Nurse Educator
Nurse Educator Vol. 40, No. 5, pp. 258-262 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Professional Values of RN-to-BSN Students in an Online Program Cynthia L. Koomey, MSN, RN & Kathryn Osteen, PhD, RN & Jennifer Gray, PhD, RN, FAAN Professional values are an important component of nursing education. This cross-sectional study assessed the professional values of 222 students in an online RN-to-BSN program. Higher scores were related to items reflecting direct patient care and accountability for nursing practice. Items focusing on nursing theory, cost of care, and professional nursing organization revealed lower scores. Keywords: nursing education; online nursing education; professional nursing values; RN-to-BSN program
O
ver the past 10 years, the number of RN-to-BSN programs has increased dramatically, with a subsequent increase in students enrolled in those programs.1 In 2011, there were approximately 90 000 students in RN-to-BSN programs, a 15.8% increase in the number of enrollments from 2010. Two national initiatives have contributed to this growth. The Institute of Medicine’s (IOM’s) 2010 report, The Future of Nursing, called for advancement in the educational level of the nursing workforce, which includes increasing the number of nurses holding the BSN.2 The IOM mandate was in response to research related to improved patient outcomes when patients are cared for by baccalaureate-prepared nurses, as compared with nurses with less formal education.3-5 Another force influencing the increase in RN-to-BSN programs and total enrollment is the MagnetA Designation Program, which links the proportion of nurses in a health care agency educated at the BSN or higher degree level with nursing excellence.6,7 Employers are encouraging nurses to return for their BSN degree, making earning a degree a criterion for advancement.
Author Affiliations: Doctoral Student (Ms Koomey), The University of Texas at Arlington; Senior Lecturer (Dr Osteen), Louis Herrington School of Nursing, Baylor University, Dallas, Texas; Associate Dean and Chair (Dr Gray), College of Nursing, The University of Texas at Arlington. The authors received no financial support for this research. Ms Koomey is employed by Academic Partnerships, a third-party company partnered with UT Arlington providing support for the online RN-toBSN program examined in this study. The other authors declare no conflicts of interest. Correspondence: Ms Koomey, 600 N Pearl St, Ste 900, Dallas, TX 75201 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: January 19, 2015 Published ahead of print: March 13, 2015 DOI: 10.1097/NNE.0000000000000156
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Hospital and other health care facilities are investing significant funds through tuition reimbursement and scholarships to support associate degree nurses (ADNs) and diplomaprepared nurses who are seeking a BSN degree. Nursing programs are investing faculty and financial resources in RN-to-BSN programs as well. Unlike prelicensure programs for which the NCLEX-RN serves as a measure of student and program outcomes, RN-to-BSN programs lack a predetermined measure of outcomes, other than the number of graduates.8 With the increase in the number of enrollments and the impact of subsequent graduates from RN-to-BSN programs on the nursing workforce, it is important to have a means by which to evaluate program outcomes.9-11 Ideally, competency assessment of the clinical practices of RN-to-BSN graduates before and after the educational program will be developed and validated as an outcome measure. In the absence of a competency measure, this study was designed to provide baseline descriptive data of RN-to-BSN students’ professional values. Instrument evaluation was an additional aim of this study.
Background and Significance Professionalism is defined by the Interprofessional Professionalism Measurement Group as ‘‘the consistent demonstration of core values evidenced by nurses working with other professionals to achieve optimal health and wellness outcomes in patients, families, and communities by wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability.’’12(p26) Nursing professional values are fundamental standards of action or behavior that are generally accepted and expected by the nursing profession.13 Novice nurses learn professional values that form the foundational framework for the professional’s identity and guide interactions with patients, colleagues, other professionals, and the public. Professional values are viewed as hallmarks of exemplary nursing practice.12,14 Education is an important component in the acquisition of strong professional nursing values.15 A nurse’s
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Nurse Educator
professional values affect critical thinking, problem solving, and prioritization of patient care needs.16 Research in the area of professional nursing values as related to the level of nursing education is scarce, and findings are inconsistent. Some evidence supports that professionalism increases over the course of baccalaureate nursing education. Hensel and Laux studied the changes in professional identity in prelicensure nursing students over the course of the nursing program.17 Findings revealed increased strength of all aspects, with the exception of one that remained stable, of professional identity. This supports the belief that professionalism is enhanced through baccalaureate education. Alverson et al18 found significant increases in the professional values of nurses on completion of an RN-to-BSN program. Socialization to the role of the professional nurse positively influenced the professional development of RNs. These findings are supportive of the influence of RN-to-BSN education on professional nursing practice. Fisher19 compared professional value development across prelicensure nursing programs that lead to the graduate earning a diploma, an ADN, or a BSN degree. Using the Nurses Professional Values Scale–Revised,13 Fisher compared professional value scores of entering and graduating students in the 3 programs. Entering and graduating students in diploma programs had statistically significant differences in their scores related to caring, trust, professionalism, and justice. Entering and graduating students in the other 2 programs had no significant differences in their professional value scores. These findings are contrary to what is expected as a result of a nursing education program and are inconsistent with findings of similar studies reported in the literature. Students in RN-toBSN programs were not included in Fisher’s19 study. In 2008, Kubsch et al20 developed the Professional Values Survey (PVS) to broadly measure nurses’ professional values across all educational levels. Using the PVS, Kubsch et al20 found that RN-to-BSN students had the strongest professional values, as compared with nurses prepared at other educational levels. The purpose of this study was to describe the importance of professional values as ranked by students in an RNto-BSN program. A secondary purpose was to evaluate the PVS and assess the potential of the instrument’s use in future research.
Methods This study used a cross-sectional survey design to describe the importance of professional values as assessed by RN-toBSN students. Convenience sampling was used to recruit nurses enrolled in a large public online RN-to-BSN program in the United States. The researchers chose the PVS to measure the importance of professional values because of the comprehensiveness of the items and strong reliability and validity.20
Instrument The PVS was developed by Kubsch et al20 to measure the importance of professional values. The items on the PVS are designed to measure several characteristics of the nursing profession, the American Nurses Association (ANA) Code of Ethics, standards of professional performance, ANA Social Policy Statement, and AACN Essentials of Baccalaureate Nursing Education. Nurse Educator
The development of the PVS was based on the concepts of Hall’s21 Care, Cure, and Core Theory. Hall viewed nursing as 3 interlocking circles: care, cure, and core. Each circle represents different aspects of nursing. Hall ascertained that the care circle portrays the technical aspect of nursing and is exhibited by bodily care provided by the nurse. The cure circle represents collaboration with physicians and other care providers for the primary purpose of healing the patient. The core circle pertains to the emotional, social, spiritual, and intellectual needs of the patient, family, and community. Professional nursing is exemplified primarily through practice related to concepts within the core circle. According to Kubsch et al,20 the care, cure, and core aspects are taught in both ADN and BSN programs; however, the care and cure aspects are emphasized in ADN programs. Hall’s core aspect represents professional nursing and is a focus in both prelicensure baccalaureate and RN-to-BSN programs. For example, in BSN programs, community health courses emphasize the cultural and environmental factors that influence the needs of patients, both as individuals and as part of a community. That content is consistent with the core circle that represents professional nursing.20 The original assessment of the PVS revealed strong content validity and internal consistency reliability.20 Assessment of the content validity of the PVS was done by a panel of experts, composed of master’s- and doctoral-prepared nursing faculty, who had graduated originally from diploma, ADN, and BSN programs. Changes were made to the PVS based on this expert panel assessment, resulting in a 50-item scale. A Cronbach’s coefficient ! of .94 was documented in the original work; Cronbach’s coefficient ! in this study was .96.
Data Collection A link to the PVS was posted in the first and last course of the RN-to-BSN program. The first course of the RN-to-BSN program had 542 students enrolled, and there were 135 students enrolled in the last course. The convenience sample was obtained from the 677 students enrolled in the 2 courses. The first course consisted of two 5-week components, and the last course was 5 weeks in duration. Both courses started on the same date. The PVS link was available for the duration of the initial 5-week component of the first course and the 5-week duration of the last course. To respond to the items on the PVS, subjects indicate the importance of each value statement on a response scale of 1 = not important to 5 = most important. The instrument is scored by calculating means for the items (range, 1-5) and for the overall scale (range, 50-250). The PVS does not contain subscales; it is a single dimension measurement tool. Data Analysis Descriptive statistics were computed for the demographic and practice characteristics of the sample. Independent-samples t test and one-way analysis of variance were performed to identify any differences between demographic variables and professional value scores. Pearson correlation coefficient calculations were performed to identify correlations between demographics or survey items and professional value scores. The data were analyzed using SPSS, version 21.0 (IBM Corp, Armonk, New York). The level of significance was set at .05. Volume 40 & Number 5 & September/October 2015
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Findings A sample of 222 students was obtained from an online RN-to-BSN program, for a 33.2% response rate. The Table, Supplemental Digital Content 1, provides the demographics of the sample, http://links.lww.com/NE/A216. Compared with Kubsch and colleagues’20 study that was primarily white (96.4%, n = 191), this sample was more racially and ethnically diverse, with 63.3% (n = 138) of the participants being white. The sample was relatively young, with 71 participants (32.0%) between 31 and 40 years of age. Only 37 of the participants were 51 to 60 years old (16.7%). The majority of participants were employed in hospitals as staff nurses. The participants’ work experience after their basic nursing educational preparation ranged from less than a year to more than 15 years. Almost half of the participants (n = 109) reported belonging to a professional organization. The PVS total scale scores ranged from 149 to 243, with a mean of 205. The overall mean score of the items on the PVS was 4.19 (SD, 0.43), indicating that RN-to-BSN students rank professional nursing values as being highly important. Individual item analysis of means revealed a range of 3.32 to 4.74, with a possible range of 1 to 5. The 10 items on the PVS with the highest means are shown in the Table and ranked in order from highest (1) to lower means (10). A higher mean indicates the subjects considered this item more important than other items. Professional values of confidentiality, human dignity, and the rights of patients were viewed by the students as the most important values. Value statements viewed as relatively less important are also shown in the Table, ranked in order from lowest mean (50) to higher mean (41). Independent-samples t test revealed no significant differences between gender or professional nursing organization membership and total PVS score. Likewise, one-way ANOVA
revealed no significant differences between age, ethnicity, department employed, title or position, or years of experience and total PVS score. There were no correlations between demographics and survey items and professional value scores. A ceiling effect was present, demonstrated by data being negatively skewed. The ceiling effect indicated that the incoming students may already have the professional values the instrument measures. Social desirability may have also been a factor. Despite assurances of anonymity, nurses may have responded in a way that conforms to known nursing values. As a result, we found little variation in scores.
Discussion The RN-to-BSN students in this study viewed the professional values included in the PVS as being very important, with the lowest item mean being 3.32. These findings were consistent with the findings of Kubsch et al,20 who found higher mean scores in RN-to-BSN students, in progress and graduated, than other levels of education. Kubsch et al20 also found that nurses who were members of professional nursing organizations had higher PVS scores. Although a statistically significant difference was not found in this sample, the large number of participants who were members may have contributed to the ceiling effect. Lower means were found on items that did not involve direct patient care, but had nursing theory, cost of care, and professional nursing organization as the focus. In addition to professional values, the other variables were demographic in nature. Iacobucci et al22 found a significant positive relationship between self-esteem and professional values in their small study of BSN students (N = 47), raising the possibility that personal psychosocial characteristics may influence the nurse’s professional values.
Table. Importance of Professional Values Among RN-to-BSN Students Rank
Item Description
Mean (SD)
Highly important professional values 1 Maintain confidentiality of patient information 4.74 (0.48) 2 Respect and protect dignity and worth of each person 4.70 (0.53) 3 Protect moral, ethical, and legal rights of patients 4.68 (0.52) 4 Are accountable for own practice 4.65 (0.51) 5 Acquire and maintain current knowledge in nursing practice 4.61 (0.54) 6 Address questionable or inappropriate practice 4.54 (0.62) 7 Communicate honestly to the patient about plan of care and prognosis 4.54 (0.57) 8 Promote full and active participation of patient in plan of care 4.53 (0.58) 9 Individualize patient care 4.52 (0.61) 10 Actions and decisions on behalf of patient are determined in ethical manner 4.51 (0.65) Less important professional values 50 Base practice on arts, humanities, and sciences 3.32 (0.99) 49 Limit practice to domain of nursing as opposed to domain of medicine 3.36 (1.04) 48 Professional work obligations extend beyond work setting and time frame 3.38 (1.03) 47 Participate in professional nursing organizations 3.40 (1.01) 46 Consider factors related to cost in planning and delivering patient care 3.53 (0.91) 45 Accept this definition of nursing: ‘‘Nursing is the diagnosis and treatment of human responses to actual and potential health problems’’ 3.73 (0.91) 44 Use nonpharmacological therapies to manage physical and psychological symptoms 3.74 (0.88) 43 View nursing as offering essential services different than those of the medical profession 3.76 (0.92) 42 Enable fair distribution of health care resources 3.79 (0.86) 41 Use nursing theory/models as foundation of practice 3.86 (0.87)
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Nurse Educator
The measurement of professional values in this study focused on nurses; however, professional values is a concept that extends to other health care professionals. For example, the American Physical Therapy Association has developed a behavioral self-assessment tool of their 7 core professional values.23 The values are similar to those measured by the PVS. Rather than focusing efforts on developing distinct tools for each health profession, there may be value in collaborative development of a tool that measures professional values across professions. Guenther et al23 used a response scale of frequency of behaviors that reflected specific professional values. The response scale used by Kubsch et al20 that rated the importance of each professional value may be less sensitive to change because of education. Future research should focus on measurement of professional values as demonstrated in nursing practice rather than level of importance as assessed by the nurse. Use of values in practice may not accurately reflect the level of importance placed on the professional value by the nurse. Future research also should compare the professional values of nurses educated through online RN-to-BSN programs with traditional, on campus RN-to-BSN programs. There may be varying levels of socialization, teaching and learning differences, and the opportunity of learning through role modeling between these modalities of education delivery. The effects of educational level, years of experience, and completion of RN-to-BSN program on professional nursing values warrant further investigation. An increase in number of new ADN graduates enrolling in RN-to-BSN programs is a recent trend.24 It is unclear if current RN-to-BSN program content is sufficient for RNs with limited experience. Another line of inquiry would be studies to describe the personal psychosocial characteristics that influence and are influenced by professional values. Consideration of a professional values survey for interprofessional use may be another promising approach and result in measures of professional values that can serve as indicators of the outcomes of educational programs. A change in the health care delivery environment, recommendations for increased education for nurses, and the surge in graduates of RN-to-BSN programs have called for measurable program outcomes for RN-to-BSN programs, including graduates’ professional values.
Limitations This research study has several limitations. Some students completed the PVS during the first course of their RN-to-BSN program, whereas other students completed the PVS during the last course of their RN-to-BSN program. There was no identifying information in the survey to link the student to their respective course. It is possible that students’ professional values are affected by their educational journey, and yet this study did not take that factor into account. A cross-sectional study design was used for feasibility purposes, but this design limited the study results because factors such as attrition and maturation were introduced. A longitudinal design would account for these factors and consequently strengthen the study. Another limitation was self-selection—students who enroll in RN-to-BSN programs may have stronger professional values from the outset and may be more likely to participate in research. Finally, this study was administered to students in only 1 RN-to-BSN Nurse Educator
program. Inclusion of students from numerous RN-to-BSN programs would further increase the generalizability of the results, but at the same time would also include additional limitations such as decreased consistency in educational methods, curriculum, and experience.
Conclusion The current research study indicated that students in RN-toBSN programs placed a high importance on professional values, particularly those involving direct patient care with a lesser importance on values related to indirect care, such as cost of care and nursing theory. These findings are not surprising. However, there is room for improvement in RN-to-BSN education that will enhance the level of professionalism in certain areas. For example, emphasis on the importance of professional nursing organization membership may result in great cohesiveness of the nursing profession as a whole. Professionalism, which may be a byproduct of nursing organization membership, may raise the professional attitudes and actions of nurses.
References 1. Fact sheet: degree completion programs for registered nurses: RN to master’s degree and RN to baccalaureate programs. American Association of Colleges of Nursing Web site. Available at http:// www.aacn.nche.edu/media-relations/DegreeComp.pdf. Published 2012. Accessed June 2013. 2. The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine of the National Academies (IOM) Web site. Available at http://www.iom.edu/Reports/2010/The-Future-ofNursing-Leading-Change-Advancing-Health.aspx. Published October 2010. Accessed June 2013. 3. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. J Am Med Assoc. 2003;290(12):1617-1623. 4. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223-229. 5. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931): 1824-1830. 6. Daly K. MagnetA: good for nurses, good for patients. Am Nurse Today. 2012;7(1):44. 7. Zimmerman D. An essential next step for nursing. J Nurs Adm. 2013;43(7-8):371-372. 8. Fact sheet: the impact of education on nursing practice. American Association of Colleges of Nursing Web site. Available at http:// www.aacn.nche.edu/media-relations/fact-sheets/impact-ofeducation. Published 2014. Accessed June 2013. 9. McEwen M, White MJ, Pullis BR, Krawtz S. National survey of RN-to-BSN programs. J Nurs Educ. 2012;51(7):373-380. 10. Hooper JI, McEwen M, Mancini ME. A regulatory challenge: creating a metric for quality RN-to-BSN programs. J Nurs Regul. 2013;4(2):34-38. 11. Kumm S, Godfrey N, Martin D, Tucci M, Muenks M, Spaeth T. Baccalaureate outcomes met by associate degree nursing programs. Nurse Educ. 2014;39(5):216-220. 12. The essentials of baccalaureate education for professional nursing practice. American Association of Colleges of Nursing Web site. Available at http://www.aacn.nche.edu/publications/order-form/ baccalaureate-essentials. Published 2008. Accessed June 2013. Volume 40 & Number 5 & September/October 2015
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13. Weis D, Schank MJ. Development and psychometric evaluation of the nurses professional values scale-revised. J Nurs Meas. 2009;17(3):221-231. 14. Eddy DM, Elfrink V, Weis D, Schank MJ. Importance of professional nursing values: a national study of baccalaureate programs. J Nurs Educ. 1994;33(6):257-262. 15. Schank MJ, Weis D. Exploring commonality of professional values among nurse educators in the United States and England. J Nurs Educ. 2000;39(1):41-44. 16. Leners DW, Roehrs C, Piccone AV. Tracking the development of professional values in undergraduate nursing students. J Nurs Educ. 2006;45(12):504-511. 17. Hensel D, Laux M. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurse Educ. 2014; 39(5):227-231. 18. Alverson EM, Brown JM, Pepa CA. Role conception of RN-BSN students. Nurse Educ. 1999;24(4):9-10.
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19. Fisher MD. A comparison of professional value development among pre-licensure nursing students in associate degree, diploma, and bachelor of science in nursing programs. Nurs Educ Perspect. 2014;35(1):37-42. 20. Kubsch S, Hansen G, Huyser-Eatwell V. Professional values: the case for RN-BSN completion education. J Contin Educ Nurs. 2008;39(8):375-384. 21. Hall LE. A center for nursing. Nurs Outlook. 1963;11:804-806. 22. Iacobucci T, Daly B, Lindell D, Griffin M. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nurs Ethics. 2012;20(4):479-490. 23. Guenther M, McGinnis P, Romen M, Patel K. Self-assessment of professional core values among physical therapists. Phys Ther J Policy Adm Leadersh. 2014;14(2):1-10. 24. McEwen M, Pullis BR, White MJ, Krawtz S. Eighty percent by 2020: the present and future of RN-to-BSN education. J Nurs Educ. 2013;52(10):549-557.
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Nurse Educator
Nurse Educator Vol. 40, No. 5, pp. 258-262 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Professional Values of RN-to-BSN Students in an Online Program Cynthia L. Koomey, MSN, RN & Kathryn Osteen, PhD, RN & Jennifer Gray, PhD, RN, FAAN Professional values are an important component of nursing education. This cross-sectional study assessed the professional values of 222 students in an online RN-to-BSN program. Higher scores were related to items reflecting direct patient care and accountability for nursing practice. Items focusing on nursing theory, cost of care, and professional nursing organization revealed lower scores. Keywords: nursing education; online nursing education; professional nursing values; RN-to-BSN program
O
ver the past 10 years, the number of RN-to-BSN programs has increased dramatically, with a subsequent increase in students enrolled in those programs.1 In 2011, there were approximately 90 000 students in RN-to-BSN programs, a 15.8% increase in the number of enrollments from 2010. Two national initiatives have contributed to this growth. The Institute of Medicine’s (IOM’s) 2010 report, The Future of Nursing, called for advancement in the educational level of the nursing workforce, which includes increasing the number of nurses holding the BSN.2 The IOM mandate was in response to research related to improved patient outcomes when patients are cared for by baccalaureate-prepared nurses, as compared with nurses with less formal education.3-5 Another force influencing the increase in RN-to-BSN programs and total enrollment is the MagnetA Designation Program, which links the proportion of nurses in a health care agency educated at the BSN or higher degree level with nursing excellence.6,7 Employers are encouraging nurses to return for their BSN degree, making earning a degree a criterion for advancement.
Author Affiliations: Doctoral Student (Ms Koomey), The University of Texas at Arlington; Senior Lecturer (Dr Osteen), Louis Herrington School of Nursing, Baylor University, Dallas, Texas; Associate Dean and Chair (Dr Gray), College of Nursing, The University of Texas at Arlington. The authors received no financial support for this research. Ms Koomey is employed by Academic Partnerships, a third-party company partnered with UT Arlington providing support for the online RN-toBSN program examined in this study. The other authors declare no conflicts of interest. Correspondence: Ms Koomey, 600 N Pearl St, Ste 900, Dallas, TX 75201 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: January 19, 2015 Published ahead of print: March 13, 2015 DOI: 10.1097/NNE.0000000000000156
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Hospital and other health care facilities are investing significant funds through tuition reimbursement and scholarships to support associate degree nurses (ADNs) and diplomaprepared nurses who are seeking a BSN degree. Nursing programs are investing faculty and financial resources in RN-to-BSN programs as well. Unlike prelicensure programs for which the NCLEX-RN serves as a measure of student and program outcomes, RN-to-BSN programs lack a predetermined measure of outcomes, other than the number of graduates.8 With the increase in the number of enrollments and the impact of subsequent graduates from RN-to-BSN programs on the nursing workforce, it is important to have a means by which to evaluate program outcomes.9-11 Ideally, competency assessment of the clinical practices of RN-to-BSN graduates before and after the educational program will be developed and validated as an outcome measure. In the absence of a competency measure, this study was designed to provide baseline descriptive data of RN-to-BSN students’ professional values. Instrument evaluation was an additional aim of this study.
Background and Significance Professionalism is defined by the Interprofessional Professionalism Measurement Group as ‘‘the consistent demonstration of core values evidenced by nurses working with other professionals to achieve optimal health and wellness outcomes in patients, families, and communities by wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability.’’12(p26) Nursing professional values are fundamental standards of action or behavior that are generally accepted and expected by the nursing profession.13 Novice nurses learn professional values that form the foundational framework for the professional’s identity and guide interactions with patients, colleagues, other professionals, and the public. Professional values are viewed as hallmarks of exemplary nursing practice.12,14 Education is an important component in the acquisition of strong professional nursing values.15 A nurse’s
Volume 40 & Number 5 & September/October 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
professional values affect critical thinking, problem solving, and prioritization of patient care needs.16 Research in the area of professional nursing values as related to the level of nursing education is scarce, and findings are inconsistent. Some evidence supports that professionalism increases over the course of baccalaureate nursing education. Hensel and Laux studied the changes in professional identity in prelicensure nursing students over the course of the nursing program.17 Findings revealed increased strength of all aspects, with the exception of one that remained stable, of professional identity. This supports the belief that professionalism is enhanced through baccalaureate education. Alverson et al18 found significant increases in the professional values of nurses on completion of an RN-to-BSN program. Socialization to the role of the professional nurse positively influenced the professional development of RNs. These findings are supportive of the influence of RN-to-BSN education on professional nursing practice. Fisher19 compared professional value development across prelicensure nursing programs that lead to the graduate earning a diploma, an ADN, or a BSN degree. Using the Nurses Professional Values Scale–Revised,13 Fisher compared professional value scores of entering and graduating students in the 3 programs. Entering and graduating students in diploma programs had statistically significant differences in their scores related to caring, trust, professionalism, and justice. Entering and graduating students in the other 2 programs had no significant differences in their professional value scores. These findings are contrary to what is expected as a result of a nursing education program and are inconsistent with findings of similar studies reported in the literature. Students in RN-toBSN programs were not included in Fisher’s19 study. In 2008, Kubsch et al20 developed the Professional Values Survey (PVS) to broadly measure nurses’ professional values across all educational levels. Using the PVS, Kubsch et al20 found that RN-to-BSN students had the strongest professional values, as compared with nurses prepared at other educational levels. The purpose of this study was to describe the importance of professional values as ranked by students in an RNto-BSN program. A secondary purpose was to evaluate the PVS and assess the potential of the instrument’s use in future research.
Methods This study used a cross-sectional survey design to describe the importance of professional values as assessed by RN-toBSN students. Convenience sampling was used to recruit nurses enrolled in a large public online RN-to-BSN program in the United States. The researchers chose the PVS to measure the importance of professional values because of the comprehensiveness of the items and strong reliability and validity.20
Instrument The PVS was developed by Kubsch et al20 to measure the importance of professional values. The items on the PVS are designed to measure several characteristics of the nursing profession, the American Nurses Association (ANA) Code of Ethics, standards of professional performance, ANA Social Policy Statement, and AACN Essentials of Baccalaureate Nursing Education. Nurse Educator
The development of the PVS was based on the concepts of Hall’s21 Care, Cure, and Core Theory. Hall viewed nursing as 3 interlocking circles: care, cure, and core. Each circle represents different aspects of nursing. Hall ascertained that the care circle portrays the technical aspect of nursing and is exhibited by bodily care provided by the nurse. The cure circle represents collaboration with physicians and other care providers for the primary purpose of healing the patient. The core circle pertains to the emotional, social, spiritual, and intellectual needs of the patient, family, and community. Professional nursing is exemplified primarily through practice related to concepts within the core circle. According to Kubsch et al,20 the care, cure, and core aspects are taught in both ADN and BSN programs; however, the care and cure aspects are emphasized in ADN programs. Hall’s core aspect represents professional nursing and is a focus in both prelicensure baccalaureate and RN-to-BSN programs. For example, in BSN programs, community health courses emphasize the cultural and environmental factors that influence the needs of patients, both as individuals and as part of a community. That content is consistent with the core circle that represents professional nursing.20 The original assessment of the PVS revealed strong content validity and internal consistency reliability.20 Assessment of the content validity of the PVS was done by a panel of experts, composed of master’s- and doctoral-prepared nursing faculty, who had graduated originally from diploma, ADN, and BSN programs. Changes were made to the PVS based on this expert panel assessment, resulting in a 50-item scale. A Cronbach’s coefficient ! of .94 was documented in the original work; Cronbach’s coefficient ! in this study was .96.
Data Collection A link to the PVS was posted in the first and last course of the RN-to-BSN program. The first course of the RN-to-BSN program had 542 students enrolled, and there were 135 students enrolled in the last course. The convenience sample was obtained from the 677 students enrolled in the 2 courses. The first course consisted of two 5-week components, and the last course was 5 weeks in duration. Both courses started on the same date. The PVS link was available for the duration of the initial 5-week component of the first course and the 5-week duration of the last course. To respond to the items on the PVS, subjects indicate the importance of each value statement on a response scale of 1 = not important to 5 = most important. The instrument is scored by calculating means for the items (range, 1-5) and for the overall scale (range, 50-250). The PVS does not contain subscales; it is a single dimension measurement tool. Data Analysis Descriptive statistics were computed for the demographic and practice characteristics of the sample. Independent-samples t test and one-way analysis of variance were performed to identify any differences between demographic variables and professional value scores. Pearson correlation coefficient calculations were performed to identify correlations between demographics or survey items and professional value scores. The data were analyzed using SPSS, version 21.0 (IBM Corp, Armonk, New York). The level of significance was set at .05. Volume 40 & Number 5 & September/October 2015
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Findings A sample of 222 students was obtained from an online RN-to-BSN program, for a 33.2% response rate. The Table, Supplemental Digital Content 1, provides the demographics of the sample, http://links.lww.com/NE/A216. Compared with Kubsch and colleagues’20 study that was primarily white (96.4%, n = 191), this sample was more racially and ethnically diverse, with 63.3% (n = 138) of the participants being white. The sample was relatively young, with 71 participants (32.0%) between 31 and 40 years of age. Only 37 of the participants were 51 to 60 years old (16.7%). The majority of participants were employed in hospitals as staff nurses. The participants’ work experience after their basic nursing educational preparation ranged from less than a year to more than 15 years. Almost half of the participants (n = 109) reported belonging to a professional organization. The PVS total scale scores ranged from 149 to 243, with a mean of 205. The overall mean score of the items on the PVS was 4.19 (SD, 0.43), indicating that RN-to-BSN students rank professional nursing values as being highly important. Individual item analysis of means revealed a range of 3.32 to 4.74, with a possible range of 1 to 5. The 10 items on the PVS with the highest means are shown in the Table and ranked in order from highest (1) to lower means (10). A higher mean indicates the subjects considered this item more important than other items. Professional values of confidentiality, human dignity, and the rights of patients were viewed by the students as the most important values. Value statements viewed as relatively less important are also shown in the Table, ranked in order from lowest mean (50) to higher mean (41). Independent-samples t test revealed no significant differences between gender or professional nursing organization membership and total PVS score. Likewise, one-way ANOVA
revealed no significant differences between age, ethnicity, department employed, title or position, or years of experience and total PVS score. There were no correlations between demographics and survey items and professional value scores. A ceiling effect was present, demonstrated by data being negatively skewed. The ceiling effect indicated that the incoming students may already have the professional values the instrument measures. Social desirability may have also been a factor. Despite assurances of anonymity, nurses may have responded in a way that conforms to known nursing values. As a result, we found little variation in scores.
Discussion The RN-to-BSN students in this study viewed the professional values included in the PVS as being very important, with the lowest item mean being 3.32. These findings were consistent with the findings of Kubsch et al,20 who found higher mean scores in RN-to-BSN students, in progress and graduated, than other levels of education. Kubsch et al20 also found that nurses who were members of professional nursing organizations had higher PVS scores. Although a statistically significant difference was not found in this sample, the large number of participants who were members may have contributed to the ceiling effect. Lower means were found on items that did not involve direct patient care, but had nursing theory, cost of care, and professional nursing organization as the focus. In addition to professional values, the other variables were demographic in nature. Iacobucci et al22 found a significant positive relationship between self-esteem and professional values in their small study of BSN students (N = 47), raising the possibility that personal psychosocial characteristics may influence the nurse’s professional values.
Table. Importance of Professional Values Among RN-to-BSN Students Rank
Item Description
Mean (SD)
Highly important professional values 1 Maintain confidentiality of patient information 4.74 (0.48) 2 Respect and protect dignity and worth of each person 4.70 (0.53) 3 Protect moral, ethical, and legal rights of patients 4.68 (0.52) 4 Are accountable for own practice 4.65 (0.51) 5 Acquire and maintain current knowledge in nursing practice 4.61 (0.54) 6 Address questionable or inappropriate practice 4.54 (0.62) 7 Communicate honestly to the patient about plan of care and prognosis 4.54 (0.57) 8 Promote full and active participation of patient in plan of care 4.53 (0.58) 9 Individualize patient care 4.52 (0.61) 10 Actions and decisions on behalf of patient are determined in ethical manner 4.51 (0.65) Less important professional values 50 Base practice on arts, humanities, and sciences 3.32 (0.99) 49 Limit practice to domain of nursing as opposed to domain of medicine 3.36 (1.04) 48 Professional work obligations extend beyond work setting and time frame 3.38 (1.03) 47 Participate in professional nursing organizations 3.40 (1.01) 46 Consider factors related to cost in planning and delivering patient care 3.53 (0.91) 45 Accept this definition of nursing: ‘‘Nursing is the diagnosis and treatment of human responses to actual and potential health problems’’ 3.73 (0.91) 44 Use nonpharmacological therapies to manage physical and psychological symptoms 3.74 (0.88) 43 View nursing as offering essential services different than those of the medical profession 3.76 (0.92) 42 Enable fair distribution of health care resources 3.79 (0.86) 41 Use nursing theory/models as foundation of practice 3.86 (0.87)
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The measurement of professional values in this study focused on nurses; however, professional values is a concept that extends to other health care professionals. For example, the American Physical Therapy Association has developed a behavioral self-assessment tool of their 7 core professional values.23 The values are similar to those measured by the PVS. Rather than focusing efforts on developing distinct tools for each health profession, there may be value in collaborative development of a tool that measures professional values across professions. Guenther et al23 used a response scale of frequency of behaviors that reflected specific professional values. The response scale used by Kubsch et al20 that rated the importance of each professional value may be less sensitive to change because of education. Future research should focus on measurement of professional values as demonstrated in nursing practice rather than level of importance as assessed by the nurse. Use of values in practice may not accurately reflect the level of importance placed on the professional value by the nurse. Future research also should compare the professional values of nurses educated through online RN-to-BSN programs with traditional, on campus RN-to-BSN programs. There may be varying levels of socialization, teaching and learning differences, and the opportunity of learning through role modeling between these modalities of education delivery. The effects of educational level, years of experience, and completion of RN-to-BSN program on professional nursing values warrant further investigation. An increase in number of new ADN graduates enrolling in RN-to-BSN programs is a recent trend.24 It is unclear if current RN-to-BSN program content is sufficient for RNs with limited experience. Another line of inquiry would be studies to describe the personal psychosocial characteristics that influence and are influenced by professional values. Consideration of a professional values survey for interprofessional use may be another promising approach and result in measures of professional values that can serve as indicators of the outcomes of educational programs. A change in the health care delivery environment, recommendations for increased education for nurses, and the surge in graduates of RN-to-BSN programs have called for measurable program outcomes for RN-to-BSN programs, including graduates’ professional values.
Limitations This research study has several limitations. Some students completed the PVS during the first course of their RN-to-BSN program, whereas other students completed the PVS during the last course of their RN-to-BSN program. There was no identifying information in the survey to link the student to their respective course. It is possible that students’ professional values are affected by their educational journey, and yet this study did not take that factor into account. A cross-sectional study design was used for feasibility purposes, but this design limited the study results because factors such as attrition and maturation were introduced. A longitudinal design would account for these factors and consequently strengthen the study. Another limitation was self-selection—students who enroll in RN-to-BSN programs may have stronger professional values from the outset and may be more likely to participate in research. Finally, this study was administered to students in only 1 RN-to-BSN Nurse Educator
program. Inclusion of students from numerous RN-to-BSN programs would further increase the generalizability of the results, but at the same time would also include additional limitations such as decreased consistency in educational methods, curriculum, and experience.
Conclusion The current research study indicated that students in RN-toBSN programs placed a high importance on professional values, particularly those involving direct patient care with a lesser importance on values related to indirect care, such as cost of care and nursing theory. These findings are not surprising. However, there is room for improvement in RN-to-BSN education that will enhance the level of professionalism in certain areas. For example, emphasis on the importance of professional nursing organization membership may result in great cohesiveness of the nursing profession as a whole. Professionalism, which may be a byproduct of nursing organization membership, may raise the professional attitudes and actions of nurses.
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19. Fisher MD. A comparison of professional value development among pre-licensure nursing students in associate degree, diploma, and bachelor of science in nursing programs. Nurs Educ Perspect. 2014;35(1):37-42. 20. Kubsch S, Hansen G, Huyser-Eatwell V. Professional values: the case for RN-BSN completion education. J Contin Educ Nurs. 2008;39(8):375-384. 21. Hall LE. A center for nursing. Nurs Outlook. 1963;11:804-806. 22. Iacobucci T, Daly B, Lindell D, Griffin M. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nurs Ethics. 2012;20(4):479-490. 23. Guenther M, McGinnis P, Romen M, Patel K. Self-assessment of professional core values among physical therapists. Phys Ther J Policy Adm Leadersh. 2014;14(2):1-10. 24. McEwen M, Pullis BR, White MJ, Krawtz S. Eighty percent by 2020: the present and future of RN-to-BSN education. J Nurs Educ. 2013;52(10):549-557.
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