MLS EDUCATIONAL RESEARCH

Method

The quantitative descriptive method was used. The García Valuative Reaction Test, modified by Álvarez (2007), was applied to a sample of 203 nursing professionals working in public and private centers in the Dominican cities of Azua, Baní, Barahona, Bonao, La Vega, San Pedro de Macorís, Santiago and Santo Domingo.

The subjects were given the informed consent form, and, when they returned it signed, the procedure was confirmed and the test was given to them, indicating that it was valid only if completed, but that they could withdraw at any time if they wished. Of the 225 professionals who agreed to participate, 22 did not complete the test.

The Valuable Reaction Test has 250 reagents with corporal, intellectual, affective, aesthetic, individual, moral, social, environmental , instrumental and religious values. As it is long, the corporal, environmental and instrumental values were suppressed, to reduce to 175 reagents, plus the general data. The test is constructed by organizing the values into groups of 25 using this scale: Very pleasant (2), pleasant (1), indifferent (0), unpleasant (-1) and very unpleasant (-2). To grade the test, the values of each answer in a category are added together and interpreted as the strength of the presence of that category in the person.

The results were analyzed with Excel and SSPS 15® by descriptive statistics and Pearson correlation. Data distribution was normal with low homocedasticity in the Levene and Brown Wells tests.

Results

The socio-demographic characteristics of the sample describe a greater presence of female professionals (n=188; 93%), between 21 and 40 years of age (n=115; 57%) and of Catholic religion (n=124; 61%).

Figure 1. Frequency distribution of scores obtained by nursing professionals in the Appreciative Reaction Test
Note: Source:Author’s own creation, 2017-2018

Figure 1 shows the behavior of the scores obtained in the seven value categories. The Pearson correlation between the scores obtained from the nurses in the test was significant at the 0.01 bilateral level. The most common value scale observed in the subjects behaved as such:

• First level: Individual values with 145 (71%) professionals in the maximum score (41-50 points).
• Second level: Affective values with 114 (56%) professionals in the maximum score.
• Third level: Affective values with 77 (38%) professionals in the maximum score.
• Fourth level: Affective values with 75 (37%) professionals in the maximum score.
• Fifth level: Affective values with 48 (24%) professionals in the maximum score.
• Sixth level: Affective values with 38 (19%) professionals in the maximum score.
• Seventh level: Affective values with 26 (13%) professionals in the maximum score.

These locations do not change when the scores for each category are added together in the second scoring range (31-40). What the analysis is saying is that the differences observed in the scores between the categories are not due to chance, since they were highly significant, with p < 0.01, but there are specific causes causing them.

Figure 2.. Behavior of the maximum scores obtained by professionals, according to their age group.
Note: Source:Author’s own creation 2017-2018

The behavior of the scores of the value categories observed in Graph 2 shows that age is not a factor that alters its initial position in the scale, except for small differences between the lowest scoring categories that were not statistically significant to the analysis of variances. Similar results were observed when analyzing the institution variables of graduation and religion.

Discussion and Conclusions

In the professionals group, the primary values are the individual values, the values from the principle of freedom, which boosts improvement. This data differs from reports in other Latin American countries (Barbero, 2013; Córdova and Modest, 2009) where the motivation for academic growth is reported to be low. When filling out this section of the survey, subjects expressed intense interest in knowing alternatives to postgraduate studies and specializations, showing that they are aware of their need to advance. These values also make it possible to act in justice for oneself and others, so that the nurse recognizes her personal worth and her limits within the healthcare team and before the patient.

Affective values are the second scale level in those nurses who were observed. They are values that belong to the principle of kindness and are manifested in affective attitudes that protect mental health. The reaction of the observed professionals when filling in this category were generally very positive and were appreciated in the disinterested and kind treatment they provided to patients, even when their working conditions were not always the best. Interpreted as part of the Araujo and Cols study (2011) and Barbosa and Cols. (2017), means that the training process fosters these values in practice, although observing them in the second position and before the findings of Bavis and Cols. (2018) and Peguero (2016), it is also inferred that they need to be reinforced so that they manifest equally in the conduct of all service professionals.

The third scale level was for intellectual values, relative to thinking skills. Professionals were comfortable with academic activities and the terms related to collaborative living with others.

The fourth position saw the moral values, referring to the integrity of being. Professionals filled in this section of the survey with little or no comment, affirming Álvarez´s (2007) conception that they belong to the intimacy of being. They are related to justice, in order to act with charity and not malice when addressing healthcare needs. Cora and Cols. (2017) express that students agree with employers in not valuing general ethics and significantly appreciating the ethics applied to nursing. So, it is possible that a specific scale for nursing care reflects better scores in this category.

The fifth position was for social values that affect interpersonal and institutional relationships in form and content. The nurses showed honest expressions of displeasure in this category, and in the next two, towards the aspects they rejected. In social values, the harshest expressions were for political terms, political pluralism, constitution, state, association and law, connecting them with the country's current situation regarding widespread corruption. But their rejection was also manifested towards the collective guidance within its institutions.

The underlying meta-cognitive factor, both for the high scores in the category of individual values and the low scores in the category of social values, may be related to their way of dealing with the pressures generated by the enactment of the General Health Law 42-01 and the recently approved Dominican College of Nursing. Law 42-01 has imposed the requirement for a degree (Art.92) and mandatory continuous personal and professional development to award new contracts (Art.95) with salary benefits according to scale (Art.96), by which they opted to finish their degrees and study specialties with little support. Nurses who cover teaching duties at universities and earned an extra salary, receive additional pressure from the 2012 Regulation that regulates the training of care professionals and requires a master's degree for everyone who teaches.

The nursing staff in the country is made up of citizens who work for the social good but receive low salaries, except in the hospitals of the new generation. And since they often come from the deprived social strata, their basic needs are barely under control and they resort to moonlighting to improve their life quality.

Amaro (2014), Carnevale (2013) and Lima and Cols. (2014) explain that moral dilemmas, moral suffering and uncertainty in nursing staff are generated by factors that, among other aspects, are related to social values. They have to face the ethical dilemmas posed by considering the patient’s wishes, confronting what they learned in the training institution against what is witnessed and required in the institution they currently work in, and working under conditions often unfavorable to them, such as the workplace environment, the nurse/patient ratio, the provision of materials and equipment, interpersonal relationships and the personal security situation.

That is why their compassionate attitude and human warmth when approaching patients is admirable and related to the high scores in the category of affective factors. This ratifies that nurses have a moral conscience of commitment to the practice of nursing care, and we must pay attention to stressful factors so that they do not reach levels that cause an imbalance.

The sixth category of affective values is defined as the appreciation of beauty and includes values related to the fine arts. Ugliness, bad aesthetics and unpleasantness are opposed to it. The nurses’ expressions revealed that they do not usually enjoy literature, painting, poetry or theater. They consider that going to museums or concerts is not for them. They were more receptive to parties. A connection was found between this opposition and their workplace environment. Due to the excessive demand of this service, with the exception of the New Generation Health Centers, nurses move around hot spaces, without decorations that need to be washed or painted.

The category of religious values achieved the last position on the scale. Surprisingly, nurses scored low even if the Dominican Republic is predominantly religious. Circumstances can be easily understood if we relate the professional’s religion to the appreciated or refused religious values and observe the nurses’ expressions when filling in this section. The reasons were the appreciated strong individual values of the accepted beliefs and the low tolerance towards other people’s beliefs. The analysis indicates that people from protestant religions defined the terms related to Catholic faith as indifferent or disagreeable, and vice versa. All of them rejected the allusions to oriental religions, which are not well-known or appreciated. Nurses displayed a low level of culture, ignorant as to the meaning of some characteristic terms of oriental cultures.

Leininger and Mcfarland (2002), as well as Mixer (2011), found that taking culture into account is a better way of obtaining high quality care and being able to predict the nursing care phenomena, a mandatory job for science. This discovery should lead to the development of studies in areas with different cultures, considered inferior by Dominicans. The purpose would be to observe how scientific and humanizing the nursing care exercise is in those conditions, what should be included in the study program, and what is required in the admission to overcome what is lacking.

It’s also possible that this respect for foreign cultures is associated to conflicts noticed among the nurses when observing their social values. Apart from being at a religious level, the possibilities of cultures being different are found in the political conceptions and in the attitudes towards their class management in the health service institutions and the professional associations.

The statistical analysis did not find any significant relation between the score obtained by professionals in the work category and the age factors, the institutions they graduated from, or their religion. However, the differences in the scores between categories were significant at a level of 0.01. This data indicates that the scale of values is not related to the educational program of the college the nurses graduated from. According to the socio-legal processes described, it seems that there is a coincidence between Barbosa and Cols’ findings. (2017) about the personal experiences, culture, legislations and current codes defining values in the nurses.

As a result, nursing professionals have a scale of values that reflects their partial application of the nursing code. This is because some of its values are highly positioned and others are lower, as in some situations in Colombia (Jiménez and Cols., 2015; Parra and Cols., 2016). Facing the curriculum review process made by Dominican nursing universities, the finding should be food for thought. They should also consider searching for different strategies that would make the integration of principles and values more significant for future profession in nursing care.

As proposed by Luengo and Sanhueza (2016), Dominican nursing universities should reach a consensus on the goals and objectives of ethical professional training. Within them, every institution must design a strategy in order to achieve this and then contribute the outstanding ones to the set. It’s necessary to structure an integration model of the set of principles and values in order to promote all of them with equal intensity.

Lastly, the contributed data made it possible to achieve the research objective: to analyze what the predominant values were that could be conditioning nursing professionals’ behaviors in the workplace environment. Many conclusions were made from the analysis of the results:

• The main interests of nursing professionals are individual values, which make them prioritize their personal needs, master their behaviors towards their environment and take legal action if necessary. Educational and labor institutions have to keep track of them, organizing activities to promote a balanced application of the values and prevent alienation and egocentrism.
• Affective values are the second level on the nursing scale. They are values about the principle of goodness connected to the first element of the ICN about the nurse and the individual. They encourage selfless services and kind treatment, regardless of workplace circumstances. Schools must organize activities for the participation of those graduated from them, preserving the levels observed.
• Intellectual values got the third position on the scale. They are important for metacognition, the creation of the individual and survival, and for creating the need for harmony with other human beings. They are related to liberty and the search for excellence expressed in the third element of the ICN: nurses and their careers. Schools have to encourage them in order to solve and prevent any interpersonal conflict. Intellectual values and individuals are a good base for introducing the practice based on evidences such as the workplace culture.
• Moral values got the fourth position. They are essential for the rest of the categories because they belong to the principle of truth. Promoting them effectively is a challenge for schools, since they are surrounded by inappropriate models presented by society.
• Aesthetic values got the fifth position, they scored low because fine arts were rejected. Schools and healthcare centers must open up to activities promoting creativity and the appreciation of beauty.
• Social values got the sixth position. They refer to unity and the fourth element of the ICN about nurses and their relationship with their colleagues. In these values, people showed strong rejections against some terms relating to politics and professional associations. Training institutions should encourage the development of healthy relationships between peers and guide social growth with clear positive models, fully and actively committed to improving society.
• Religious values got the seventh and last position. They belong to the truth and underlie all the elements of the ICN. The service professionals seemed to appreciate the dogmas of their religions and reject those belonging to other religions. That led to a low score for them. Nursing schools must incorporate spirituality through the approaches of tolerance, understanding and respect.