Exploring nurses’ experiences of value congruence and the perceived relationship with wellbeing and patient care and safety: a qualitative study

Abstract

Background
Values are of high importance to the nursing profession. Value congruence is the extent to which an individual’s values align with the values of their organisation. Value congruence has important implications for job satisfaction.

Aim
This study explored nurse values, value congruence and potential implications for individual nurses and organisations in terms of wellbeing and patient care and safety.

Method
Fifteen nurses who worked in acute hospital settings within the UK participated in semi-structured telephone interviews. Thematic analysis was utilised to analyse the data.

Results
Four themes were identified: organisational values incongruent with the work environment; personal and professional value alignment; nurse and supervisor values in conflict; nurses’ values at odds with the work environment. Perceived value incongruence was related to poorer wellbeing, increased burnout and poorer perceived patient care and safety. The barriers identified for nurses being able to work in line with their values are described.

Conclusions
Value congruence is important for nurse wellbeing and patient care and safety. Improving the alignment between the values that organisations state they hold, and the values implied by the work environment may help improve patient care and safety and support nurses in practice.

Full text

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
Exploring nurses’ experiences of value congruence and the perceived relationship with wellbeing
and patient care and safety: a qualitative study
Abstract
Background: Values are of high importance to the nursing profession. Value congruence is the extent
to which an individual’s values align with the values of their organisation. Value congruence has
important implications for job satisfaction.
Aim: This study explored nurse values, value congruence and potential implications for individual
nurses and organisations in terms of wellbeing and patient care and safety.
Method: Fifteen nurses who worked in acute hospital settings within the United Kingdom
participated in semi-structured telephone interviews. Thematic analysis was utilised to analyse the
data.
Results: Four themes were identified: organisational values incongruent with the work environment;
personal and professional value alignment; nurse and supervisor values in conflict; nurses’ values at
odds with the work environment. Perceived value incongruence was related to poorer wellbeing,
increased burnout, and poorer perceived patient care and safety. The barriers identified for nurses
being able to work in line with their values are described.
Conclusions: Value congruence is important for nurse wellbeing and patient care and safety.
Improving the alignment between the values that organisations state they hold and the values
implied by the work environment may help improve patient care and safety and support nurses in
practice.
Key Words: Nurses, Values, Wellbeing, Patient care, Patient safety, Burnout, Qualitative, Interview
Introduction
Values are recognised as important within nursing (Rassin, 2008), and recent policy initiatives to
recruit nursing staff based on their values underlines the centrality of values for the profession
(Department of Health, 2012). All Registered Nurses (RNs) possess values that will influence their
attitudes, behaviours and emotions. Being aware of values that motivate RNs supports them in
practice. RNs without self-awareness of their motivating values may struggle with their professional
role; whereas RNs with an understanding of their values often achieve personal satisfaction (Altun,
2002). Studies have revealed a relationship between RN values and concepts of wellbeing such as
levels of burnout (Saito, Igarashi, Noguchi‐Watanabe, Takai, Y., & Yamamoto‐Mitani (2018), and job
satisfaction, and performance outcomes (Atefi, Abdullah and Wong, 2014). Importantly, these
studies explored either personal values (Atefi, Abdullah and Wong, 2014) or professional values
(Ravari et al., 2013) and found both sets of values to influence RN job satisfaction and performance.
There is a growing awareness that healthcare staff wellbeing and work related wellbeing concepts
such as burnout may have implications for patient safety. Therefore, it is possible that associations
between RN values and wellbeing concepts may also be relevant in terms of patient care and safety.
For RNs who work in acute hospital settings, depressive symptoms have been found to be directly
associated with poorer perceptions of patient safety at an individual and organisational level
(Johnson et al., 2017). Furthermore, chronic stress has been negatively associated with perceptions
of safety and the ability to act as a safe practitioner (Louch et al., 2017). These findings are
concerning given that RNs perform a key role in ensuring patient safety as they monitor and
coordinate patient care (Kirwin et al., 2013) and therefore have opportunities to reduce adverse

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
events and prevent errors before they occur. RN staffing levels are a key issue in patient safety. A
crucial review and discussion paper identified a positive relationship between RN staffing levels and
patient outcomes including: lower death rates, reduced incidents of falls, shorter hospital stays, and
less missed care opportunities in acute hospital care settings (Griffiths et al., 2016). The relationship
between RN staffing levels and patient outcomes is of particular concern in the UK due to the
current shortfall, with more than 10% of nursing posts vacant in (Buchan et al., 2019). Furthermore,
research highlights that inadequate staffing impacts not only patient care and safety, but also
negatively affects RN wellbeing (Sizmur & Raleigh, 2018.).
Whilst professional and personal values have been studied simultaneously (Rassin, 2008), few
studies have explored the relationship between these sets of values, and their association with
organisational values. This is important, as the relationships between wellbeing, burnout and patient
care and safety are likely to be influenced by value congruence: the alignment of an individual
employee’s values with those of the organisation in which they work (Verplanken, 2004). Value
incongruence has been related to significant negative outcomes for RNs including low job
satisfaction (Kaya, Çelik & Dalgıç, 2020), higher burnout (Leiter et al., 2009), greater intention to
leave, decreased patient satisfaction (Grates & Mark 2012) and increased staff turnover (Shao et al.,
2018). One study found a significant inverse correlation between value congruence, job satisfaction
and quality of patient care (Kramer and Hafner, 1989). However, there have been some mixed
findings in this area, with one study concluding that value congruence was not related to job
satisfaction (Kalliath et al., 1999), which underlines the need for further research to explore these
relationships.
Studies to date highlight the importance of values for RNs and suggest potential relationships
between value congruence, wellbeing and patient care and safety. However, these studies have
predominantly used quantitative methods and there has been no study to date that explores RNs
perceptions of these potential relationships.
Aims
The study aims:
To explore perceptions of values and value congruence with RNs employed in acute hospital
settings.
To understand how values and value congruence are perceived to be related to RN wellbeing,
patient care and safety.
Methodology
The study adopted an exploratory qualitative approach (Sandelowski, 2000). An essentialist
approach was considered most appropriate as it reported the reality of the participant’s experiences
and related meaning (Braun and Clarke, 2006). To guide and enhance the transparency of study
reporting, the COREQ checklist was applied by one author (AD) (Tong, Sainsbury and Craig, 2007).
Design
Semi-structured telephone interviews were conducted with RNs working in acute hospital settings.
Telephone interviews are a popular method with healthcare staff due to the flexibility of time and
place they offer participants who work shifts (Carr and Worth, 2001). Research suggests that there is
little difference in the responses yielded between telephone and face-to-face interviews (Carr and
Worth, 2001). The interviews lasted an average of 30 minutes.

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
The interview schedule was informed by relevant literature (Altun, 2002; Atefi, Abdullah and Wong,
2014; Grates & Mark, 2012; Rassin, 2008; Verplanken, 2004) with several areas of focus including:
important values for nurses, value congruence and the implications of value congruence. The semi-
structured interview style and schedule allowed for flexibility within the interview, which enabled
the pursuit of issues raised by the study participants. Pilot interviews, conducted with research and
community nurses (n=2), helped refine the topic guide. The interview schedule followed an iterative
approach in which earlier interviews with participants influenced subsequent interviews.
Participant selection and recruitment
Any UK based RN working in an acute hospital setting was eligible to participate. Nurses responded
to advertisements on social media platforms (Facebook and Twitter) to register their interest in
participating. Social media allowed for the recruitment of RNs from multiple organisations of
different sizes from varied geographic locations with a broad range of experiences. This was to
ensure the interviews included RNs perceptions from different organisational cultures. The study
assumed a hybrid sampling method (Barber, 2001), using a combination of opportunity and
purposive sampling. Opportunistic sampling was utilised in the first instance, an approach often used
to recruit nurses (Barnfield, Cross & McCauley (2018). Following this, purposive sampling was
embraced, which allowed a level of control over the cases sampled (Barber, 2001). The recruitment
strategy followed an iterative approach, whereby the researcher (AD) engaged in preliminary
analysis which shaped the subsequent sampled cases (Cohen and Crabtree, 2006). Subgroups not
represented within the sample were subsequently targeted e.g., different NHS bands and
specialities.
Participants were recruited between May and November (2018). There were 26 responses to the
advertisements, and 15 nurses completed the interviews. The nurses who initially expressed an
interest in participating but did not complete an interview were not required to provide a reason for
non-participation. However, those who did provide a reason for not being able to complete an
interview cited differing work patterns or busy schedules. The participants were based across nine
different hospitals which varied in geographical location and size, in England and Scotland.. The
majority of participants were female (93.3%), White British (93.3%) and Band 5 (66.66%; see Table
1).
Recruitment was ongoing until data saturation had been reached. Data saturation (Saunders et al.,
2017) was considered to be achieved when new interview participants were not expressing new
insights, thus leading to informational redundancy. One researcher (AD) listened to audio recordings
of completed interviews in order to establish when informational redundancy was being reached.
Ethical considerations
Ethical approval was granted by [removed for peer review] (Ethics Reference No: PSC-304;
26/03/2018). All participants consented to participating in the interview and being audio recorded.
Data analysis
The interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used:
this offers a flexible approach for data analysis to provide a rich and detailed account (Braun and
Clarke, 2006). This was appropriate for understanding RNs’ values and their experiences of value
congruence and its impact on wellbeing and patient care and safety. Data analysis involved six steps
(Braun and Clarke, 2006). In the first step, familiarisation with the data occurred through listening to
the audio recordings, reading and re-reading transcripts with initial observations being noted. In the

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
next stage, all transcripts were read and coded by one author (AD). Additionally, two authors
independently coded a third of the transcripts (GL and JJ). After discussion and consensus between
three authors (AD, GL and JJ), initial codes were generated, and applied to the full dataset. In stage
three, codes were gathered into potential themes. In the fourth stage, the themes were reviewed in
relation to the coded extracts and the entire data set. In stage five, with further analysis, these
themes were refined to generate clear definitions and names. Finally, meaningful extracts were
identified to represent the themes. Throughout the analysis stages, one author (AD) simultaneously
charted the data by creating tables with initial codes, pulling data from further transcripts into this
and then visually grouping these to form the final themes.
Results
Four key themes were identified, which described the different aspects of value congruence
experienced by RNs: organisational values incongruent with the work environment; personal and
professional value alignment; nurse and supervisor values in conflict; and nurses’ values at odds with
the work environment.
Organisational values incongruent with the work environment
There was incongruence described by most RNs across all bands, between organisational values and
the work environments created in practice. The values that the RNs described as reported by their
organisations included honesty, compassion, care, respect and being patient centred. However, the
RNs perceived that organisations aimed to meet policy driven targets, and that managing limited
resources and funding had become the most valued aspects for the organisations. Service pressures
created barriers (e.g., staffing levels) which were perceived as preventing the nurses from being able
to work in line with their values, eroding value congruence between RNs and their organisation. This
incongruence was described by RNs from all bands (5-8), however the extent to which RNs viewed
these pressures within the wider context varied. Band 5 RNs, described this incongruence as being
created at the organisation level, whereas higher banded RNs (i.e., 7, 8) described the incongruence
as emerging due to external pressures from national policies or directives. Regardless of origin, this
incongruence impacted on RNs’ perceived levels of wellbeing and feelings of wanting to leave the
profession, across all bands. It also led to RNs feeling disenfranchised: RNs described their
organisations as either using values as ‘buzz words’ or trying to enforce these values without
creating an environment where it was possible for nurses to enact these to promote patient care
and safety. The result was that this incongruence created tensions between the RNs and their
organisations:
“If I’m being totally honest I feel like they just tap these words out to like make them look
good, but they don’t create an environment in order to fulfil them. So they say this is what
we are striving for and this is what we are doing, but at the end of the day all it comes down
to is money in the budget and that’s the most important thing to them like the managers and
stuff. Like if I say, ‘well you know we want more staff so I can give person centred care', they
would just say ‘well you should be giving that anyway’ erm and they say ‘well we have to
look at the budget’ and that’s all they look at, is the numbers [sic]” ( P6 Female, Band 5)
“Nurses hate tick boxes they are just meaningless but governments love them but that’s not
what patient care is all about […] I feel as though hands-on patient care is getting
compromised by some of these things [sic]” (P15 Female, band 7)

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
“I think that hospitals that are under extreme pressure at the minute and I think that
sometimes causes the conflict between your values and you know your actions [sic]” (P4
Male, Band 8)
Personal and professional value alignment
There was a clear perceived relationship between personal and professional values. RNs described
these as being inseparable and that both were integral to their role. RNs highlighted a specific value
set required to be, and perform as, a nurse. The values most frequently described as important were
related to both personal and professional life, for example, compassion and respect for others,
integral to promoting patient experiences of care and safety. The interplay between personal and
professional values with those of the workplace was considered important for RN wellbeing. Any
value congruence or incongruence experienced by RNs within the workplace applied to their
personal values, as well as professional:
“I think what you bring to nursing is what you value, you know you can’t draw a line in the
sand between them both you know what is important to you outside of work is always going
to transfer to what you do inside of work and vice versa. [sic]” (P12 Female, Band 7)
“I feel like to be considered a nurse you have to have values that match up with the
professional remit otherwise there are going to be issues. [sic]” (P14 Female, Band 5)
Nurse and supervisor values in conflict
Some RNs described a lack of congruence between their own values and the values held by their
supervisors. There was a difference between the positions of supervision identified between the
different bands of RNs. Band 5 RNs mainly discussed their immediate leaders on their ward or unit
(e.g. matron, lead nurse); whereas RNs in higher bands (Band 7) more often referred to the
management tier of their organisation or of the NHS. RNs described some of their supervisors as
holding a different set of values to themselves, which could lead to supervisors asking or expecting
them to behave in a way that was not in line with their own values. For example, Band 5 RNs
reported the importance (to them) of providing good quality and safe patient care, whilst they
perceived their supervisor’s values were related more to efficiency or numbers. Many RNs described
their supervisors as prioritising the saving of money, conducting audits or managing the flow of
patients through the hospital. This perceived values conflict was viewed as having an impact on
patient safety, as nurses described being asked to act in a way that led to some potentially unsafe
behaviours. Furthermore, the perception of a different value set among senior nurses also impacted
upon levels of wellbeing or burnout. The quality of patient care that nurses felt they could provide
was considered to be closely linked with their wellbeing. Nurses who described experiencing a
conflict in values with those of their supervisors, felt they were unable to provide the care they
wanted to provide, and perceived this as being linked to poorer wellbeing:
“The Matron
1
asked me to move this patient that was close to dying on to the corridor. I was
just like that is ridiculous obviously that goes against all your values but then so stuff like that
and when they have patients on corridors and stuff like that. That was really hard to see
patients on corridors, but not in bed areas. That goes against your values, like imagine
coming to see your relative in hospital and they’re on the corridor [sic]” (P8 Female, Band 5)
1
A Matron is the head of a nursing team. They carry out RN duties, but also look after a team of staff
(www.nurses.co.uk, 2020).

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
“When it goes higher up it will always come down to money and that’s where you will kind of
lose your sense of values and because it’s not about the care anymore it’s about the business
when it gets to the top of the NHS I think that upset me quite a lot because I didn’t feel like it
was something that I could control [sic]” (P 13, Female, Band 7)
Nurse values at odds with work environment
RNs discussed that care they were able to deliver within the current system was not in line with their
own values. They valued providing high quality, compassionate patient-centred care. However,
service pressures and the demand on staff created a work environment which was incongruent with
RN values, as these staff were no longer able to dedicate time to provide patient care. Building upon
the previous theme, the discord within the work environment described by RNs was exacerbated by
incongruence with supervisors. However, the incongruence within the work environment was a
culmination of many factors. The challenges described within the work environment influenced the
quality and safety of care that RNs perceived they could deliver. This inability to deliver safe and
good quality patient care impacted on RNs’ impression of their wellbeing, and feelings of wanting to
leave the profession:
“The ability to be able to deliver care that is in line with your values is a massive influence on
job satisfaction and being happy at work. So yeah absolutely, it is important for those
elements of staff wellbeing that they are able to deliver nursing... that they are able to feel
that they are delivering nursing that’s important to them. [sic]” (P 12 Female, Band 7)
“Sometimes that can really upset you because you I wanna be a good nurse you know I
wanna show people that I wanna care for them and I don’t feel like I'm giving that to them
because I haven’t got the time and I think that’s when you are really tested because you’re
not thinking about your values you've not got enough time to give the kind of care that you
want to give so that’s when your most tested. [sic]” (P 13 Female, Band 5)
Discussion
This is the first study to explore the relationship between value congruence, wellbeing and patient
care and safety for RNs using in-depth, qualitative methods. The study found that there is alignment
of personal and professional values of RNs. However, there were several areas of incongruence that
RNs experienced between their values, and their supervisors and work environment, and between
the organisation’s values and work environment. This incongruence was perceived to negatively
impact upon the relationships between quality of patient care and safety, and RN wellbeing.
This study builds upon previous literature assessing RNs’ values by providing depth and
understanding of the association between personal and professional values (Riklikiene, Karosas and
Kaeliene, 2017). Personal and professional value alignment was reinforced: RNs believed there to be
very little difference between their own personal values and professional values, and that having an
inherent set of values was integral to the profession. This finding is supported by the literature
reporting on RNs personal (Horton, Tschudin and Forget, 2007) and professional values (Weis and
Schank, 1997). This alignment of the personal and professional values for nurses may lead to further
ramifications for personal wellbeing as the sources of value incongruence at work cannot be
separated from professional values.
Our findings contribute to the existing literature by describing the relationship between value
congruence, wellbeing and patient care and safety. This adds to existing knowledge that value
incongruence is linked with poorer staff wellbeing (Verplanken, 2004), and higher staff turnover

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
(Grates & Mark 2012) as it provides supporting accounts which show how these concepts are
connected. Previous qualitative research established the relationships between burnout and patient
care and safety for physicians as being potentially circular (Hall et al., 2017). This finding is supported
by the current study, and together it suggests that value incongruence may be one catalyst for this
negative cycle of high levels of burnout amongst nurses, and poorer perceptions of patient care and
safety.
Further, the service pressures RNs described in this study which eroded values-based practice (i.e.
staffing levels and external policy context) were also identified in a review which focussed on
contributory factors to patient safety incidents (Lawton et al., 2011). This finding supports the
relevance of value congruence in the context of the work environment and patient safety
implications. This study highlights the different contexts of pressures for nurses of different bands.
Nurses in higher bands seemed more able to view service pressures within the wider context of
external policies.
These findings raise important implications for supporting staff wellbeing within the current system.
It is important to consider how to support nurses’ personal and professional values due to their close
alignment: values-based recruitment and employment would support this endeavour. The
incongruence identified by RNs between an organisation’s values and their work environment was
considered to be related to poorer wellbeing and a poorer quality of care and safety for patients.
Currently nurses are being recruited on the basis they hold the values of the organisation, through
values-based recruitment (DoH, 2012), however, this study demonstrates if these values are not
upheld within the work environment there will be a negative impact upon wellbeing and patient
care and safety. This relationship is further supported by longitudinal qualitative research following
students to newly qualified nurses: newly qualified nurses experienced burnout, disillusionment and
planned to leave the profession because the work environment prevented them behaving in line
with their values (Maben and Macleod Clark, 2007). Our findings suggest that organisations must
support an environment that is aligned with the values of the nurses recruited. If they do not do this,
they risk making nurses vulnerable to this potential negative cycle of poor wellbeing and burnout
leading to poor patient care and safety (Hall et al., 2017) relating to value incongruence.
Strengths and limitations
A strength of this study was the diverse sample across different specialities of RNs, a range of
experience (i.e. Bands and job title), and geographically diverse trusts. Despite this diversity the
majority of RNs included within this study were white, female and band 5: there was not the
diversity in ethnicity and nationality that exists in the current nursing workforce. Although a
telephone interview method was adopted with the aim of being as accessible as possible, further
research should explore these findings with these harder to reach groups.
Future research should also explore the possibility of a values based intervention to support nurses,
as this study shows a relationship between value incongruence and wellbeing, patient care and
safety. So, this may be an effective tool for supporting wellbeing, and improving patient care and
safety.
Conclusion
In summary, the current study has created a greater understanding of the relationship between
perceived nurse wellbeing and patient care and safety, by demonstrating the influence of value
incongruence upon these concepts for RNs. RNs reported that despite personal and professional
value congruence, they often experienced incongruence between their own values and the values

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
they perceived their supervisors to have, and a mismatch between working in line with their values
within the work environment. Furthermore organisational values were perceived to be challenging
to uphold within the work environment, with several barriers described as preventing RNs ability to
work in line with their values. This finding is important for the practice of values-based recruitment
and the potential for values focussed interventions to support nurse wellbeing.
Key points
 RNs’ personal and professional values were closely aligned.
 The values of hospital organisations were described as being incongruent with the RNs’ work
environments.
 RNs experienced perceived value incongruence in different forms and described this as
having an impact upon wellbeing and patient care and safety.
 As nurses are increasingly being employed through values-based recruitment, organisations
need to ensure that the work environment and the organisations’ values are aligned to
support RN wellbeing and patient care and safety
 Future research should explore the use of a values based intervention to support wellbeing
and patient care and safety.
Ethical Permissions
Ethical approval was granted by [removed for peer review] (Ethics Reference No: PSC-304;
26/03/2018).

Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
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Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
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Running Head: NURSES EXPERIENCES OF VALUE CONGRUENCE, WELLBEING AND PATIENT SAFETY
Table 1: Participant characteristics within the sample.
Characteristic
Frequency
Percent
age (%)
Gender
Male
1
6.66
Female
14
93.3
Ethnicity
White British
14
93.3
Mixed Other
1
6.66
Age
21-25
6
40
25-34
3
20
35-44
2
13.33
45-54
1
6.66
55-64
2
13.33
NHS pay band
(www.nurses.
co.uk, 2020)
5 (First level of RNs, will include
newly registered nurses )
10
66.66
6 (More experienced nurses)
1
6.66
7 (Advanced Nurse or Nurse
Practitioner)
3
20
8 (Matron or Senior Nurse)
1
6.66
Speciality
Palliative care
1
6.66
Cardiac
1
6.66
Acute/ General diseases
1
6.66
Infectious diseases
1
6.66
Renal medicine
1
6.66
Paediatrics
3
20
Acute cardiology
1
6.66
Critical care
1
6.66
General surgery
1
6.66
No speciality
2
13.33