview, cross-sectional surveys and secondary analysis.
The methods chosen to investigate the questions were appropriate to the stated
purpose of the research. The studies used a variety of sampling methods, all with a
precise definition as to why they were chosen. Most had descriptions of study
limitations; these were mainly sample and design issues, including small sample size,
convenience sampling, limited collection in one setting and limitations of cross-
sectional design.

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The main themes that emerged and which have been used here to present the
literature were:
. The role of the nurse;
. The concept of ‘care’;
. The concept of value;
. Values and culture;
. Moral values and the impact on nursing;
. Personal value;
. Organizational value;
. Factors influencing the value of nursing.

The role of the nurse

The role of the nurse has always had its roots in moral values, often being considered a
vocation.5 However, in the modern world nursing is no longer a predominantly
religious profession.15 The ‘nurse’ is now defined as ‘a person, often a woman,
who is trained to tend the sick and infirm, assist doctors etc.’16 and as someone that
‘assists patients under the direct supervision of medical officers’.17
Thupayagale and Dithole argued that for many years nursing struggled ‘with an inner
hunger; a deep need for professional congruency and effectiveness’ (p. 142).18 They
added that the perception of many people, except those aligned to nursing, is to see
nursing too much as an inferior and inadequate undertaking to regard it as a ‘profession’,
thus drawing attention to its stagnation or lack of adequate recognition as a profession.
Compared with other health disciplines such as medicine, pharmacy and psychology,
nursing is viewed as having a lower status.18 This demonstrates how the role of nursing
is aligned with a particular ‘value’ compared with the other health disciplines.
The role of the nurse also includes having to deal with and adapt to a variety of
situations and events, including: caring for people with long-term illnesses and
conditions and for those who are at the end of their life, health promotion, and fun-
damental care such as bathing, comforting and assisting patients and their relatives.15
It is therefore not surprising to find that the term ‘nursing’ is synonymous with caring
for the sick and ‘lame’.15,19
Henderson defined the unique function of the nurse as
to assist the individual, sick or well, in the performance of those activities contributing to
the health or its recovery (or peaceful death) that he would perform unaided if he had the
necessary strength, will or knowledge. And to do this in such a way as to help him gain
independence as rapidly as possible (p. 15).20
This role seems to have changed little, as illustrated by the UK Royal College of
Nursing, which defines nursing as
the use of clinical judgment in the provision of care to enable people to improve, maintain,
or recover health, to cope with health problems, and to achieve the best possible quality of
life, whatever their disease or disability, until death (p. 5).21
Recent empirical studies on emotions and the therapeutic use of self in nursing
observe that, although physical and emotional closeness and intimacy are values
promoted by the ‘new nursing’, relationships of ‘emotional intensity’ with their
patients have not always been facilitated by nurses (p. 393).22

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The concept of ‘care’

Developments in patterns of care delivery have been accompanied by renewed interest
in the meaning and importance of care.23 Not surprisingly, care is increasingly
understood as a topic of such fundamental social importance that its neglect or
marginalization within sociology and related disciplines can no longer be defended.
The concept of care also provides a perspective that cuts across a number of topics
and levels of analysis, linking micro interactions and macro structures, drawing
together formal and informal aspects of social relationships rather than treating
them as distinct or specialized topics.24
26 Chamberlayne and King24 consider that
caring offers a doorway to the study of informal systems of welfare by extending
comparative social policy while at the same time transcending a purely welfare-regime
approach.
In nursing it can be argued that ‘emotions in nurse
/patient relationships are
managed through a form of knowing the patient, which creates a feeling of closeness
but at the same time maintains a distance’ with which both parties are comfortable.22
The intricate nature of caring in nursing has often been debated given that nursing has
historically emphasized the need for nurses to separate their professional life from
private emotions.

The concept of value

The literature highlights the integral role that values play in people’s lives. Values
determine a person’s beliefs and actions. They can also be seen as being a much more
fundamental part of human existence, with values directing the priorities we live by
and shape our being in the world.27 In our literature review we found many aspects
and definitions of values but very few articles gave specific definitions of the value of
nursing. Many authors defined nursing through story telling, such as the RCN’s
publication of The values of nursing.28 We also found that ‘respect’9
31 and ‘caring’ were
often discussed, stating that they are the ‘essence of the profession’.30,32,33 Within
caring there is a philosophy of ‘moral commitment towards protecting human dignity
and preserving humanity’ (p. 31).34 Below are listed all the other terms related to
values in nursing that we found in the literature used.

. Responsibility; . Supporting and empowering

. Honesty; individuals;
. Patient participation; . Reciprocal trust;
. Preservation of wholeness and . Sound knowledge;
humanity; . Clinical competence;
. Patient autonomy; deep human . Relationship;
connection; . Continuity;
. Dignity; enabling hope; compassion; . Homogeneity;
teamwork; . Harmony;
. Making a difference; . Self-sacrifice;
. Versatility; . Hard work;
. Altruism; . Control;
. Nurturing; . Diversity;
. Integrity; . Patient choice;

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. Self-protection; . Obligation;
. Personhood; . Moral attitude;
. Privacy; . Person focused;
. Creativity; . Judgment; freedom;
. Aesthetics; . Individualism;
. Management; . Positive acknowledgement and
. Economic returns; personal achievement.
. Courage;

There is an assumption that values are determinants of social behaviour, thus it is

important to understand the connection between personal values and job descrip-
tions,35 especially if good outcomes are to be achieved.33,35
37 Values influence job
satisfaction, motivation and commitment,38 and, consciously or unconsciously, values
affect the way people act in their personal and professional lives.39

Values and culture

The link between values and culture is not surprising since values are influenced by
a range of factors.37,40 For example, a person’s culture has great bearing on what
value system he or she may adhere to since it shapes the ideas, values and belief
systems to which that person is committed.41,42 By culture we mean those aspects
comprising geographical, historical, societal, linguistic and ethnic dimensions.43
American culture is linked to individualism and self-reliance, whereby an indivi-
dual’s rights are more important than those of society. Other cultures practice
collectivism, whereby the need of society outweighs that of the individual.40 Hence, a
person’s individual value system emerges from the culture with which he or she
associates.
Although the image of a nurse has many common features across cultures, popular
portrayals tend to be culture specific.15,36,37,44 Wros et al. highlight that Japanese
and American nurses hold common values that are ‘woven into the fabric of their
patient care; they also have many practices that are based on their cultural background
and reveal the heterogeneity of nursing across the two cultures’ (p. 138).36 Williams45
argues that an organization’s members will hold values that tend to be, on average,
synonymous with those of their nation’s culture. However, it is important to highlight
that, owing to an increasingly global and multicultural society, the cultural values
of individuals already residing within a country may vary substantially. This may also
be reflected within work groups and organizations.40
All nursing codes have values embodied in them. In the UK, registered nurses are
required to follow the Nursing and Midwifery Council’s code of professional
conduct.46 It is interesting that Japan and the USA have similar membership codes
for nurses and therefore should subscribe to the same values. However, Japanese
nurses value continuity, homogeneity, harmony, self-sacrifice and hard work, whereas
USA nurses focus on control, diversity, patient treatment choice and self-protection.36
In some respects it can be argued that the value of nursing is diverse in a global
sense, with geographical, regional and cultural influences. However, it is important to
note here that, for many years, Japanese (and Chinese) nurses were nurtured on
textbooks of American and British bioethics with little consideration of differences in
culture.47,48

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Moral values and the impact on nursing

A dictionary definition of moral values is that they are ‘concerned with or relating
to human behaviour, especially the distinction between good and bad or right and
wrong behaviour’.16 As such, moral values have a great influence on the way nurses
think and act and therefore play a major role in patient care.31 Conflict can occur
when values differ, resulting in stress, anxiety, burnout and even resignation.49 This
can impact on the organization, resulting in poor patient care and failure to meet
standards and targets.40 The importance of understanding the moral values in
nursing was highlighted in a study by Naden and Eriksson,31 who used a
phenomenological
/hermeneutic approach, collecting notes taken by four nurses,
observation of the four nurses for up to four months, and interviews conducted
with these nurses as well as 30 patients on a medical and a surgical ward. Specific
values found were: courage, responsibility, respect, obligation and moral attitude.
Moral attitude leads to values being realized and can result in patients feeling
positive about the care they receive. Nortvedt emphasized the importance of
empathy and altruistic feelings in nursing and saw them as moral judgements,
stating that: ‘Values can be actualized to a large extent through a moral attitude that
is characterized by sensitive and careful communication’ (p. 91).50 Understanding
and concordance of moral values are therefore vital for the whole health care
environment.
Nurses’ values are linked to factors contributing to job satisfaction or dissatisfac-
tion.39,40,51 When nurses become dissatisfied with their work they often distance
themselves from patients, from nursing tasks,52 and from their inner selves.53 A Greek
study33 states that, if employees were able to live out their moral values, they would
experience job satisfaction and therefore resignation intention would decline. Such
information indicates that, if managers focus more on helping employees to attain their
moral values, retention figures could rise. Butterworth et al.’s research54 indicated that
nurses’ occupational stress levels are increasing in England. The shortage of nurses
and high staff turnover are seen to be compromising nurses’ ability to provide the
competent and compassionate care that is at the core of their moral value system.30
33
This also reflects the responsibility that nurses have towards patients and why moral
values are embedded in codes of conduct.55

Personal value
Research regarding value systems has shown that personal value systems influence
professional lifestyle.35,38,39 In essence, when applied to nursing this indicates that
nurses’ personal value systems influence the actions they take. This has many
implications. If nurses are influenced by a strong value system, they will tend not to
conform to conditions with which they disagree.56 This may also change the way in
which nurses practice. Wros et al.36 clearly state that professional values differ between
American and Japanese nurses. Different practices are apparent with regard to
advocacy. Advocacy is a strong American value that is always considered when
caring for patients; however, in Japan nurses advocate for their patients only if asked to
do so by the patients themselves.36
Begat et al.,30 Fealy,15 McNeese-Smith and Crook,27 and Perry39 all concur with
the statement by the World Health Organization that to be able to ‘meet the challenges

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of their profession, nurses need to be clear about why they think and act as they do,
and they need to perceive themselves as being empowered’ (p. 222).57 This provides
more evidence of the importance for nurses to have a clear understanding of what
their values are.
From a nursing management perspective, understanding the values that motivate
individual staff is an important tool for managers. In a survey of 412 nurses, McNeese-
Smith and Crook27 reported a number of benefits of understanding these values and
state that such knowledge can improve worker production, assist in team performance
and cohesion, and aid performance counselling. These are all traits of the nursing
profession that require attention. According to Fealy the ‘good nurse ideal was
inseparable from the values that constructed nursing practice and defined its
boundaries’ (p. 654).15 Good nursing is defined by its values. It is therefore important
for nurses to understand the values with which they practice, so that good nursing
practice can be achieved.

Organizational value
Another important aspect relating to the value of nursing stems from organizational
value. In the work-place, it is argued that an individual’s values are shaped by the
positions and responsibilities held,58 the effect of taking responsibility, achieving
results, developing a sense of worth, and recognizing and using skills and abilities.
Buffon et al.58 also looked at the values of an organization and how these are de-
termined. The most influential factors are: ‘Integrity; respect; customer focus;
involvement; quality; creativity/innovation; accountability and fairness’ (p. 248).58
Indeed, health care organizations and systems are prime examples of differing cultures
within a working environment, and as such tend to have a variety of individual value
systems.59 This in turn may lead to a range of individual professional goals and
targets. Such an environment may have links to the feelings of ‘being lost’ and
‘undervalued’ that many nursing staff have communicated.60

Factors influencing the value of nursing

When seeking to understand what the global value of nursing is, it becomes evi-
dent that the western hemisphere is becoming much more individualistic and
materialistic.31 The development of technology, especially information technology,
has contributed to a rapid change in values, such as increasing the turnover rate of
patients in hospital, patient focused care and nurses’ job satisfaction.35
The study undertaken by Rognstad et al.35 examines how Norwegian society has
changed by comparing the values that modern nursing students hold to values evident
100 years ago. Using a quantitative longitudinal survey design. Rognstad et al.
surveyed 301 nursing students and discovered that the once highly valued ideals of
nursing
/ humility, solidarity and unity
/ have now been replaced by diverse ideas
regarding life and expectations. They found that the key nursing values in today’s
culture were: freedom, individualism, positive acknowledgement and personal
achievement. The authors attributed these differences in values to changing culture
and society, with particular reference to the developments of information technology.
World-wide migration, changes in demographic patterns, varying fertility rates, in-
creased numbers of multiracial and multiethnic individuals, and advanced technology

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all contribute to changes in cultural diversity and therefore influence values. However,
it is important to recognize that cultures that influence values are not unique to
geographical areas but are also part of institutions, for example, the culture of
a hospital.61
63
Globalization results in people travelling longer distances for business and pleasure,
leading to an increased global market and the internationalization of organizations.
This in turn leads to increased migration figures across the world,64 which have
considerable impact on the daily work of nurses, with such realities as avian flu and
international terror now a world-wide issue; such circumstances affect our health, our
need for health services and the way in which nurses work.64 At the same time, the
health care system is continuing to evolve. Medical advancement is based on
developments in pharmacological and physiological research and on the implementa-
tion of technology within all aspects of health care.59 In addition, the extension of
nurses’ role, including undertaking surgical procedures and performing venepunc-
ture, as well as nurse prescribing, must have an impact on the value of nursing.65

Discussion and implications for nursing

Nurses have experienced great change in the last few decades in both organizational
and individual culture, which Begat et al. believe is ‘putting extra pressure on nurses’
(p. 222).30 Such situations encourage nurses to have diverse life views and expecta-
tions, which can be truly ambivalent and heterogeneous and therefore greatly influ-
ence their value system. In multicultural societies, the cultural values of individuals
already residing within a country can be substantial and are reflected within certain
work groups.35 These values also impact on the personal lives of nurses, influencing
their decision making in family, religious and community environments.
There is currently very little reported research available on the value of modern
nursing in a global context. Much of the literature in this review has highlighted the
implicit need for understanding values owing to the fact that these underpin society,
and, more important to this study, to the way in which nurses interact with each other
and with patients, and how satisfied they are with their job. Our study did not aim to
consider values and patient outcomes or satisfaction, although this would be a logical
sequence when investigating the value of nursing further.
Understanding the moral values in today’s nursing practice will help nurses to
work together with a common comprehension of their aims. This should also allow
greater appreciation of the practice of nursing, highlighting the equal importance of
both fundamental basic nursing care and the advanced clinical roles. However, when
these values have been identified, a number of barriers hinder their inclusion in
nursing practice. Fundamental or basic nursing care holds less of a position of
importance in society compared with more technically advanced clinical nursing
roles.
To overcome these many barriers, a shift in thinking will need to take place. Nursing
unions are among the few organizations that hold the power and authority to influence
such change. If nurses hold shared values, they themselves form a powerful group
who can start to influence the thinking about and attitudes towards the nursing
profession by policy makers and governments. We can only hypothesize how this may
happen. The little research in these areas gives no information on how changes may be

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tackled and what the results may be. The only deduction we can make is that a
cohesive nursing work-force will lead to greater job satisfaction and ultimately better
patient care. This can happen only when nurses have a greater understanding of the
role of nursing and what it means. The appeal of nursing as a realistic and successful
profession needs to be built, tackling the recruitment problem, and establishing a
strong career-focused work-force.
This literature review has highlighted past values in nursing and has also touched
on the impact of developing technology in medicine, as well as the impact of culture
and globalization. We echo Malone’s6 appeal that ‘promoting the value of nursing has
to come from nurses themselves’ in that we need to utilize the body of evidence to
demonstrate the positive impact nurses have on patient care.

Conclusions and implications for research

Limitations of the review
We recognize that the difficulty with using an integrative review strategy is that the
methods of analysis, synthesis and drawing of conclusions are poorly planned. This is
because it endeavours to review many different types of research and incorporates
many purposes.7,8 Despite the number of studies in the literature relating to the value
of nursing, there are, for instance, many gaps in the scientific base of knowledge
related to male nurses. Male nurses have not been studied adequately because of
the limitations in sampling design, with too few men in many samples. Many have
been convenience samples, limiting the generalizability of the findings. Because of the
small sample sizes and the predominantly female presence in nursing, analyses by sex
has been limited.
There is also a need for longitudinal studies that analyse the changes that occur
in the lives, perceptions and needs of nurses over the duration of their career.
Reports of such studies across countries would help to inform global policies in
nursing recruitment and retention. Longitudinal studies on the value of nursing
could answer questions that are not possible to resolve by cross-sectional designs.
Studies that explore differences in the value of nursing by sex and over time are
needed.
Our colleagues have made us aware of studies that would have been as relevant as
those included in the literature review, but, because of the search carried out by
specific key words, they were not included. This is an indicator of the limitations of
key words and indeed of search databases. We add details of some of these studies to
complement the above text.66
70

Implications for policy makers

The findings of this review have implications for policy makers at many levels. It is
becoming increasingly important for governments to see health issues as being related
to economic and foreign policies.71 Issues of national and international security
and protection, and abuses of humanitarian law and human rights result in
widespread illness and disease. Recruitment and retention and personnel
/ what

Nursing Ethics 2007 14 (6)

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728 K Horton et al.

type, how many, for which needs
/ have long been seen as vital aspects of policies in
health care, with ripple effects on basic and secondary education, taxation and the
general well-being of a society. For nurses to be involved in policy making at high
levels, it is important that they understand clearly what the value of nursing is in terms
of the wider global economy and planning for good governance.

Acknowledgements
We would like to thank the researchers of the Value of Nursing project. We thank in
particular Dr Douglas Olsen, Professor Samantha Pang and Professor Janet Storch for
their valuable comments on earlier drafts of this text.

Khim Horton and Verena Tschudin, Faculty of Health and Medical Sciences, University of
Surrey, Guildford, UK.
Armorel Forget, Royal Surrey County Hospital, Guildford, UK.

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 Nursing Ethics 2007 14 (6)

732
Appendix 1

K Horton et al.
Outline of studies

Reference Purpose Methods Country Results Comments

of origin

Allan and To explore the Ethnographic case study England Nurses justified their new Emotions are acknowledged and
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Barber, 200522 nature of advanced approach, including advanced nursing roles to managed in response to perceived
fertility nursing 4 weeks of participant develop a therapeutic use patient and nurse needs. The authors
roles and to observation and of self. suggest that nurses offer and that
describe these semistructured interviews patients ‘sense’ something more than
roles with 5 nurses, 1 health care instrumental care, even when engaged
assistant, 1 doctor and in routine tasks.
3 infertile couples
Barron and West, To investigate Secondary analysis from England Many nurses leave to care There are positive links between job
200572 factors associated British Household Panel for their families. Nurses seem satisfaction and commitment to the
with qualified Survey data collected to be vulnerable to leaving early organization. Most important
nurses in Britain between 1991 and 2001; in their careers, but those who elements to dissatisfaction are lack of
moving to different sample size 5000 house- survive the first few years are promotion and training opportunities.
employment holds likely to remain in their Nurses born outside of UK are less likely
statuses profession. Job characteristics to leave early. Using initiative is the key
key to leaving: low pay, to job satisfaction and retention. Now is
managerial responsibility. the time to re-examine the value that is
attached to the caring work of nursing.
Begat et al., 200530 To examine nurses’ Descriptive
/correlational Norway Nurses’ satisfaction and job Main job stress and anxiety factors were
satisfaction with study using stress is significantly correlated to do with ethical conflicts. Gives
their psychosocial questionnaires with ethical conflicts in which examples of values. Nurses’ own values
work environment, Sample: n 71 nurses nurses base their actions on and norms influence their actions. The
their moral from 2 hospitals knowledge, principles, other organizational values are part of nurses’
sensitivity and nurses’ knowledge and their psychosocial work environment. Often
differences in feelings. Significant correlation these are conflicting, and nurses are
outcomes of clinical between ‘independence’ and forced to compromise their moral
nursing supervision ‘relationship with colleagues’ integrity.
in relation to and ‘collaboration and good
nurses’ well-being communication’ and ‘work
demands’.
 Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

of origin

Cowin, 200173 To develop a tool Exploratory and Australia Final version of the measure Shows that nurses’ self-concept is
to measure confirmatory, using expert contained 36 items in 6 subscales. multidimensional. This measure is now
self-concept, panel to review factors Both groups rated their utilized in a causal study to examine the
specifically for in the subscales self-concept in a positive manner, effects of a positive self-concept on job
nurses Sample: 2 groups of nurses suggesting that they were satisfaction and nurse retention.
participated: group 1 comfortable and confident as
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comprised 482 students, nurses. However, leadership

and group 2 consisted of was scored lowest.
2000 randomly selected
qualified nurses
Dombeck, 200344 To explore how Ethnography: sample USA/Japan All nurses were profoundly Nurses are seen as passive and
nurses construe n 36 affected by the socially decorative. Some see caring at the
and understand Participant observation accepted ‘feminine’ image of heart of nursing, others see it as a
their professional employed; individual nursing. perpetuation of subservience. Work
culture and their conversations audio-taped Implications: raises the need for cannot be understood outside the
professional new models of nursing education context of the sociocultural arena in
personhood and leadership to deal with old which it is enacted.
images and make nursing
attractive to a diverse population.
Fagerberg, 200359 To understand the Phenomenological
/ Sweden 3 themes: the meaning of caring A complex interrelationship between
meaning of hermeneutic method and protection of patients; the health care organizations, individual
registered nurses’ Sample: 16 registered meaning of work organization attributes and patient care. Therefore
narratives of their nurses 5 years after in nurses’ work; and the implied it is important to support nurses’
work experience graduation meaning of using one’s professional and personal development.
5 years after individual attributes in one’s

The value of nursing

graduation professional role.
Fagerberg and To understand how Phenomenological
/ Sweden 4 perspectives: having the Narratives changed as nurses became
Nursing Ethics 2007 14 (6)

Kihlgren, 200074 nurses experience hermeneutic method patient in focus; being a team more experienced. Does this mean that
the meaning of their involving 20 nursing leader; preceptorship; and task the value of nursing also changed over
identity as nurses students orientation. Nurses did not time?
when students change their perspectives, but
and 2 years showed transition over time.
post-registration The dominating perspective is
understood as the professional
identity of nurses.

733
 Nursing Ethics 2007 14 (6)

734
Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

K Horton et al.
of origin

Faithfull and Explores the nature Qualitative design; data England Valuing nursing as a therapy in Suggests that fundamental values of
Hunt, 200575 of the role of the drawn from field notes itself is often overlooked. nurse-led care need to change. Describes
nurse in the and qualitative comments Analysis highlighted 7 meaning of values and values integral to
development of a during a pilot study professional values integral to nurse-led care. Highlights that there has
nurse-led service nurse-led care and leadership. been a significant shift in nursing values,
These include: therapeutic therefore the concept of nursing has
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support, working with changed. Co-operation and

uncertainty, timeliness, enhanced understanding is often hindered because
professional autonomy, and of a lack of awareness of differing
continuity and trust in care. professional/organizational values.
Fealy, 200415 To provide a Using critical discourse Irish Discusses the identity of nurses The origins of the ‘good nurse’ ideal
discourse analysis within the method Republic/ throughout time. were identified. Suggests that the image
concerning the of historical research, this UK of the nurse is both culture specific and
good nurse study uses documentary changes to reflect the underlying
primary sources sociocultural context, and political
Used theoretical sample of power and influence.
the full range of early Irish
nursing journals
Goopy, 200541 To explore the key Ethnography: field work in Australia Local culture is vital to social All nurses are educated within broad
aspects of social an intensive care unit of a relations and the impetus behind standards that reflect, to varying degrees,
relations and local major public hospital in work-place management and the ideals of what it means to be a nurse;
staff culture in Rome, Italy: 37 nurses, organization. however the actions and practices of
Italian nurses 46 medical doctors nurses are embedded in their socio-
cultural milieu and their value systems.
Argues that what a nurse does and what
a nurse represents are intelligible only
when considered from within the
consciousness of his or her cultural
identity.
Gregg and To explore the Grounded theory USA/Japan Recognizing the value of nursing Very little literature exists about how
Magilvy, 200132 process of approach, with constant is crucial to the process of individual nurses establish their own
establishing the comparative analysis establishing professional identity. professional identity. Highlights the
professional Sample: n  18 nurses Establishing one’s own philo- importance of work experiences, and
identity of Semistructured interviews sophy of nursing and gaining that ‘nursing was part of their lives and
Japanese nurses and participant influences from education were nursing was representative of their
observation in natural valued. Japanese culture values existence’ (p. 53).
settings modesty. Many participants
expressed their self-confidence.
 Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

of origin

Heung et al., To determine how Phenomenological study Hong Kong The SARS crisis enhanced a Values: commitment to the profession
200476 the impact of the involving 10 nursing reconstruction of worldview and and moral responsiveness to society.
severe acute students affirmed the professional identity Understood the value of health.
respiratory of nursing students. Recognized the value of nursing as a
syndrome (SARS) profession that concerns others’ lives
event might have and being altruistic in nature.
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affected nursing
students in
identifying with the
nursing profession
Itzhaky et al., To compare Cross-sectional Israel Nurses have higher levels of Suggests that nursing education
200455 empowerment, questionnaire survey: knowledge, self-concept, critical prepares nurses to feel more capable
skills, and values ofrandomly recruited awareness and propensity to act and competent than social workers to
social workers and sample of social workers than social workers. Both groups treat patients. This may be related to
nurses from 3 social services seem to prefer to work in groups, nurses’ roles and tasks being more
departments (n  213) and believing that it contributes to defined.
nurses (n 152) from 2 their professional identity.
randomly selected regional
hospitals
Lemonidou To explore students’ Phenomenological design Greece The process of developing an Nursing is caring and nurturing in
et al., 200433 lived experience of based on journal narrative awareness of personal values nature. It is focused on supporting and
ethics and their analysis through empathizing with empowering individuals
/ restoring
perceptions and Sample: 75 student nurses patients was identified as the balance and integrity. Nursing students
understanding of core theme of students’ need to develop their self-awareness as
encountered ethical experience. ethical agents.

The value of nursing

conflicts and
dilemmas
Nursing Ethics 2007 14 (6)

Maclntosh, 200329 To explore Grounded theory USA/ Three stages
/ assuming One of the biggest values is that of
experienced nurses’ approach with substantive Canada adequacy, realizing practice, and respect. Has implications for nurse
perceptions of how and theoretical coding and developing a reputation
/ occur education to help prepare nurses for
they became constant comparative when nurses encounter realities in the work-place and to be
professional analysis discrepancies and dissonance. active in developing their professional
Sample of registered Feeling respected and feeling identity.
nurses: n  21 professional are influenced by
how others respond to nurses
themselves.

735
 Nursing Ethics 2007 14 (6)

736
Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

K Horton et al.
of origin

Martin et al., To determine the Survey design with a USA Key findings relate to sex and This study shows new information
200377 congruency in value convenience sample of ethnicity. Ethnic groups differed about the professional values held
orientation of 1450 graduating nursing on the responses to 3 of the by graduating students.
graduating nurses students in Texas subscales representing nurses’
values: respect for human dignity,
safeguarding the client and
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public; and collaborating to meet

public health needs.
McNeese-Smith To identify the Random survey, using USA Measured 15 stated values. Management strategies to meet nurses’
and Crook, extent to which valid and reliable Nurses in top jobs valued their values and increase their satisfaction
200327 values are instruments to measure associates, creativity, aesthetics and retention were also presented. Need
associated with the variables of interest and management, while those in to identify the values that influence
age and job stage Sample: 412 nurses in the bottom third valued economic motivation and job satisfaction.
3 hospitals returns.
Nelson and To examine one Historical record Australia Nurses keep trying to re-invent Argues that the ‘devaluing of nursing
Gordon, 200478 aspect of the history observation themselves; this is causing big skill and competence that takes place
of nursing’s search problems. They need to stop within nursing has led to a flight from
for social legitimacy doing it! Must recognize the skills the ‘tasks’ of nursing and a denigration
of the past. of technical competence as mindless,
mechanical work’ (p. 260). Nurses rate
highly on the public’s scale; especially
for being ethical and honest: Is this
based on up-to-date knowledge or
traditional stereotypes?
Parkes et al., To determine how Quantitative Australia A collectivist tends to have Explores much about values, especially
200140 congruence on Sample drawn from greater commitment and longer participants’ original cultures. However,
individualism
/ 2 matched organizations tenure in organizations. it does not discuss what values are. Is
collectivism affect in Australia (n 160, and Individually, collectivism was of limited use in how values could
individual 104) and Southeast Asia positively corelated with influence nursing.
outcomes such as (n 122, and 195) organizational commitment and
commitment, job tenure, but not with job
satisfaction and satisfaction. No effects were
tenure across na- found for predicted 3-way
tional cultures and interactions between individual
across organiza- values, organizational values
tional cultures and national cultures.
within countries
 Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

of origin

Pask, 200379 To determine the Applied philosophical England Nurses experience value of Nurses’ opinion of themselves is
nature of moral method using interviews 2 kinds: value that is recognized dependent on their ability to see the
agency in nursing with nurses as being intrinsic to the moment; good in what they do.
and why nurses see Sample: 5 nurses and that which is experienced
value in the work when the self of the nurse
they do. achieves that which he or she
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set out to achieve.

Pellatt, 200380 To identify how Ethnographic/interpretive England Suggests that patients value the Nurses need to develop their bedrock
nurses and patients field-based approach nursing contribution as a means role in a way that empowers patients.
perceive the involving 28 nurses of emotional and physical
nursing role in support but not necessarily
spinal cord injury as rehabilitation.
rehabilitation
Perry, 200539 To determine what Interpretive/ Canada Key themes: affirming the value Nurses who were satisfied with their
contributes to the phenomenological of the person, defending dignity, career choice ‘live out their core values
professional approach using web-based enabling hope, and helping and engage in interdependence’ (p. 41).
fulfilment of data collection method patients to find meaning. Nurses Nurses really value making a conscious
registered nurses Sample: Over a 1-year who thought they provided good difference to patients’/relatives’ lives.
period, about 200 quality care and had good
researcher
/participant relationships with patients were
interactions took place and satisfied with their careers.
more than 100 narratives
were collected
Rognstad To determine what A follow up to an earlier Norway Response rate of 68.1%. Survey Professional practice should be
et al., 200435 motivates nursing survey about motivation found ambiguity in the helping anchored in virtues and values, and

The value of nursing

students at the end for and beliefs about a motive and this was supported the learning and practice of professional
of their studies to degree programme among by interview data and indicates caring should give students an
Nursing Ethics 2007 14 (6)

help other human first-year nursing students an emphasis on both self-esteem opportunity to form and develop
beings; to establish (n 315); 18 students also and other-concern. All 18 student virtues such as altruism and courage.
what helping others interviewed interviewees expressed a wish for
means to them and acknowledgement and positive
what would be the feedback when helping others.
consequences for
modern nursing
and education of a
shift in value

737
 Nursing Ethics 2007 14 (6)

738
Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

K Horton et al.
of origin

Shih et al., 200281 To compare the Purposive sample of Taiwan Their rescue experiences further Most of the nurses recognized the need
impact of rescue 46 nurses; in-depth convinced them of the value of to be more considerate, altruistic health
experiences on semistructured nursing and confirmed them as care givers. From this study we can learn
Taiwanese female interviews valuable and competent helpers. how clinical situations (i.e. death and
and male nurses Male and female nurses valued dying, emergency and disaster) impact
who worked as different things. The experience on nurses’ own biopsychosocial
/
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rescuers following helped to improve their spiritual well-being. The value of

the earthquake of professional competency, nursing was ‘the sum of a lot of routines
21 September, 1999 reinforce their commitment to with no ending points for people with
nursing and cause them to different tasks’ (p. 667).
aspire to more positive
life goals.
Tzeng, 200238 To examine the Descriptive correlational Taiwan A gap between expectation and Nurses’ important profiles (i.e. values)
correlation between study using a reality is a source of nurses’ may influence levels of job satisfaction,
nurses’ job questionnaire dissatisfaction. work motivation, organizational
satisfaction factors Sample: n 786 commitment and intention to quit.
and expectations registered nurses Therefore it is important to match the
about their jobs right person to the right job.
Varcoe et al., To explore the Interpretive, constructivist Canada Ethics is a process of enactment. Much emphasis on the importance of
200449 meaning of ethics paradigm employing focus Nurses are ‘moral agents
/ values and conflicts in different areas,
and the groups (n 19); sample involving lots of ‘in-betweens’ but specific values not mentioned.
enhancement of included 87 nurses from a such as their own values/
ethical practice wide range of practice organization values. Nurses
in nursing settings value each other highly
/ used
as a resource.
Verplanken, To determine how Cross-sectional survey Norway Organizational values play an The ward/organizational ‘culture’
200451 value congruence using questionnaire important part in employees’ influences nurses’ job satisfaction.
relates to job Sample: 56 nurses on job satisfaction. Human relations values refer to the way
satisfaction 3 surgical wards of a work is organized, such as degree of
regional hospital autonomy and influence employees
have, and the general morale in the
work-place.
 Appendix 1 (Continued)

Reference Purpose Methods Country Results Comments

of origin

Watson et al., To compare and Survey method using UK/Spain There are similarities between Caring is central to nursing. Culture is
200343 contrast perceptions Caring Dimensions Spanish and UK nurses’ comprised of geographical, historical,
of caring in nursing Inventory perceptions of caring societal, linguistic and ethnic
between Spanish Sample: UK n  1430; dimensions. Different cultures express
and UK nurses Spain n 224 different levels of importance of
individual aspects of caring.
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Wimpenny To explore the Serial taped group and Belgium/ Development of key themes: If we don’t engage with nurses/nurse
et al., 200582 evolving nature of individual interviews Scotland personal values and culture, educationalists in Europe we will have a
an understanding of engagement and culture, narrower, limited view of culture and a
culture through personality and culture, and lack of sensitivity in understanding
attendance at an physicality and culture. about our own and others’ culture.
intensive pro- Teaching and learning about culture is
gramme for nurses central to the development of modern
in Belgium and relevant practice in a multicultural
world. This will lead to a greater
understanding of cultural issues in
nursing and health care education.
Wong and To reveal early lived Phenomenological Hong Kong Clinical learning is essential to Values about nursing are learnt through
Lee, 200083 nursing experiences approach involving professional development: how primary socialization.
and explore the thematic analysis of critical one learns to be a nurse.
impact of such incidents provided by 77 Therefore it is important that the
experiences on participants clinical setting is a positive one
long-term that encourages learning and
professional shows good practice.
development

The value of nursing

Nursing Ethics 2007 14 (6)

739
 Appendix 1 (Continued)
Nursing Ethics 2007 14 (6)

740
Reference Purpose Methods Country Results Comments

K Horton et al.
of origin

Wros et al., 200436 To build on the Secondary analysis of USA/Japan Nurses from the USA and Japan Confirms that there are commonalities
knowledge base data from two share common values and ethical and differences in nursing values and
informing phenomenological studies concerns as professional nurses, ethical concerns. Nurses also have many
multicultural of nurses in the USA and including competence, respect for practices based on their cultural
nursing ethics by Japan. Individual the patient, responsibility, background. Nurses from both cultures
examining and interviews and focus relationship and connection, felt the need to preserve and protect the
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comparing the group interviews were importance of family, caring, a trust and relationship between patients
background conducted good death, comfort, truth telling, and physicians.
meanings and understanding the patient/
values behind the situation, and anticipatory care.
ethical concerns of However, nurses from each
nurses from Japan country also hold unique values
and the USA not found in the nursing practice
of the other country.
Yamaguchi, 200437 To explore the Cross-sectional Italy Nurses were considerably less Sociocultural and organizational factors
sociocultural ethnographic study using well educated than doctors and influence the work culture of nurses.
organizational ethnomethodology were used to medical power and Nurses need to question tradition and
factors that Sample: n 25; 4 focus status. They were directed in seek university education so that they
influence the work groups nearly all activities by physicians. are recognized by doctors, management
culture of nurses in Little leadership from nursing and the public for their contribution to
an operating theatre management led nurses to be patient care outcomes and the value of
in Italy defensive towards change. the nursing profession.