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Nursing Attitudes Questionnaire: Testing the Psychometric Characteristics of the Italian Version (NAQ-IV)

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16 May 2024

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Abstract
Introduction: The image of the nurse is a source of concern because of its impact on recruitment to the profession, policy decisions about the profession, funding of nursing services, consumer use of nursing services and how the image of the nurse affects nursing practice. Aim: This study aims to assess the psychometric properties of the Italian version of the Nursing Attitudes Questionnaire (NAQ-IV). Methods: 564 persons between the years 2022 and 2023 with heterogeneous ages and occupations from Northern, Central and Southern Italy participated in the study. Cronbach's alpha, item versus total correlations, skewness and kurtosis were calculated; factor analysis was performed using principal axis factoring and the viramax rotation method. Results: The results showed a Cronbach's alpha of 0.89 on the scale and between 0.88 and 0.89 between the factors; all items tested for correlation between the item and the total and the criteria for variance in the responses. Factor analysis showed a 4-factor model explaining more than 59.91% of the variance, with the largest variance being explained by the 'Role & professionalism' factor (25.96%). Conclusion: These results allow for a discussion regarding the theoretical framework of the NAQ-IV and provide a reliable and valid instrument for the comparison of welfare, organisation of health services, role, professionalism, stereotypes, values, advocacy, motivation and perceived satisfaction with the figure of the nurse and nursing care.
Keywords: 
Nursing Attitudes Questionnaire
;  
NAQ-IV
;  
NAQ
;  
validation
Subject: 
Public Health and Healthcare  -   Nursing

Introduction

Attitudes towards nursing have been theoretically defined "as the view that people have regarding the professional roles, values and activities of nurses, and the responsibilities that nurses have towards society" [1].
The media image of the nurse is a source of concern because of its impact on recruitment into the profession [2]; the decisions of politicians who enact laws defining the scope and financing of nursing services; the use of nursing services by consumers and the self-image that nurses perceive [3] and which may affect nursing practice [4].
The Nursing Attitudes Questionaire (NAQ) is an instrument that assesses people's perceptions of nursing care [1]. The NAQ was adapted by Toth et al. [1] from an earlier instrument developed by Hoskins [5]. The validity and reliability of the instrument has been tested in previous studies [6,7]. It is a Likert instrument consisting of 30 items, 5 points, where 1 means strongly agree and 5 means strongly disagree. The NAQ scores therefore range from 30 to 150 points, where higher scores indicate a more favourable attitude towards nursing care, while lower scores reflect a less positive perception. Seven items are recoded before statistical analysis [1].
The instrument measures attitudes towards nurses using statements that reflect the roles of the professional including: values, responsibilities, characteristics of nurses, professionalism and societal stereotypes. A panel of experts supported the content validity of this instrument while construct validity was established using the contrastive group approach. Cronbach's alpha ranged from 0.75 to 0.80 in previous studies [1]. The original language instrument was tested among the population of nursing students [1,8,9,10].
In Italy the instrument was tested with a sampling afferent to the world of entertainment (VIP) [11] on high school students during meetings to orientate them for access to university and specifically to the Degree Course in Nursing [12] and in the post-pandemic period by COVID-19 on the Italian population from north to south Italy [2]. The Italian studies used the NAQ in its original form, no factor analysis calculations were performed but only internal consistency (α = 0.89) ) [11]. Compared to the stereotypes of the past [4], the Italian results showed, an improvement in the perception of the image of the nurse, probably due to the influence of the mass media, family ties with nurses and previous hospitalisations, especially during the pandemic period. However, despite these results, the attractiveness of the nursing profession in Italy remains rather low. This could be attributed to the questionable level of respect that institutions have for the nursing field, the perception of inadequate salary, insufficient political representation, the prevailing association of nursing with the female gender being more inclined to nursing than to a university career, the lack of respect and an unsatisfactory nursing work environment [2]. For these reasons, it is considered useful to refine an instrument to measure people's perceptions of the nursing profession.
The aim of this study was to validate the Italian version of the Nursing Attitudes Questionnaire NAQ-IV (Nursing Attitudes Questionnaire - Italian Version) and to test its psychometric properties on the Italian population of non- students in nursing in the post-pandemic period.

Methods

Translation Procedures

To establish the content validity of the NAQ scale, a forward-back translation procedure was applied. The White and Elander criteria were used as in the pilot study [11]. Firstly, the NAQ scale was translated into Italian and submitted to a panel of experts (5 nurses with expertise in nursing education and research) who compared the original English version of the scale with the Italian version and ensured the semantic and cultural consistency of the items. Secondly, an English lecturer translated the Italian version into English as a blind. Finally, the back-translated and the original instrument were compared by a native speaker.
The reliability of the NAQ has been tested in previous studies [1,8,9,10]. However, these studies used scores from the entire NAQ to compare demographic data or interventions. No factor analysis was performed to test construct validity. It is unclear which items contribute to which factor or dimension of the concept 'attitude towards nursing care' [10]

Sampling Procedures

Adults from heterogeneous professions were included in the study. In contrast to previous studies studies [1,8,9,10], the sampling was collected in Italy and the questionnaire was completed by citizens from the north to the south of the country.

Sample Description

A total of 564 people were interviewed [2]. People interviewed in the post-pandemic period throughout Italy were included in the validation study. Data were collected in the period from August 2022 to January 2023. Regarding the origin of the sample, 13.7% (n = 77) came from the north, 8.0% (n = 45) from the centre and 77.0% (n = 434) from the south [2]. Missings were detected for the independent variables.
The sample consists of 26.4% (n = 149) males, 73.6% (n = 415) females. The age group for 34.9% (n = 197) is between 20 and 30 years, 20.7% (n = 117) are between 31 and 40 years, 22.7% (n = 128) between 41 and 50 years, 14.9% (n = 84) between 51 and 60 years and 6.0% (n = 34) between 61 and 70 years. 51.4% (n = 290) have a high school diploma, 28.9% (n = 163) a university degree, 11.0% (n = 62) a middle school degree, 7.1% (n = 40) a postgraduate degree and 1.2% (n = 7) a primary school degree. With regard to employment, 34.2% (n = 193) of the sample were civil servants, 18.8% (n = 106) were private employees, 22.7% (n = 128) were students, 11.0% (n = 62) were self-employed, 3.7% (n = 21) were unemployed, 4.1% (n = 23) were retired, and 4.1% (n = 23) were housewives. 75.1% (n = 262) had at least one hospital admission and 72.7% (n = 402) had contact with a nurse.

Data Collection Procedures and Additional Variables

The data were collected from previous studies on the image of the nurse in the period from 2017 to 2023. The research project that activated the studies on the image of the nurse was authorised by the Unibo Bioethics Committee on 08/02/2017 prot. 13221. Sampling was collected on a voluntary basis after explaining the purpose of the studies. Anonymity was guaranteed and there is no information in the database that can be traced back to the identity of the sample. Documents and access to the data were only granted to the author responsible for the research projects. The questionnaires were completed on an online platform in self-administration mode. The respondents were given ample time to reflect and answer the questions.

Statistical Methods

Statistical analysis was conducted with the Office 2003 demo and Excel version statistics programmes. Descriptive univariate parametric analyses (ANOVA) were performed, calculating the mean and standard deviation (SD) of the cardinal variables.
Internal consistency was measured with Cronbach's alpha [13] and the change in alpha values was calculated if each item was deleted one by one in order to identify the contribution of each item to overall internal consistency [14].
The scores of items 4, 9, 15, 17, 19, 23, 27 (7 items) of the "Stereotypes" area (Table 1) were recoded before statistical analysis. The recoding mode on the Likert scores was: 5=1; 4=2; 3=3; 2=4; 1=5 [1].
Kurtosis and Skewness were calculated to check the variability of responses [15]: acceptable values are considered to be between -1 and 1, however values between |1| and |2| are not considered critical [16].
If the percentage of missing data in the total amount of variables for each respondent was more than 7%, the case was deleted by list [17].
The corrected element for total correlations was evaluated by considering values below 0.30 as unacceptable correlations [15,18].
Exploratory factor analysis was conducted with two aims: instrumental reduction by eliminating unnecessary items and identification of the main factors for data reduction. The questionnaire was analysed with two sections.
Each section was assessed prior to factorial analysis by the Kaiser-Meyer-Olkin index (KMO) to ensure adequate sampling. KMO values ranged from a minimum of 0.85 for the first section to a maximum of 0.92 for the second section, both of which showed adequate sample size. Bartlett's test of sphericity, an indicator of the strength of the relationship between variables, was highly significant (p<.001) in all sections, allowing for legitimate factoring [19].
Data reduction was a primary objective; therefore, principal component analysis extraction was used [19,20]. Orthogonal rotation (viramax) was performed assuming correlation between factors [19,21].
Item retention was based on factor loading and the item-total correlation of the reliability analysis, theoretical considerations and the significance of the information obtained.
A factor loading of more than 0.35 was desirable for each application.
Spearman's correlation coefficient (Rho) was used to determine the relationships between the summary variable and the research instrument.

Results

The Cronbach's alpha in the 30 items was 0.893 and varied between 0.88 and 0.89 among the factors identified in the theoretical structure of the NAQ [1]. No changes were found in the internal consistency reliability after eliminating the items one by one. No changes in internal consistency reliability were found after eliminating each item one by one.
Skewness and kurtosis showed a normal distribution in the item responses in most items, and a weak tendency towards higher levels of agreement in items (mean score < 3.50) 4, 9, 15, 17, 19 (Stereotypes domain), 18 (Role & professionalism domain), 12 and 28 (Motivation & Satisfaction domain). With regard to these items, no statistical transformations were adopted because the skewness and kurtosis deviation was not critical and the methods used in the data analysis were not influenced by the data distribution [16].
The correlations between item and total were above 0.50 (p = <.001) for all items, however the factor item "Nurses must wear a white uniform to be identified" had a lower correlation. The numbering alongside the items in Table 1 respects the original sequencing of the original instrument [1] (Table 1).

Validity

The criteria for performing the factor analysis were verified KMO was .930 and Bartlett's sphericity test showed a p-value of <.001 (chi square=10786 and df=435) [22]. Exploratory factor analysis (EFA), with varimax rotation, showed through the Scree Plot, a 4-factor model showing 53.9% variance in the scale (Figure 1).
The main factor explaining the variance is "Role & professionalism" (25.96%) and the second is a sub-factor detected in the factor "Stereotypes" which explains 14.70% of the variance, "Values & advocacy" explains 10.48% of the variance, "Motivation & Satisfaction" 8.77%. EFA was performed using the viramax rotation method: the correlation matrix showed correlations of more than |0.45| between most of the factors. Confirmatory factor analysis (CFA) seems to confirm the structure based on the data collected. The numerical sequencing of the table, respects the Italian version of the tool (NAQ-IV) (Table 2).
The goodness of fit of the four-factor solution assessed in the CFA used several criteria: chi square/degrees of freedom (χ2/df) and root mean square error of approximation (RMSEA). The test for exact fit thus indicated an X² = 2.567 (p = <.001), SRMR 0.0939, RMSEA 0.0981 (IC 90%=0.0945-0.120), TLI 0.777 and CFI 0.795.
The correlation coefficient of rS showed for the 4 areas of the NAQ-IV, a correlation with a p-value = <.001 (Table 3).
The goodness of fit of the four-factor solution was assessed in the CFA using multiple criteria: chi square (χ2), chi square/ degrees of freedom (χ2/df) and root mean square error of approximation (RMSEA). The test for exact fit indicated an X² = 2.567 (p = <.001), SRMR 0.0939, RMSEA 0.0981 (CI 90%=0.0945-0.120), TLI 0.777 and CFI 0.795.

Discussion

The psychometric characteristics of the Italian version of the NAQ (NAQ - IR) show a 4-factor aggregation and a good internal consistency of the items. However, previous studies although conducted using the scores of the entire NAQ in 2016 Hoeve et al., in a study conducted on a population of nursing students in the Netherlands, used the NAQ by reducing it to 18 items and subdividing it into two factors: "Nursing Agency" (14 items α = ,74) and "Advocacy & Empathy" (4 items α = ,63). CFA showed a fit with X² = 3.69; CFI = ,90; RMSEA = ,046; α = ,79. The study by Hoeve et al. [10] aimed to assess on a court of 1st year nursing students what was the sample's orientation and attitudes towards nursing at the beginning of the educational programme. The research was conducted alongside the NAQ in order to primarily assess the students' orientation towards the profession at the beginning of the educational programme. For this reason it was necessary to extrapolate from the NAQ the items aimed at the purpose of the study [23,24,25].
The Italian studies, on the other hand, were oriented towards the evaluation of the perception of ordinary people towards the image of the nurse and nursing care and showed an overall result on the NAQ and the content areas indicated by Toth et al. [1] in which, however, the authors did not determine a factor analysis but rather concentrated on a percentile calculation of the items (< 10th and > 90th percentile). In the Italian studies, the content validity was supported by a panel of experts who revised the NAQ twice to determine its representativeness and the relevance of the items grouped into areas following the procedure suggested by Toth el al. [1] on the student sample divided into two groups: students with career orientation and students without orientation [12] In the Italian study of 2017 and later, although a factor analysis and adjustment calculation was not determined on the collected data, the overall internal consistency and correlation coefficients between areas were determined [2,11]
Although the NAQ-IV presents 14 items in the first factor, there is no evidence of verisimilitude with the first factor explored by Hoeve et al. [10] as the constituent items are not reported in their study. However, even in the Italian version of the NAQ, the methodology followed for naming the areas followed the study by Hoeve et al. [10]. A team of four researchers examined the items of the NAQ to verify that their wording reflected the measured concept: the image of the nurse and the sampling attitude towards nursing. The specific meaning of each element was examined for apparent validity. The identified domains are confirmed by previous studies on the NAQ, phylogeny, organisational, educational and care models of the nursing profession. The domains "Role & professionalism" and "Stereotypes" express the concepts highlighted by the study of Toth et al. [1] and Bolan & Grainger [8], "Values & advocacy" refers to the extent to which nurses speak and act on behalf of patients and specifically on the unmet needs of patients by making the satisfaction of needs a value to the profession [8,23,26]. With regard to nurses' motivation and satisfaction, a significant intrinsic relationship between these two elements has been found to improve nursing care and the related image [2,27].
Cronbach's alpha coefficient on the total scale of the NAQ-IV, used in the interviews with ordinary people recorded a value of 0.89 with a range of 0.88 to 0.89. These results seem consistent with previous studies in which the sampling consisted of nursing students only. In fact, research on Canadian students showed an alpha variation of 0.80 to 0.82 [8], whereas Toth et al. in 1998 tested a range of 0.75 to 0.80 [9]. The NAQ-IV therefore seems to be a reliable instrument for assessing people perceptions of the image of the nurse and nursing care. Furthermore, there seems to be no indication to eliminate any items based on the loading of the EFA items [14]. A good variability of responses was found so we could state that item formulation does not generate a preferred response towards higher or lower levels of agreement and this could confirm the assumption of variability of the Likert scale [15].

Conclusions

This study demonstrated a satisfactory psychometric property in the Italian version of the Nursing Attitudes Questionnaire. With respect to previous validation works, the NAQ-IV investigated the perception of the image of the nursing profession and nursing care on a population that was not exclusively student but heterogeneous in terms of profession, culture and age. Specifically, the NAQ-IV structured four factors investigating the respondents' perceived role, professionalism, stereotypes, values, advocacy, motivation and satisfaction with the nursing profession. The instrument could be useful to investigate how society perceives the role and functions of the nurse and what value they attach to the profession. In previous Italian studies, the NAQ has provided significant insights into the motivations that make the profession unattractive to young people who need to undertake education to enter the workforce [2,11,12].
The NAQ-IV could be an interesting instrument to assess the internationally perceived image and nursing care among ordinary people. An international multi-centre approach could therefore be useful to confirm the theoretical framework in the structure of the NAQ-IV.

Appendix A

Nursing Attitudes Questionnaire—Italian Version (NAQ-IV)

Scala di valutazione:
1=forte disaccordo; 2=disaccordo; 3=né accordo né disaccordo; 4=accordo; 5=forte accordo.
Ruolo & professionalità
1. Gli infermieri rappresentano una risorsa per le persone con problemi di salute
2. Essere un infermiere/a richiede intelligenza
3. Il servizio espletato dagli infermieri è importante quanto quello fornito dai medici
4. Gli infermieri integrano gli insegnamenti sanitari nella pratica assistenziale
5. La ricerca scientifica è vitale per la professione infermieristica
6. Gli infermieri sono in grado di operare in modo autonomo
7. Gli infermieri devono avere il diritto di scioperare
8. Gli uomini sono dei bravi infermieri
9. Il lavoro di infermiere è emozionante
10. Gli infermieri integrano i risultati delle ricerche scientifiche nella pratica clinica
11. L' obiettivo più importante della ricerca infermieristica è quello di migliorare l' assistenza al paziente
12. Gli infermieri attribuiscono valore al tempo che trascorrono al letto dei pazienti per prendersi cura di loro
13. Gli infermieri devono avere una laurea per praticare la professione
14. Gli infermieri che hanno conseguito una laurea magistrale danno contributi importanti per la cura dei pazienti
Stereotipi
15. Gli infermieri devono indossare una divisa bianca per essere identificati
16. Se gli infermieri trascorressero più tempo a prendersi cura di pazienti e meno all' università tutti ne trarrebbero beneficio
17. Gli infermieri sono ripagati sufficientemente per il loro lavoro dal sapere che stanno aiutando altre persone
18. Gli infermieri eseguono le richieste del medico senza obiezione
19. Molti infermieri che ricercano un avanzamento nella loro attività professionale, in realtà vorrebbero essere piuttosto dei medici
20. Gli infermieri sono adeguatamente pagati per il lavoro che svolgono
21. Uno dei vantaggi di essere un infermiere è quello di sposare un medico
Valore & advocacy
22. Gli infermieri sono coloro che sostengono i diritti dei pazienti
23. Gli infermieri tutelano i pazienti all' interno del Sistema Sanitario
24. Gli infermieri partecipano allo sviluppo delle politiche sull' assistenza sanitaria
25. Gli infermieri sono in genere gentili e compassionevoli
Motivazione & Soddisfazione
26. Gli infermieri sono politicamente attivi
27. Gli infermieri pronunciano nettamente contro condizioni inadeguate di lavoro
28. Il lavoro di infermiere è una professione rispettata
29. Gli infermieri aggiornano costantemente la loro pratica in relazione alle ultime scoperte sull' assistenza sanitaria
30. Gli infermieri sono soddisfatti del lavoro che svolgono

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Preprints 106685 g001
Figure 1. Scree plot.
Figure 1. Scree plot.
Preprints 106685 g001
Table 1. Position and shape indices, item-total correlation and Cronbach's Alpha.
Table 1. Position and shape indices, item-total correlation and Cronbach's Alpha.
NAQ - IV M±SD Skewness Kurtosis Corrected item to total correlation Cronbach’s alpha if item deleted KMO Measure of Sampling Adequacy (MSA)
Role & professionalism (α = 0.934; KMO = 0.947) (14 Items)
5. Nurses act as resource persons for individuals with health problems 4.24±0.959 -1.42 2.07 0.729*** 0.885 0.953
7. It takes intelligence to be a nurse 4.13±0.960 -1.09 1.03 0.733*** 0.885 0.949
8. The service given by nurses is as important as that given by physicians 4.24±0.970 -1.30 1.44 0.751*** 0.884 0.948
10. Nurses integrate health teaching into their practice 4.01±0.912 -0.826 0.826 0.751*** 0.885 0.957
11. Research is vital to nursing as a profession 4.04±0.984 -0.875 0.434 0.751*** 0.884 0.944
13. Nurses are capable of independent practice 3.79±1.13 -0.655 -0.265 0.631*** 0.885 0.953
16. Nurses should have a right to strike 3.99±1.02 -0.808 0.251 0.659*** 0.886 0.967
18. Men make good nurses 3.46±1.20 -0.469 -0.505 0.402*** 0.893 0.932
20. Nursing is exciting 3.87±1.01 -0.573 -0.142 0.755*** 0.884 0.957
21. Nurses incorporate research findings into their clinical practice 3.80±0.987 -0.464 -0.150 0.766*** 0.884 0.948
22. The major goal of nursing research is to improve patient care 4.04±0.995 -0.913 0.527 0.795*** 0.884 0.946
24. Nurses value time at the bedside caring for patients 3.70±1.04 -0.495 -0.076 0.673*** 0.886 0.962
25. Nurses should have a Baccalaureate degree for entrance into practice 4.07±1.02 -0.872 0.258 0.758*** 0.884 0.946
26. Nurses with advanced degrees make important contributions to patient care 3.59±1.08 -0.483 -0.136 0.552*** 0.888 0.941
Stereotypes (α = 0,865; KMO = 0.865) (7 Items)
4. Nurses should wear a white uniform in order to be identified 2.90±1.28 0.136 -0.992 0.470*** 0.898 0.874
9. Everyone would benefit if nurses spent less time in school and more time caring for patients 3.15±1.33 0.009 -1.09 0.568*** 0.898 0.868
15. Nurses are compensated sufficiently for their work by the knowledge that
they are helping people		 3.34±1.24 -0.174 -0.879 0.664*** 0.898 0.883
17. Nurses follow the physician’s orders without questions 3.29±1.20 0.061 -0.814 0.682*** 0.896 0.874
19. Many nurses who seek advanced degrees in nursing would really rather be physicians 3.46±1.23 -0.274 -0.770 0.640*** 0.894 0.848
23. Nurses are adequately paid for the work they do 3.63±1.22 -0.403 -0.752 0.730*** 0.894 0.876
27. One advantage to being a nurse is to marry a physician 4.09±1.18 -1.02 0.054 0.720*** 0.894 0.860
Values & advocacy (α = 0,838; KMO = 0.769) (4 Items)
1. Nurses are patient’s advocates 3.87±1.05 -0.655 -0.163 0.763*** 0.889 0.877
2. Nurses protect patients in the health care system 4.02±1.00 -0.924 0.494 0.790*** 0.887 0.883
3. Nurses participate in the development of health care policies 3.87±1.05 -0.737 0.011 0.651*** 0.889 0.940
6. Nurses in general are kind, compassionate human beings 3.58±1.02 -0.531 0.103 0.497*** 0.891 0.934
Motivation & Satisfaction (α = 0,727; KMO = 0.697) (5 Items)
12. Nurses are politically active 3.29±1.09 -0.302 -0.180 0.486*** 0.892 0.921
14. Nurses speak out against inadequate working conditions 3.54±1.05 -0.266 -0.262 0.475*** 0.889 0.938
28. Nursing is a respected profession 2.90±1.20 0.087 -0.732 0.412*** 0.899 0.884
29. Nurses consistently update their practice in relation to current health trends 3.61±1.04 -0.291 -0.370 0.469*** 0.887 0.951
30. Nurses feel good about what they do 3.19±1.03 -0.218 0.067 0.612*** 0.893 0.909
α = 0.893, KMO = 0.930
*** p = <.001.
Table 2. Explorative Factor Analysis, PAF, direct viramax rotation.
Table 2. Explorative Factor Analysis, PAF, direct viramax rotation.
EFA CFA
NAQ - IV r Estimate SE Z p
Role & professionalism
1. Nurses act as resource persons for individuals with health problems 0.710 0.742 0.0344 21.55 < .001***
2. It takes intelligence to be a nurse 0.752 0.734 0.0346 21.20 < .001***
3. The service given by nurses is as important as that given by physicians 0.752 0.763 0.0346 22.08 < .001***
4. Nurses integrate health teaching into their practice 0.714 0.721 0.0323 22.30 < .001***
5. Research is vital to nursing as a profession 0.688 0.773 0.0350 22.08 < .001***
6. Nurses are capable of independent practice 0.474 0.748 0.0428 17.45 < .001***
7. Nurses should have a right to strike 0.674 0.693 0.0383 18.11 < .001***
8. Men make good nurses 0.471 0.476 0.0496 9.60 < .001***
9. Nursing is exciting 0.716 0.792 0.0362 21.90 < .001***
10. Nurses incorporate research findings into their clinical practice 0.684 0.775 0.0352 21.98 < .001***
11. The major goal of nursing research is to improve patient care 0.792 0.814 0.0347 23.43 < .001***
12. Nurses value time at the bedside caring for patients 0.624 0.716 0.0391 18.32 < .001***
13. Nurses should have a Baccalaureate degree for entrance into practice 0.841 0.786 0.0366 21.49 < .001***
14. Nurses with advanced degrees make important contributions to patient care 0.598 0.613 0.0427 14.36 < .001***
Stereotypes
15. Nurses should wear a white uniform in order to be identified 0.633 0.643 0.0532 12.10 < .001***
16. Everyone would benefit if nurses spent less time in school and more time caring for patients 0.620 0.792 0.0538 14.72 < .001***
17. Nurses are compensated sufficiently for their work by the knowledge that
they are helping people		 0.738 0.928 0.0468 19.83 < .001***
18. Nurses follow the physician’s orders without questions 0.745 0.854 0.0462 18.49 < .001***
19. Many nurses who seek advanced degrees in nursing would really rather be physicians 0.749 0.839 0.0479 17.51 < .001***
20. Nurses are adequately paid for the work they do 0.822 0.994 0.0440 22.60 < .001***
21. One advantage to being a nurse is to marry a physician 0.756 0.943 0.0432 21.84 < .001***
Values & advocacy
22. Nurses are patient’s advocates 0.808 0.915 0.0359 25.49 < .001***
23. Nurses protect patients in the health care system 0.785 0.912 0.0336 27.14 < .001***
24. Nurses participate in the development of health care policies 0.695 0.744 0.0398 18.67 < .001***
25. Nurses in general are kind, compassionate human beings 0.558 0.557 0.0416 13.40 < .001***
Motivation & Satisfaction
26. Nurses are politically active 0.471 0.648 0.0456 14.21 < .001***
27. Nurses speak out against inadequate working conditions 0.515 0.633 0.0440 14.40 < .001***
28. Nursing is a respected profession 0.676 0.622 0.0544 11.44 < .001***
29. Nurses consistently update their practice in relation to current health trends 0.530 0.618 0.0442 13.96 < .001***
30. Nurses feel good about what they do 0.506 0.691 0.0426 16.24 < .001***
Table 3. NAQ-IV area correlation index.
Table 3. NAQ-IV area correlation index.
1 2 3 4
1. Role & professionalism 1
2. Stereotypes 0.239*** 1
3. Values & advocacy 0.533*** -0.143*** 1
4. Motivation & Satisfaction 0.536*** -0.237*** 0.478*** 1
*** p = <.001.
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