1. Introduction

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Nursing profession is one of the decent professions in the world, whether by virtue of its social value, its sensible values, or the noble value of human life itself, health, and feelings. Ethics and professional values of this profession have been set and clarified to all nurses starting from college education to practice settings. The majority of healthcare professionals including nurses work to the highest standards to deliver safe and high quality care for patients. Since their everyday job is providing high-quality care, at times when they are increasingly confronted with professional and ethical dilemmas, nurses should meet high ethical standards of practice and conduct. According to Olson (1998), interest in nursing and healthcare ethics has emerged as a result of an increased awareness of the complex ethical problems in health care [1]. Facing the rapidly changing values in society and health care, nurses encounter more challenges and ethical dilemmas in the delivery of care to clients. In addition, modern healthcare system put the nurses under the responsibility of demonstrating skills of effective decision making, be emotionally intelligent, innovative and deliver continuous, safe, compassionate, patient-centered care [2]. So personal and professional values of nursing care are the guidelines of nurse behavior, and clarifying professional values is essential for the nurses.

The adoption of professional values is of primary importance as they form the identity of a profession and serve as a guide to action. Professional values “are standards for action that are accepted by the practitioners and professional group and provide a framework for evaluating beliefs and attitudes that influence behavior”[3].

Professional values form the basis for nurse attitudes and behavior, and are a keystone to guide nurses' clinical decisions in practice [4]. Jordanian nursing council (2016) defined Professional standards as the rules to provide competent profession, that nurses are required to achieve in their performance, including performance, knowledge, professional communication, professional development, leadership and management, and resource utilization [5].

Many studies addressed the issue of professional values content. Professional nursing values are including altruism, autonomy, human dignity, integrity and social justice [6]. While Yarbrough et al. (2008) mentioned that professional values include respect for human dignity, protection of patient privacy, protection from harm, and personal and professional responsibility and accountability[7]. Other authors recommended the following values in their developed professional values assessment tool which were derived from American Nursing Association code of ethics (2001) that include: caring, activism, trust, professionalism, and justice [8]. In Jordan the code of ethics for nurses, which was first published in 1996, describes the primary goals, obligations, duties, and values of nursing profession. The major principles are: respect for human dignity and the uniqueness, safeguards the client's right to privacy and confidentiality, safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person, responsibility and accountability, maintains competence in nursing, informed judgment, professional knowledge development, improve standards of nursing, maintain the integrity, and collaborate with members of the health professions to meet the health needs of the public [9].

Providing health care now a day is under pressure, significant stress has been placed on nurses' workplaces. Under the progressively growth of organizational challenges in health-care delivery today, there are important values that shape the ethical climate in workplaces and affect the well-being of nurses. Ethical climate is defined by Olson (1998) as “an organizational variable that can be managed and changed in order to improve the workplace environment. It consists of perceptions of organizational practices and conditions that facilitate the discussion and resolution of difficult patient care issues, and provides the context for ethical decision-making in the clinical setting” [1]. An ethical climate represents those shared perceptions of organizational practices related to ethical decision- making and reflection and includes issues of power, trust and human interactions within an organization [1].

Also ethical climate is best understood as a group of prescriptive climates reflecting organizational procedures, policies, and practices with moral consequences. As the work climate has an effect on the behavior of employees in organizations [1]. Some researches had demonstrated a positive link between ethical climate and professional values, and cognitive moral development [10]. Extant research has found relationships between ethical climate and a number of unethical behaviors including deception, lying, stealing, fabricating reports [11], disobeying company rules, being an unethical collaborator, personal aggression, and organizational misbehavior [12]. A good work climate provides social support, shared goals and an tools for coping with stress [13]. Stringer (2002) supported the same results by suggesting that a good work climate increases employees’ motivation, which, in turn, has a strong impact on people’s ways of working and performance [14]. A study suggested that nurses’ values could be affected by their interactions within their work environment. So it was then assumed that work climate would enhance intrinsic as opposed to extrinsic work values because work climate should enhance nurses’ work in line with teamwork goals [15].

Although literature shows a predictive linkage of work climate and professional values, it has been noticed that the correlational effect of these variables has been rarely considered in literature. And based on the literature review, we built a hypothesis for this study to test the correlation between hospital ethical climate and professional values [16].

As long as workplace issues continue to be seen as a major cause of the healthcare shortage [17], it is clear that a positive ethical climate is an important determinant of nurses’ job satisfaction. Despite recent research that points to the importance of developing and measuring professional nursing values, few researchers have examined the professional nursing values of registered nurses in the workforce and none have specifically examined professional values and its correlation to hospital ethical climate of RNs in Jordan. So the purpose of this study is to describe the perception of professional values and hospital ethical climate among nurses in Jordan and the correlation between nurses professional values and hospital ethical climate.

2. Material & Methods

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2.1. Ethical Consideration
Permission to conduct the study was obtained from the Institutional Review Board (IRB) of the university where the researchers work in. The permissions to join the nurses social media private groups temporary by the researcher for the purpose of explaining the study to the group members and assure anonymity and confidentiality was taken from the administrator of each group. Study participation is voluntary. Survey included informed consent before starting the questionnaire. Nurses were asked to participate by completing the questionnaires and submitting the completed forms, and then the researcher withdrew from group before getting any response to assure the privacy, and autonomy of the participants.

2.2. Sample & Data Collection
The sample size and added sufficient number for possible dropping out of participants was 150 registered nurses were recruited through social media from well-known nurses groups (Face book, Twitter, LinkedIn, and WhatsApp). The survey was administered through an online survey platform. In order to increase population homogeneity, selection criteria listed below was used to limit factors that would likely decrease generalizability of the study. The study was conducted between February and March, 2018. A convenience sample was used because randomized sampling of all potential subjects would require many sites with additional expenses beyond the scope of this level of inquiry. Each subject met the following selection criteria: being a registered nurse, currently working in hospital or health centers, caring for patients as a staff, experienced in nursing for a minimum of one year, working in the current institution for at least 6 months.

2.3. Instruments
It includes three sections: social-demographic information: gender, age, working unit, institution sector, level of education, work experience, professional title, and years of experience in the same institution. The second section is the nurses professional values scale-revised (NPVS-R): the first tool used in the study is an established instrument for the measurement of nurses' professional values by Weis & Schank (2009). This scale consisted of 26 items that covered the following domains: caring, activism, trust, professionalism, and justice. The score of each item ranged from 1 (not important) to 5 (very important). The higher the score, the stronger the nurses professional value orientation . Overall, Cronbach's alpha coefficient was (0.92). The third section include Hospital Ethical Climate Survey (HECS) developed by Olson (1995) for measurement of nurses’ perceptions of ethical climate in health care institutions. It is a 26-item instrument using a Likert-type scale. Five factors were identified by Olson which affects the ethical climate as perceived by the nurse working in a hospital. These were relationships with (a) peers, (b) patients, (c) managers, (d) the hospital, and (e) physicians. Psychometric testing information on the HECS provided by the author[1]. The Cronbach’s coefficient alpha for the HECS in this study was (0.922).

2.4. Data Analysis
The sociodemographic results showed that sample of (N=150), male and female participants were comparable with a mean age of 30 years old. The majority of participants hold a Bachelor degree (n=140, 93.3%). Additionally, participant of this study had an average of 5 years experience as registered nurses, and average of 2.5 years of employment in the same hospital. 70% were from governmental sector and another 30% were from private. 75% were bedside nurses, and the other 25% were nurses working in the administration, education, infection control and quality departments.

In terms of professional values of nurses, Table (1) shows the results of highest and lowest ranked responses means and total mean score of the NPVS-R. The Weighted average of the whole questionnaire was (4.15), with standard deviation of (0.50) which indicate general trend (Very Important) according to the 5-point Likert scale. The highest average was awarded to the item “Maintain confidentiality of patient”, with mean of (4.8), followed by “Protect moral and legal rights of patients”, with mean of (4.74), followed by item “Seek additional education to update knowledge and skills” with mean of (4.65). Then item 4, and 3 as shown in Table (1). Whereas the lowest average was awarded to the item “Confront practitioners with questionable or inappropriate practice”, with mean of (2.00). Then items 2, 3, 4, and 5 respectively with means of (2.16, 2.30, 2.35, and 2.60).

Table 1

Table (2) shows the rank order of the five highest and five lowest scores of perception of hospital ethical climate. It shows that the highest score item was for” When I’m unable to decide what’s right or wrong in a patient care situation, my manager helps me.” (4.82). And the lowest score item was for “Physicians ask nurses for their opinions about treatment decisions” (1.75) “. Three of the highest ranked items were related to relationship with manager, while three of the lowest mean items were related to the relationship with the hospital. The total perception was high with a mean of (4.19, SD=0.58).

Table 2

In regards to The correlation between total mean of perception of professional values and HECS was moderate significant positive correlation (r= 0.421, P>0.5).

In Regards to professional values, the average mean score was significantly high which means that nurse have strong professional values. This was consistent with other studies [18,19]. Caring items were rated as the highest by the participants. This result was similar to that formerly reported by many researchers [18,20-22]. In the studies also conducted by other researchers the most important professional values for nurses were related to caring. This can be due to the nurses who providing care to patients which has continued to be steady, despite significant changes to the health care system [8,23]. The reason for caring to be the highest ranked may due to the fact that nurses mainly consider values that are directly related to nursing daily clinical work. Also these values might inherently exist in individuals with tendency towards nursing profession.

Maintaining privacy and confidentiality in addition to Safeguarding patient's moral and legal rights were the highest major professional value due to nurses beliefs in values conformity and patient’s security as it cannot be unnoticed that countries who’s majority of population are Muslims are demonstrating high level of moral and ethics and consider privacy and confidentiality as one of patient’s essential rights which mainly affected by the religion and culture. Regarding the fifth items “Protect health and safety of the public”, it was similar to Lui, et al. (2007) study results that nurses do not ignore or allow to perform or take any actions that causes safety problems to the patients [24].

On the other hand, it is not reasonable that “Confront practitioners with questionable or inappropriate practice” and” provide care without prejudice of varying lifestyles” were the lowest ranked items, it may be because of time limitation and work overload that prevent the nurses from even noticing the other practitioners wrong practices. Beside that confrontation sometimes considered as a role of nurses in managerial positions who have the right to questioning the nurses' practices. “Participate in public policy decisions affecting distribution of resources’’ was low item mean because policy decisions in Jordan are done by higher authorities or councils therefore, there is no significant participation for nurses, and this result is consistent with Cheng, et al. study [21]. Previous studies proved that nurses were only included in a few administrative decisions[25]. In addition “Participate in nursing research and/or implement research findings”, mean was low may be due to nurses are waiting for a long time until they start to conduct researches due to the work overload and they focusing only on practice and patient care role. It is worth mentioning that the lower scoring domains in NPVS-R address nursing issues outside the nurse-client relationship such as public policy, environment, professional nursing organizations, and research, and professional organizing. As the profession continues to transform, nurses need to view professionalism and activism as equally important to caring because there are international calls for nurses from many nursing organizations to look beyond and raise their profession to influence healthcare reform.

The participants in the current study reflect positive perception of their hospitals ethical climate. According to Olson (1995) the way nurses perceive their work environment can affect their professional values and attitude towered ethical issues, and decision-making [26]. This study results were dissimilar to Allari, and Abumogli results in (2013) who showed that the general view of nurses at that time was neutral [27]. And according to Olson, a positive ethical climate is needed to support professional nursing practice. The importance of relationships among the health care team within the work environment was demonstrated in items with the highest and lowest scores on the HECS [26]. The most positive perception was related to the nurses’ views of their managers which reveals the importance of employing highly qualified managers, and shows the participation of Jordanian nursing managers in their teams' conflict management. Mrayyan (2006) study showed that nurses reflected satisfaction with co-workers such as immediate supervisors, and the amount of responsibility and participation in organizational decision-making, which is accordingly give support to this study result[28]. These factors, according to the reviewed literature influence perception of their hospital ethical climate.

The relationship with physicians and the hospital received as the lowest scores showed the endless power struggle between nurse and physician and the power differential between nurses and doctors that can be both a barrier to good care. Nurses felt subordinate to physicians, often feeling that they were not heard and had no impact on decision making [29]. It is necessary for nurse managers to consider ethical work environment conditions in hospitals and create more constructive conditions; which might play a role in improving the professional values among nurses, which was shown to be positive for participants in the present study.

On the other hand, the results showed a strong positive correlation between perception of professional values and hospital ethical environment. Such results were also similar with the results of other studies which also found that ethical work climate is a multidimensional construct influence employees' job attitudes and job behaviors [30]. And mostly has a positive influence on ethical behavior. The opportunity for unprofessional behaviors appear to be more predominant in organizations where the ethical climate is unethical[30]. For the nurses it is obvious that ethical work environment facilitate the best ability to work professionally and ethically. Many studies found that emotional Exhaustion and depersonalization which can be developed by poor ethical work environment were negatively correlated with professional value and personal accomplishment.

There are, however several limitations of our study such as the sample size which was inadequate and convenient. In addition, the researcher didn’t analyze if the hospital ethical environment was a predictor of professional value, a question that will be addressed in future studies. But in overall, the results of this study indicated that professional value is significantly correlated to hospital ethical climate, and it is imperative that managers strengthen the hospital ethical environment that accordingly will secure professional value among nurses, that eventually will improve the quality and safety of nursing care.

4. Conclusion

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As the first study that explored issues related to nurses professional values and hospital ethical climate, the finding provided a foundation for the development of evidence-based interventions, designed to improve the nursing profession. This study has revealed that nurses in Jordan have high professional values. And professional values that were related to caring role were more important than the values related to non-clinical roles such as activism. Nurses’ own perception of hospital ethical climate is positively correlated with professional values, and the most significant relationship that affects professional values was with the manager. Therefore, the role of nursing managers to boost the professional values, support less-important professional values, and increase the nurses’ awareness as well as understanding of the importance of these professional values that will accordingly improve the hospital ethical environment as well. It is suggested that continuous education programs be designated according to the emerging ethical challenges based on professional values. Furthermore, good communication among health care members, improvement of organizational ethical climate, appropriate supportive system, and development of professional culture could lead to observing professional values in clinical practice.

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