The effect of patıent advocacy on professıonal values in nurses: a correlatıonal study

Abstract

Background

Patient advocacy, which is an integral part of patient care processes, envisages the defense of patients on issues such as patient rights and ethical values and is a concept directly related to the core values of the nursing profession. It is thought that nurses’ patient advocacy behaviors are linked to their perceptions of professional values. Therefore, this study aimed to determine the effect of nurses’ patient advocacy behaviors on professional values.

Methods

The study is descriptive, correlational, and cross-sectional. It was conducted with 527 nurses working in a city hospital in Istanbul between August and September 2023. Data were collected using the Information Form, Patient Advocacy Scale for Nurses, and Professional Values Scale. Descriptive tests, correlation analysis, and simple linear regression analysis were used to analyze the data. A STROBE checklist was used to report the study.

Results

Nurses’ Patient Advocacy Behaviors score was 163.84 (SD = 22.88) and the Professional Values score was 110.26 (SD = 16.29). The study determined that there was a significant, positive, and moderate relationship between the total scores of patient advocacy behaviors and the perception of nurses’ professional values (r = 0.628). It was found that female nurses had more professional values than male nurses, nurse managers had more professional values than other nurses, and day shift nurses had more professional values than night shift nurses (p > 0.05). It was determined that the model created for the perception of professional values was significant and patient advocacy behaviors explained 51.4% of the variance of the perception of professional values.

Conclusion

It was found that there was a moderate and positive relationship between patient advocacy behaviors and professional value perceptions of nurses. According to this result, it is recommended that more training on patient advocacy and professional values be included in the nursing education curriculum, the quality of the training should be improved, more studies should be conducted on these issues, and policymakers and hospital administrators should encourage nurses.

Introduction

According to the Turkish Language Association Dictionary, defense is defined as “a writing or speech that aims to justify a person or an idea, defender’s statement” [1]. Advocacy is the participation of individuals, families, groups, and society in decision-making processes [2]. The concept of advocacy in nursing is similar to the help given to individuals within the counseling framework [3]. Patient advocacy is a situation that ensures the protection of the patient’s preferences [4]. The concept of patient advocacy in nursing was emphasized in those years by Florence Nightingale, the founder of modern nursing, with her practices supporting ventilation, cleaning, and sanitation and the importance of creating a healthy care environment [5]. In 1976, patient advocacy was included in the nursing codes defined by the American Nurses Association (ANA). Modern nursing roles include caregiving, research, education, decision-making, patient advocacy, management, communication coordinator role, comforting role, rehabilitating role, therapeutic role, career development, counseling role, and being autonomous and responsible [6]. Patient advocacy is integral to nursing care processes [4]. With this role, the nurse helps the patient to express themselves and protect their rights and protects them against unethical and illegal behavior of healthcare professionals [6]. Patient advocacy is the responsibility of all healthcare professionals. Since nurses are the most populous group among healthcare professionals, their voices are more potent, and they can defend patients more effectively [5]. Therefore, while providing health services, they should influence decision-makers, demonstrate individual-specific care, organize, and actively participate in political processes [4].

Values are beliefs that create moral standards in human behavior and contribute to decision-making and problem-solving [7]. Values are a part of ethical systems that try to determine or evaluate moral behavior [8]. Professional values are motivational sources that professional members accept, affect attitudes, behaviors, and beliefs, strengthen professional identity and performance, and increase commitment to the profession [9]. Values guide the behavior of professional members in their work and are effective in creating positive behavior patterns in communication [10]. Values need to be defined correctly for professional nursing because the values of nurses correspond to their values by fulfilling their duties and responsibilities [11]. Developing the nursing profession’s values is essential in improving the quality of care and enabling nurses to continue their duties with satisfaction [8]. Nurses should know the values of the individuals they care for and their values, which will effectively provide quality care [12, 13]. The values of nursing are respect for human dignity, social justice, altruism, autonomy, honesty, sensitivity and accuracy in care, accountability, individual and professional competence, and empathy [8].

When the studies on patient advocacy in the literature are examined, it is higher in nurses than physicians [14], that they find advocacy important, that they encounter conflicts while fulfilling this role [3], that there is no clarity in advocacy concepts and practices, that institutional barriers are experienced, and that nurses do not have sufficient knowledge, skills and awareness in this regard [15]. In the study conducted by Nsiah and colleagues, it was found that the basis of patient advocacy is based on the patient-nurse relationship [16], nurses’ refusal of patient advocacy roles is an ethical problem [17], and nurses engage in patient advocacy to protect patient dignity [18].

When the studies on professional values in the literature are examined, it is seen that different study groups, such as students, academicians, and clinician nurses, were studied. For example, in studies conducted on students, vocational value scores are exceptionally high in female students and those who prefer their profession fondly [12, 19], in studies conducted on clinician nurses, it was found that those who were satisfied with their profession were higher in those with a bachelor’s degree, and in studies conducted on academicians, it was found that academic nurses had strong professional values [9, 20].

The nurse’s goal as an advocate is to create a safe environment for the healthy or sick individual. Nurses should defend the rights of individuals by reporting practices that may pose a danger while providing care to the authorities. While doing so, they should be aware of the cultural beliefs and values of the individual and family [21]. Values in nursing include professional judgments and the provision of assistance to people. Nursing practices involve making many decisions. Since the values of each individual are different, the decisions will be different. What is important here is that decisions should be based on professional values [8].

The core values of the nursing profession include respect for human dignity, equality, justice, altruism, and honesty These values guide nurses in assuming patient advocacy roles, while professional values and autonomy shape and strengthen their advocacy behaviors [4, 7]. Based on all this information, this study aimed to determine the relationship between nurses’ patient advocacy behaviors and professional values.

Methods

Design

This was a descriptive and correlational study. Study reportage was informed by the STROBE guidelines [22].

Sample

The study population consisted of nurses (N = 2900) working in a public-private partnership municipal hospital in Istanbul. In the calculation of the sample, it was planned to reach at least 384 nurses by using power analysis and measuring with a 95% confidence interval and 5% margin of error [23].

The study sample consisted of 527 nurses who voluntarily participated and completed the questionnaire completely and correctly. Simple random sampling was used as the sampling method and also voluntary participation was taken as a basis. Access to the participants was provided through direct communication with the nurses in the hospital.

Inclusion criteria

Having at least two months of working experience, voluntarily accepting to participate in the study, completing the questionnaire completely and accurately.

Exclusion criteria

Not having two months of working experience, incomplete or incomplete completion of the questionnaire, refusal to participate in the study.

Data collection tools

This study was conducted in a city hospital in Istanbul in August and September 2023. This hospital is one of the largest health institutions in Turkey and has a wide range of patients and health professionals working in different branches. The nurses in the study are individuals who work in different departments and have different experiences. The data were collected using the Nurse Information Form, Patient Advocacy Scale for Nurses (PASN) and Nurses’ Professional Values Scale (NPVS)-Revised. The data collection tools consisted of a total of 76 questions and the approximate response time was 15–20 min. The questionnaires were distributed to the participants by visiting the work areas, and they were given one week to complete the questionnaire and were asked to complete the questionnaire within this period. After 1 week, the questionnaires were collected back.

Nurse information form

This form, in which the socio-demographic status of the participants is questioned, consists of 11 questions, including age, gender, marital status, educational status, years of work in the profession and organization, position and unit worked in, type of work, income level, and current job satisfaction.

Patient advocacy scale for nurses

The ‘Patient Advocacy Scale for Nurses’ in the literature was used to evaluate the patient advocacy behaviours of nurses. The scale, developed by Ezgi Şermet in 2019, consists of 39 items and 7 sub-dimensions: “Treatment and Care (TC),” “Equality,” “Patient Rights (RR),” “Information,” “Right to Choice (ROC),” “Cultural Care (CC)” and “Privacy.“ [24]. The scale is a 5-point Likert scale with the options “Never-1”, “Almost never-2”, “Whenever possible-3”, “Almost always-4” and “Always-5”. The total score range is 39–195; it is interpreted that patient advocacy increases when the score approaches 195, and patient advocacy decreases when the score approaches 39. The Cronbach’s α internal consistency coefficient of the original scale was found to be 0.92, 0.84, 0.85, 0.82, 0.77, 0.81, 0.81, and 0.60 in the sub-dimensions of TB, Equality, HH, Informing, SH, KB and Privacy, respectively. In this study, Cronbach’s α was 0.92, 0.92, 0.86, 0.88, 0.87, 0.89, 0.89, and 0.88 in the TB, Equality, HH, Information, SH, CR, and Privacy sub-dimensions, respectively.

Nurses’ professional values scale-revised

In order to evaluate the professional values behaviours of the nurses, the ‘Nurses’ Professional Values Scale-Revised’ in the literature was used. It was developed by Weis and Schank [25], and its Turkish validity and reliability were conducted by Acaroğlu [26]. It consists of 26 items and 3 sub-dimensions: “Care,” “Professionalism,” and “Trust.” The scale is a 5-point Likert scale with the options “Not important-1”, “Somewhat important-2”, “Important-3”, “Very important-4,” and “Very important-5,” and there are no reverse coded items. The total score range of the scale is between 26 and 130, and the higher the score obtained from the sub-dimensions and the total scale, the stronger the compliance with professional values. The Cronbach α value of the original scale was 0.92. In the Turkish validity and reliability study, the Cronbach α internal consistency coefficient was 0.96, 0.90, and 0.77 in the sub-dimensions of Care, Professionalism, and Trust, respectively, and 0.96 in the total scale. In the present study, Cronbach’s α was 0.96, 0.91, 0.86, and 0.97 in the sub-dimensions and total scale, respectively.

Data analysis

SSPS 22.0 package program was used for statistical analysis of the data. The distribution of the data was determined by Skewness and Kurtosis tests. Skewness value (-0.409;-0.985) and Kurtosis value (-0.744;0.780) were between − 1.5 and + 1.5 and considered to be normally distributed [27]. Descriptive statistical methods were used to analyze the data. Independent samples t-test, one-way analysis of variance (ANOVA), and Tukey HSD were used for intergroup comparisons. The significance level was taken as 0.05. The eta square (η²) value was analysed to determine the effect size of independent variables. Pearson correlation tests were applied. Multiple Linear Regression (Stepwise method) analysis was performed. Categorical variables were added to the regression model as dummy variables.

Ethical considerations

Ethical approval for this study was obtained from the Non-Interventional Clinical Research Ethics Committee of Başakşehir Çam and Sakura City Hospital (Helsinki Committee/IRB) (Approval Date: April 19, 2023; Reference No: 2023 − 168). Institutional permission was granted by the Istanbul Provincial Health Directorate (Approval Date: August 17, 2023; Reference No: 222467585/2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Prior to data collection, all participants were provided with detailed information about the purpose of the study and written informed consent was obtained from each participant.

Results

Characteristics of the participants

Personal and professional characteristics of the participants are shown in Tables 1 and 2. The majority of the nurses who participated in the study were female (70.8%), single (67.4%), between the ages of 27–28 (37.4%), bachelor’s degree holders (92.6%) and working in the position of nurse (84.1%). It was determined that the nurses mostly worked in specialized units (39.5%), worked night shifts (72.5%), were between 2 and 3 years in the profession and in the institution (50.5% and 65.8%, respectively), had a moderate income level (56.5%) and were moderately satisfied with their jobs (45.2%).

Table 1.

Personal characteristics of nurses (N = 527)

Variables		n	%
Gender	Female	373	70.8
	Male	154	29.2
Marital status	Married	172	32.6
	Single	355	67.4
Age	24 and ↓	61	11.6
	25–26	171	32.4
	27–28	197	37.4
	29 and ↑	98	18.6
Education Status	Associate Degree	9	1.7
	License	488	92.6
	Postgraduate	30	5.7

n: Number, %:Percentage

Table 2.

Professional characteristics of nurses (N = 527)

Variables		n	%
Worked Position	Executive Nurse	71	13.5
	Nurse	456	86.5
Working Unit	Internal Clinics	98	18.6
	Surgical Clinics	118	22.4
	Featured Units*	208	39.5
	Polyclinics	60	11.4
	Other	43	8.2
Mode of Working	Day shift	145	27.5
	Night shift	382	72.5
Years in the profession	2–12 months	56	10.6
	1–3 years	266	50.5
	4 years and above	205	38.9
Year of Working at the Institution	2–12 months	96	18.2
	2–3 years	347	65.8
	4 years and above	84	15.9
Income Level	Very bad	97	18.4
	Minimum level	103	19.5
	Medium level	298	56.5
	Very good	29	5.5
Job Satisfaction	Very satisfied	38	7.2
	Moderately satisfied	238	45.2
	Partially satisfied	155	29.4
	Not satisfied at all	96	18.2

n: Number, %:Percentage, *Specialized units: Operating Room, Dialysis, Emergency, Intensive Care, etc

The relationship between patient advocacy and professional values

The mean scores, standard deviation values, and the relationship between Patient Advocacy and Professional Values scales and subscales are shown in Table 3. It was found that the mean total score of the nurses was 163.84 ± 22.88, and the mean total score was 110.26 ± 16.29. It was determined that there was a statistically positive and moderately significant relationship (r = 0.628; p < 0.001) between the nurses’ mean total score on the PASN and the mean total score on the NPVS.

Table 3.

Descriptive statistics and correlation matrix of PASN and NPVS

Variable	Mean (SD)	1	2	3	4	5	6	7	8	9	10	11	12
1. Treatment and Care	53.93 (7,90)	1
2. Equality	35.09 (4.90)	0.780**	1
3. Patient Rights	27.98 (5.13)	0.696**	0.584**	1
4. Information	12.86 (2.23)	0.732**	0.759**	0.684**	1
5. Right to Choose	16.74 (3.03)	0.711**	0.693**	0.728**	0.789**	1
6. Cultural Care	8.56 (1.56)	0.685**	0.671**	0.653**	0.700**	0.771**	1
7. Privacy	8.68 (1.47)	0.668**	0.772**	0.552**	0.748**	0.723**	0.699**	1
8. PASN	163.84 (22.88)	0.924**	0.876**	0.834**	0.867**	0.866**	0.810**	0.801**	1
9. Maintenance	64.19 (9.74)	0.535**	0.611**	0.423**	0.586**	0.544**	0.523**	0.596**	0.614**	1
10. Professionalism	33.38 (5.27)	0.546**	0.546*	0.452**	0.565**	0.527**	0.492**	0.565**	0.602**	0.880**	1
11. Trust	12.70 (2.07)	0.476**	0.506**	0.357**	0.496**	0.473**	0.429**	0.490**	0.525**	0.765**	0.781**	1
12 NPVS	110.26 (16.29)	0.557**	0.606**	0.444**	0.596**	0.556**	0.527**	0.601**	0.628**	0.980**	0.949**	0.838**	1

r: Pearson Correlation Coefficient, **p < 0.001 *p < 0.05

Comparison of general characteristics of nurses with patient advocacy and professional values

The comparison of general characteristics of nurses with patient advocacy and professional values is shown in Table 4. When the general characteristics of the nurses were compared with the PASN, it was determined that female nurses had more patient advocacy behaviors than male nurses, nurse managers had more patient advocacy behaviors than other nurses, day shift nurses had more patient advocacy behaviors than night shift nurses and nurses who were satisfied with their job had more patient advocacy behaviors than those who were partially satisfied (p < 0.05). No significant differences were found with marital status, age, educational status, unit of employment, years of employment in the profession and institution, and income level variables.

Table 4.

Comparison of general characteristics of nurses with PASN and NPVS(N = 527)

Variable		n	PASN Mean (SD)	NPVS Mean (SD)
Gender	Female	373	165.60 (22.33)	111.28 (16.55)
	Male	154	159.70 (23.70)	107.79 (15.42)
		t	2.702	2.308
		p	0.007	0.022
		η2	0.014	0.009
Marital Status	Married	172	164.23 (23.11)	110.15 (15.88)
	Single	355	163.65 (22.80)	110.31 (16.51)
		t	0.272	− 0.103
		p	0.786	0.918
		η2	0.000	0.000
Age	24 and ↓	61	165.41 (24.06)	110.92 (16.88)
	25–26	171	161.77 (22.86)	110.13 (15.68)
	27–28	197	164.18 (22.99)	109.82 (16.52)
	29 and ↑	98	165.80 (21.99)	110.96 (16.29)
		F	0.814	0.144
		P	0.487	0.933
		η2	0.043	0.035
Education Status	Associate Degree	9	170.00 (33.81)	113.78 (15.97)
	License	488	163.85 (22.40)	110.15 (16.16)
	Postgraduate	30	161.87 (27.16)	110.93 (18.76)
		F	0.437	0.246
		p	0.646	0.782
		η2	0.002	0.001
Worked	Nurse manager	71	169.51 (21.39)	115.72 (15.67)
	Nurse	456	162.96 (23.00)	109.40 (16.24)
		t	2.375	3.143
Position		p	0.020	0.002
		η2	0.010	0.018
Working Unit	a.Internal clinics	98	162.58 (23.52)	107.97 (16.20)
	b.Surgical clinics	118	163.63 (21.98)	109.75 (17.20)
	c.Private clinics	208	162.63 (24.50)	110.29 (16.77)
	d.Polyclinics	60	168.03 (18.10)	113.85 (11.35)
	e.Other	43	169.19 (21.04)	11.79 (16.99)
		F	1.426	1.327
		p	0.224	0.259
		η2	0.011	0.010
Mode of Working	Day shift	145	167.32 (22.45)	113.79 (13.70)
	Night shift	382	162.52 (22.93)	108.92 (16.99)
		t	2.182	3.080
		p	0.030	0.002
		η2	0.009	0.018
Years in the profession	a0-12 months	56	166.71 (22.51)	111.55 (15.87)
	b1-3 years	266	161.82 (23.07)	108.81 (16,41)
	c4 years and ↑	205	165.67 (22.60)	111.78 (16,16)
		F	2.142	2.129
		p	0.118	0.120
		η2	0.044	0.050
Year of Working at the Institution	a0-12 months	72	165.40 (23.35)	110.36 (16.81)
	b1-3 years	150	163.29 (22.51)	110.34 (16.21)
	c4 years and ↑	73	164.33 (24.00)	109.79 (16.21)
		F	0.340	0.042
		p	0.712	0.959
		η2	0.018	0.020
Income Level	Very bad	97	166.28 (24.14)	111.60 (18.52)
	Minimum level	103	164.01 (22.99)	107.41 (18.19)
	Medium level	298	162.61 (22.57)	110.45 (14.74)
	Very good	29	167.72 (21.32)	113.90 (15.71)
		F	0.934	1.774
		p	0.424	0.151
		η2	0.005	0.010
Job Satisfaction	a.Very satisfied	38	172.87 (21.60)	116.63 (14.71)
	b.Moderately satisfied	238	164.53 (21.75)	110.23 (14.96)
	c.Partially satisfied	155	159.19 (23.56)	109.18 (16.42)
	d.Not satisfied at all	96	166.06 (23.73)	109.52 (19.26)
		F	4.575	2.247
		p	0.004	0.082
			a > c
		η2	0.026	0.013

t: Independent samples t test, Mean ± SD: Mean ± Standard Deviation, F:One Way ANOVA, p < 0.05

When the general characteristics of the nurses were compared with the NPVS, it was found that female nurses had more professional value than male nurses, executive nurses had more professional value than other nurses, and day shift nurses had more professional value than night shift nurses at a small effect level (p < 0.05). No significant differences were found between marital status, age, educational status, unit of employment, years of employment in the profession and institution, job satisfaction, and income level characteristics (p > 0.05).

Regression analysis between patient advocacy and professional values

The results of a simple linear regression analysis to determine the factors affecting nurses’ professional values are presented in Table 5. The model for perceptions of professional values was statistically significant, and patient advocacy behaviors affected professional values in nursing. In addition, the explanatory coefficient of the model was calculated as 51.4%. When demographic variables were added to the model as dummy variables, it was determined that NPVS had a statistically significant effect on PASN. As the participants’ perception of NPVS increased, it was found that it caused an increase of 70.2% in PASN. On the other hand, only income level was found to have an effect on demographic characteristics. It was found that those with very poor income level had a 14.6% higher effect on PASN compared to those with moderate income level.

Table 5.

Variables predictive of nurses’ professional values score

Variables	ß	t	p	F	Model (p)	R 2
NPVS	0,702	10,234	0,000*	6,908	0.000**	51.4
Age	0,085	0,543	0,588
Years in the Profession	-0,036	-0,230	0,818
Year of Working at the Institution	-0,139	-1,887	0,061
Gender [Female = 1]
Gender [Male = 2]	-0,088	-1,300	0,196
Marital Status [Married = 1]
Marital status [Single = 2]	-0,007	-0,100	0,920
Education Status [License = 1]
Education Status [Associate Degree = 2]	-0,011	-0,164	0,870
Education Status [Postgraduate = 3]	-0,072	-1,006	0,316
Worked Position [Executive Nurse = 1]
Worked Position [Nurse = 2]	0,002	0,028	0,978
Working Unit [Polyclinics = 1]
Working Unit [Internal Clinics = 2]	-0,003	-0,037	0,971
Working Unit [Surgical Clinics = 3]	0,067	0,861	0,391
Working Unit [Featured Units = 4]	-0,078	-0,975	0,331
Working Unit [Other = 5]	0,063	0,796	0,428
Income Level [Medium Level = 1]
Income Level [Very Bad = 2]	0,146	2,034	0,044*
Income Level [Minimum Level = 3]	0,020	0,284	0,777
Income Level [Very Good = 4]	-0,057	-0,848	0,398
Job Satisfaction [Moderately Satisfied = 1]
Job Satisfaction [Very Satisfied = 2)	0,026	0,381	0,704
Job Satisfaction [Partially Satisfied = 3)	-0,105	-1,545	0,125
Job Satisfaction [Not Satisfied at all = 4]	-0,023	-0,323	0,747

ß:Standardized regression coefficients; t:significance of regression coefficients F: Regression ANOVA test statistic; R²:coefficient of determination; p:p probability of significance of regression coefficients, **p < 0.001 *p < 0.05

Discussion

Patient advocacy practices of nurses are ethically based and closely related to the legal and moral aspects of the profession [28]. Each discipline has professional ethical rules and values; interpreted by the American Nurses Association (ANA), these rules express professional values and are essential in developing professional identity while imposing various obligations on nurses [29]. In this study, nurses’ commitment to patient advocacy and professional values was high. In a study investigating the patient advocacy roles of nurses, it was reported that positive feedback is pleasing, while negative feedback leads to disappointment [30]. A study conducted with Japanese nurses reported that advocacy roles were performed based on cultural values and patient rights [31]. A study comparing professional and student nurses in terms of professional values found student nurses’ compliance with professional values to be higher [32]. The results of the study in the literature are compatible with the results of this study. Technological developments lead to the expansion of the professional role of the nurse. They are expected and desired to fulfill the advocacy role, which is one of these roles, and internalize it as a professional value.

In this study, it was determined that the patient advocacy behaviors of nurses were higher in women, executive nurses, nurses working day shift, nurses with 4 or more years of work, and nurses who were satisfied with their profession. Alanezi’s study stated that women exhibited advocacy behaviors at a higher rate than men. In Kurt and Gündoğan’s study, it was stated that the advocacy behaviors of male nurses were higher than those of female nurses [14, 18]. It is thought that different factors other than gender also shape advocacy behaviors. The developed empathy skills of female nurses are seen as an essential factor for patient advocacy [33].

While a safe working environment positively affects patient advocacy, it is negatively affected in environments with a risk of dismissal and conflict with physicians [33]. In this study, the high level of patient advocacy among nurse managers may be because they feel more secure due to their managerial power. Similarly, working conditions also affect patient advocacy. Staff, patient density, and the need to allocate more time to patients positively impact patient advocacy [34, 35]. Although it is thought that patient and work intensity will be higher during the daytime shift, the fact that the number of employees is higher during the daytime and, therefore, nurses can spend more time with patients may be the reason why nurses working in the daytime shift, which is one of the findings of this study, can show patient advocacy behaviors more. In this study, the patient advocacy behaviors of nurses with 4 or more years of experience were higher than those with 1–3 years of experience.

Similarly, Alanezi’s study found a positive relationship between experience and patient advocacy behavior [18]. A study investigating patient advocacy behaviors in nurses with different levels of education stated that advocacy behaviors were gained more through post-graduation work than education [30]. Similarly, in this study, patient advocacy behaviors increased as the working years of nurses increased. In addition, professional satisfaction increases patient advocacy behaviors. In a concept analysis study, the concepts of professional motivation and professional commitment stand out in terms of professional characteristics that nurses should have to defend their patients [36]. The fact that nurses love their profession and have high professional satisfaction increases professional commitment and enables them to perform their professional roles, including patient advocacy, at a high rate.

In this study, differences were found between the personal and professional characteristics of nurses and their professional values, and it was found that women, executive nurses, daytime workers, and those who were satisfied with their jobs had higher compliance with professional values. In studies evaluating the professional values of operating room nurses and nursing students’ perspectives on professional values, women’s compliance with professional values was higher than men’s [37]. The fact that the nursing profession is practiced more by women and that it suits women may be the reason for the high level of professional values in female nurses. Similarly, in related studies, it was found that charge nurses had a higher perception of professional values than ward nurses [20], and executive nurses had a higher perception of professional values than direct care nurses [38]. In another study comparing Turkish and Iranian nurses, it was reported that there was no difference between managers and other nurses [39]. The results of the study are partially consistent with the literature. According to the law, since at least undergraduate and preferably postgraduate education is compulsory to become a nurse manager, the high level of education may be the reason for the high level of professional values in nurse managers. In addition, the perception of professional values of nurses working day shift was also found to be high. It was reported that a similar result was reached in a study on the subject [13]. Another finding of this study is that nurses who are satisfied with their profession have a high perception of professional values. In another study, no significant difference was found between choosing the profession willingly and professional values [10]. In another study, the professional values of those who did not want to leave their profession were high [13]. Although this study’s and other studies’ results differ, professional values are expected to be high in nurses who love their jobs.

Another result of this study is that there is a relationship between patient advocacy behaviors and professional values. Although there are no studies in the literature looking for the relationship between nurses’ patient advocacy behaviors and their perceptions of professional values, it has been emphasized in various studies that nurses’ advocacy roles are essential in providing quality and safe patient care [40]. In the same direction, it is stated that the professional values of nursing constitute the standards that ensure that the care needs of a healthy or sick individual are met safely and that professional values increase the success of nursing care outcomes by improving professional behaviors [41]. In a study conducted with professional and student nurses in Iran, it was reported that care and justice were perceived as the most important caring values, but professionalism and activism were expressed as the least important professional values [32]. Similarly, in a study conducted with nursing students studying at different universities in Brazil, care was found to be the most and professionalism the least perceived professional value [42]. In another study on the same subject conducted in Jordan, care was expressed as the most perceived professional value by nursing baccalaureate students [43]. The fact that patient advocacy is the basis of the care dimension and that care is perceived as the main professional value is important in terms of revealing the relationship between both concepts. In another study investigating patient advocacy in advanced practice registered nurses, it was emphasized that the development of patient advocacy roles of nurses, whose professional roles are expanding and becoming more complex at this level, is important for providing advanced nursing care [30]. It can be thought that nurses’ patient advocacy roles affect their professional values, and as a result, quality and safety in care increase in parallel with the development of care behaviors.

Conclusions

In this study, it was determined that nurses’ patient advocacy behaviors and perceptions of professional values were high and there was a positive and moderately significant relationship between patient advocacy and professional values. The model for the perception of professional values was significant and showed that patient advocacy behavior was a key determinant of the perception of professional values. According to this result, topics such as professional values of nursing, ethical values, patient rights, and patient advocacy should be included more in the nursing education curriculum and training should be supported by different methods such as case studies and simulations. Managers in health institutions should create a supportive climate for the dilemmas experienced by nurses in ethical and patient advocacy issues and legal arrangements should be made. Necessary arrangements should be made for nurses to take on more advocacy roles for patients and nurses should be encouraged through regular in-service trainings. To increase the effect of professional values on patient advocacy behavior, it is important to improve the ethical sensitivity of nurses. For this, training should be organized and management policies that improve nurses’ compliance with professional ethical rules should be developed. It shows that the patient advocacy roles of nurses and the perception of professional values meet in the basic role of nursing and nursing care, which is the focus of nursing, and this situation affects the provision of quality and safe care.

Lımıtatıon

This study has some limitations. The research data are based on nurses’ self-reports, and their thoughts on patient advocacy and professional values may vary over time. In addition, the research was conducted in a city hospital managed by a public-private partnership. Due to the different management systems, nurses’ opinions in this institution may differ from those of other public or private hospitals.

Implications for nursing health policy

This study revealed the strong relationship between nurses’ patient advocacy behaviours and professional values and highlighted the values of the nursing profession as an important factor affecting the quality of healthcare services. The findings of the study show the importance of a strong integration of ethical values, patient rights and patient advocacy in nursing practice.

Professional values, ethical principles and patient advocacy should be included more in nursing education curricula. In addition to theoretical trainings, case studies, simulations and practical applications should be supported, which will increase nurses’ knowledge and skills and encourage patient advocacy. Managers should provide guidance and psychological support to nurses, which will strengthen professional values and patient advocacy. Necessary arrangements should be made in health policies in order for nurses to fulfil their patient advocacy duties effectively. Continuous trainings should be organised to increase the compliance of nurses with ethical rules. In these trainings, topics such as patient advocacy, ethical values and patient rights should be included.

Abbreviations

PASN

Patient Advocacy Scale for Nurses

NPVS

Professional Values Scale

Author contributions

S.Ç., E.S., N.U., and E.U.K. contributed to: (1) the conception and design of the study, (2) data collection, (3) data analysis and interpretation (primarily by S.Ç.), (4) drafting the article, and (5) final approval of the version to be submitted. Correspondence to S.Ç.

Funding

No financial support was received in the conduct of this research.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Non-Interventional Clinical Research Ethics Committee of Başakşehir Çam and Sakura City Hospital (Helsinki Committee/IRB) (Approval Date: April 19, 2023; Reference No: 2023 − 168). Institutional permission was granted by the Istanbul Provincial Health Directorate (Approval Date: August 17, 2023; Reference No: 222467585/2023). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Prior to data collection, all participants were provided with detailed information about the purpose of the study and written informed consent was obtained from each participant.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.