Article

Nursing Ethics
1–12
Korean nurses’ ethical ª The Author(s) 2014
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dilemmas, professional values 10.1177/0969733014538892
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and professional quality of life

Kyunghee Kim
Chung-Ang University, Republic of Korea
Yonghee Han
Hallym Polytechnic University, Republic of Korea

Ji-su Kim
Chung-Ang University, Republic of Korea

Abstract
Background: In the changing medical environment, professional stress continuously increases as the
individual’s quality of life suffers. Of all the healthcare professions, nursing is especially prone to burnout,
compassion fatigue and reduced compassion satisfaction, due to the tensions resulting from the physical
and psychological stress of caring for extremely ill patients.
Objectives: This study examined the professional quality of life of clinical nurses in Korea and the
relationship between their experiences in ethical dilemmas and professional values.
Methods: This was a cross-sectional study of a convenience sample consisting of 488 clinical nurses. We
used four questionnaires to measure the participants’ demographic characteristics, experiences in ethical
dilemmas, professional nursing values and professional quality of life (ProQOL assessment, Version 5).
Ethical considerations: This study received approval from the Institutional Review Board of Bronco
Memorial Hospital. Written informed consent was given by all participants.
Results: The nurses’ professional quality of life was affected by ethical dilemmas and professional nursing
values. The factors influencing compassion satisfaction were age, client domain of ethical dilemmas, social
awareness, professionalism of nursing and the roles of nursing services in professional values. The factors
influencing burnout were marital status (married), religion (yes), human life domain, professional work
domain of ethical dilemmas, social awareness and the role of nursing services in nursing professional
values. The factors influencing secondary traumatic stress were human life domain, client domain and
the professional work domain of ethical dilemmas.
Conclusion: Intervention to help nurses increase their professional quality of life will have a greater chance
of success if they are based on the nurses’ values and beliefs about the ethical dilemmas they face and foster
the establishment of positive professional values.

Keywords
Compassion fatigue, compassion satisfaction, ethical dilemma, professional nursing values, professional
quality of life

Corresponding author: Ji-su Kim, Chung-Ang University, 84 Heukseok-Ro, Dongjack-Gu, Seoul, 156-756 Republic of Korea.
Email: jisu-80@cau.ac.kr

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2 Nursing Ethics

Introduction
As medical technology and standards of living improve, so do patients’ demands for a diversified healthcare
system. In the ever-changing medical environment, professional stress continually increases as the individ-
ual’s quality of life suffers. The professional quality of life (ProQOL) of nurses refers to the quality of pos-
itive and negative emotions they feel in the professional context of helping others. These emotions include
the opposing concepts of compassion satisfaction (CS) and compassion fatigue (CF), including burnout
(BO) and secondary traumatic stress (STS) that healthcare professionals feel when they provide assistance
to their clients.1,2 The ProQOL of those in varied occupations has been examined for more than a decade,
and there are ongoing studies on the subjective view that each professional has of their job.2–8
Of all the healthcare professions, nursing is especially prone to burnout, compassion fatigue and reduced
compassion satisfaction due to the tensions resulting from the physical and psychological stress of caring for
extremely ill patients.7,9 The reduced compassion satisfaction and increased compassion fatigue have a neg-
ative influence on nurses’ mental and physical health, undermine the quality of nursing care and eventually
exert a negative effect on the nurse’s performance.3,9–11 Programmes to improve the ProQOL of nurses are
needed, but few studies have been conducted on this topic. Most previous studies describe ProQOL as it is
experienced by nurses working in specialty areas, such as emergency rooms, intensive care units (ICUs) and
oncology wards. The remainder of ProQOL studies in nursing focus on the relationship between subordinate
concepts and demographic characteristics or between job satisfaction and job stress.8,11–13 Therefore, it is
necessary to examine the ProQOL of nurses who work in a variety of settings and to consider the variables
influencing ProQOL issues that are not limited to job satisfaction and job stress.
The goals of healthcare professionals are inherently ethical and involve protecting patients from harm
while providing care that benefits them.14 Various factors are associated with the development of ethical
dilemmas among nurses, including advances in medical technology, increased life expectancy, the high cost
of healthcare in an environment of limited resources, lack of time to provide care and conflicting values and/
or cultures among patients, nurses and other healthcare professionals.14,15 The development of medical
technology and the growth of the nursing profession have brought about nurses’ increased participation
in human rights and life and death decision-making situations. Nurses in Korea experience a myriad of ethi-
cal dilemmas in the clinical field, but the availability of an ethics code does not guarantee them definitive
answers.16,17
Nurses are often confronted with ethical dilemmas requiring them to choose between unsatisfactory
alternatives. The nurse experiences conflict when each choice that is ethically supported is also considered
ethically problematic.18 The ethical issues that nurses face during clinical trials are likely to cause ethics-
related stress, which may progress to professional stress, a combination of emotional, physical and psycho-
social effects of the ethical pains they have experienced.19 Ethical conflicts eventually become an obstacle
to nursing service, and a barrier to the development of the profession, as well as the individual nurse.20 Pre-
vious research8 has revealed that nurses who had difficulty controlling their emotions during abortion care
experienced an ethical dilemma that was positively correlated with compassion fatigue. The higher number
of ethical dilemmas experienced by the nurses negatively influenced their ProQOL.8 However, investiga-
tions on the relationship between ethical dilemmas and ProQOL have not been published.
Nurses assume professional responsibility for their clinical functioning when faced with ethical dilem-
mas that are difficult to solve. They determine the most suitable behaviour for the situation at hand and base
their choices on the values they hold. These values are behavioural resources for ethical competence in the
clinical setting and for encounters with contemporary ethical concerns. In other words, the professional
aspect of nursing, including its philosophies, values and ideologies, can be combined with the occupational
aspect, and the values derived from this combination should promote the professional satisfaction of indi-
vidual nurses and the public’s recognition of our values. One’s professional role in nursing is inseparable

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Kim et al. 3

from one’s ethical values.21,22 Professional values affect the nurse’s quality of life because they determine
the motives of someone who is attempting to deal with an ethical dilemma. Professional values are directly
related to whether nurse’s efforts will result in feeling satisfied and rewarded23–25 and play a significant role
in the burnout that nurses experience.26 Nurses with positive professional values tend to be more content
with their employment27 and achieve greater results than other nurses because of their engagement with,
and intense commitment to, the organization. Therefore, nursing values can be understood as a main con-
cept in problem-solving strategies used by the profession to solve current problems. However, investiga-
tions that have examined the relationship between nurses’ professional values and ProQOL have not
been published.
Thus, this study examined the ProQOL of clinical nurses in Korea and the relationship between their
ethical dilemmas and professional values. The ultimate goal of this study was to generate basic data that
might guide the development of interventions to improve the ProQOL of nurses.

Objectives
This investigation was designed to (a) assess the nurses’ ProQOL, experiences of ethical dilemmas and pro-
fessional values; (b) examine the differences among the nurses’ ProQOL in relation to their demographic
characteristics; (c) identify the relationships among the nurses’ ProQOL, ethical dilemma experiences and
professional values and (d) identify the factors that have the highest influence on the nurses’ ProQOL.

Methods
Design
This was a cross-sectional study that examined the relationships between ProQOL, ethical dilemmas and
professional values of Korean nurses working in a clinical setting.

Sample and data collection

The participants were a convenience sample of nurses employed for more than 1 year. We collected data
from four university hospitals located in three provinces of Korea to minimize characteristics that could
be affected by the size of one hospital. A total of 500 questionnaires were distributed to the four hospitals
between 10 November and 30 November 2013 and 488 of them were completed and returned (return rate:
97.6%). The researcher explained the purpose of the study at a visit to the Directors of Nursing and obtained
approval from the head nurses of the inpatient units and special unit (ICU, operating room and emergency
room) to allow the participants to seal an envelope containing their completed questionnaires and store them
in a safe place until the researcher collected them. The researcher distributed the survey, and the nurses who
wished to participate signed their names to the front page confirming their understanding of the study’s pur-
pose after they read it. The data were collected using self-report questionnaires after the participants
returned their consent forms.

Instruments
The instruments used in this study were as follows: (a) the ProQOL assessment, Version 5; (b) a demo-
graphic questionnaire (age, gender, marital status, religion, educational status, number of years as a clinical
nurse, type of department and position); (c) an ethical dilemmas’ questionnaire and (d) a professional nursing
values’ questionnaire.

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4 Nursing Ethics

ProQOL (Version 5). The ProQOL is an instrument developed by Stamm1,2; the tool is available to the
Korean public and is accessible for free (http://www.proqol.org). The sub-scales of the instrument
consist of the subordinate concepts of compassion satisfaction, burnout and secondary traumatic
stress. The ProQOL has 30 questions, and its responses are rated on a 5-point Likert scale with
5 representing the highest level of the concept. The ProQOL sub-scales are not designed to be
summed to form a total ProQOL score. At the time of the instrument’s development, the Cron-
bach’s as were compassion satisfaction (a ¼ .88), burnout (a ¼ .75) and secondary traumatic stress
(a ¼ .81). In this study, the measures of internal consistency were compassion satisfaction (a ¼
.88), burnout (a ¼ .69) and secondary traumatic stress (a ¼ .78).
Ethical dilemmas. We used Lee and Yoo’s16 questionnaire, which is an amended version of the tool
developed by Han.28 The final instrument consists of questions about ethical dilemmas most
likely to occur in current nursing practice. This instrument is freely available to the members of
the Korean Hospital Nurses Association. It is composed of four sub-domains that assess the expe-
rience of different types of ethical dilemmas: human life domain (respect for life and human rights),
client domain (nurses and clients), professional work domain (nurses and their professional work)
and supporter domain (nurses and supporters). At the time of the instrument’s development, 1 point
was assigned to each experience of an ethical dilemma in each domain. In this study, we used a
5-point Likert scale with 5 points representing the highest level of experience with the types of ethi-
cal dilemmas. Two head nurses with more than 20 years of clinical experience and two professors
of nursing science tested its content validity. At the time of the instrument’s development, its inter-
nal consistency was a ¼ .87; in the study by Lee and Yoo,16 it was a ¼.89. In this study, the relia-
bility measures were a ¼ .93 for the instrument as a whole and a ¼ .72–.85 for the sub-domains.
Professional nursing values. Yeun et al.25 provided their consent for the study’s use of their instrument
measuring professional nursing values. The original instrument has five domains: self-concept of
the profession, social awareness, professionalism of nursing, roles of nursing services and origin-
ality of nursing. The instrument has six questions using a 5-point Likert scale, with the higher
points representing higher levels of professional values. At time of the instrument’s development,
the reliability of the tool was a ¼ .92 and for the sub-factors, a ¼ .53–.85. A content validity test
was conducted by two head nurses with more than 20 years of clinical experience and two profes-
sors of nursing science, and the validity of the original nursing domain was found to be question-
able. This finding was not surprising as there were only three questions assigned to the domain,
leaving it with fewer questions than the other sub-factors. The three questions were long, their
meanings were vague and they required reverse responses. Since a ¼ .45, the domain was excluded
in the final selection of questions. Therefore, we assessed four domains for this study: self-concept
of the profession, social awareness, professionalism of nursing and the roles of nursing services.
The internal consistency (a ¼ .92) for the instrument as a whole was higher after excluding the nur-
sing domain. The Cronbach’s a coefficients of the remaining sub-domains ranged from .70 to .84.

Ethical considerations
This study received approval (2013-B-002) from the Institutional Review Board of Bronco Memorial
Hospital. The purpose of the research was explained in advance to the participants who gave written con-
sent based on the premise that their participation in the study would be voluntary. Participants were aware
of their right to withdraw from the study any time. They confirmed their awareness that the research data
only would be used for research purposes and that their anonymity was guaranteed. Participants were also
aware that the completed questionnaires would be kept by the research director during the study and that
all the questionnaires would be discarded at the end of the study.

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Kim et al. 5

Table 1. Levels of the ProQOL, ethical dilemma and nursing professional values (N ¼ 476).

Variable Minimum Maximum Mean (SD) Average score

ProQOL (number of items: 3)

CS 17 47 32.8 (5.1)
BO 15 39 29.0 (4.2)
STS 13 43 27.3 (5.1)
Ethical dilemma (number of items: 4) 50 156 101.0 (16.8) 3.0
Human life domain 9 34 19.8 (4.4) 2.8
Client domain 6 26 17.2 (3.6) 2.9
Professional work domain 21 66 43.8 (7.0) 3.1
Supporter domain 8 34 20.2 (3.8) 2.9
Nursing professional values (number of items: 4) 21 130 102.5 (11.7) 3.6
Self-concept of the profession 18 45 33.3 (4.0) 3.7
Social awareness 12 38 26.3 (4.0) 3.3
Professionalism of nursing 2 25 18.8 (2.3) 3.8
The roles of nursing services 5 20 14.8 (1.9) 3.7
ProQOL: professional quality of life; SD: standard deviation; CS: compassion satisfaction, BO: burnout, STS: secondary traumatic
stress.

Data analysis
Data were analysed using SAS 9.3 (SAS Institute Inc., Cary, NC, USA). Before the analysis, the data were
examined for outliers and missing responses. We calculated the means and standard deviations of the parti-
cipants’ scores on the ProQOL, ethical dilemmas and professional values questionnaires. We conducted t-tests
and one-way analysis of variance for the ProQOL according to the demographic characteristics of the parti-
cipants and performed post hoc analyses using Scheffe’s test. Correlations among the scores on the ProQOL,
ethical dilemma and professional values questionnaires were performed using Pearson’s correlation. Linear
multiple regression was performed to identify the factors influencing the participants’ ProQOL scores (i.e.
predictors). Linear multiple regression analysis with forward selection of influencing factors was used to iden-
tify the factors that had the highest association with the ProQOL scores, that is, the outcome variable. The
influencing factors were the participants’ demographic characteristics (gender, age, marital status, religion,
educational status, the number of years as a clinical nurse, type of department and position). These data were
selected as the independent variables based on their confirmed correlations among all the survey items. Step-
wise hierarchical regression analysis was then used to determine the significance of the factors influencing
(independent variables: ethical dilemma, professional nursing values and demographic characteristics) the
ProQOL scores (dependent variable). Values of p < 0.05 were considered statistically significant.

Results
ProQOL, ethical dilemmas and professional nursing values
Table 1 shows the participants’ scores on the measures of compassion satisfaction, burnout, secondary trau-
matic stress, ethical dilemmas and professional nursing values. The ProQOL scores for the level of compas-
sion satisfaction were higher than the levels of burnout and secondary traumatic stress, which are measures
of compassion fatigue. The ethical dilemmas that the participants experienced at a medium level, on aver-
age, and the order of the average scores were professional work domain, client domain, supporter domain
and human life domain. The level of professional values that participants recognized as above average and

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6 Nursing Ethics

Table 2. ProQOL by demographic characteristics (N ¼ 476).

ProQOL

CS BO STS

Variables n (%) Mean (SD) p Mean (SD) p Mean (SD) p

Age (years)
20–29a 293 (62.0) 32.0 (4.6) <0.001 29.6 (4.0) <0.001 27.3 (5.0) 0.893
30–39b 124 (26.2) 33.2 (5.5) a¼b<c 28.7 (4.2) c<a¼b 27.2 (5.3)
40–49c 56 (11.8) 36.1 (5.5) 26.6 (4.3) 27.0 (4.7)
Gender
Male 6 (1.3) 35.2 (6.4) 0.253 27.2 (6.6) 0.299 27.7 (5.9) 0.839
Female 470 (98.7) 32.8 (5.1) 29.0 (4.2) 27.2 (5.0)
Marital status
Married 349 (73.3) 32.2 (4.7) <0.001 29.5 (4.1) <0.001 27.3 (5.2) 0.542
Single 127 (26.7) 34.5 (5.8) 27.5 (4.3) 27.0 (4.7)
Religion
Yes 188 (40.5) 33.8 (5.3) <0.001 28.0 (4.2) <0.001 26.9 (5.2) 0.370
No 276 (59.5) 32.2 (4.8) 29.6 (4.2) 27.4 (5.0)
Educational status
Collegea 238 (50.0) 31.9 (4.6) <0.001 29.7 (4.1) <0.001 27.4 (5.0) 0.127
Bachelorb 150 (31.5) 32.6 (5.2) a¼b<d 28.8 (4.4) d<a¼b 26.5 (5.0)
RN-BSNc 20 (4.2) 33.8 (5.5) 28.7 (3.4) 28.1 (5.2)
Graduate aboved 68 (14.3) 36.1 (5.4) 27.0 (4.2) 28.1 (5.1)
Type of department
Inpatient unit 281 (59.9) 32.6 (4.9) 0.229 29.2 (4.1) 0.203 27.2 (4.8) 0.724
Special unit* 188 (40.1) 33.1 (5.2) 28.7 (4.3) 27.4 (5.4)
Position
Nursea 406 (88.8) 32.4 (5.0) <0.001 29.3 (4.3) <0.001 27.3 (5.0) 0.788
Charge nurseb 38 (8.3) 34.8 (4.7) a<b<c 27.6 (3.2) a¼b<c 27.2 (4.8)
Head nursec 13 (2.8) 39.3 (5.6) 24.0 (4.1) 26.4 (4.5)
Number of years as a clinical nurse
1–3a 149 (31.7) 31.9 (4.3) 0.001 29.6 (4.2) <0.001 27.2 (4.7) 0.837
3–5b 94 (20.0) 32.2 (4.8) a¼b<d 29.7 (3.9) d<a¼b 27.6 (5.5)
5–10c 114 (24.3) 33.0 (5.2) 28.9 (4.1) 27.0 (5.8)
10d 113 (24) 34.2 (5.8) 27.6 (4.3) 27.1 (4.3)
ProQOL: professional quality of life; CS: compassion satisfaction; BO: burnout; STS: secondary traumatic stress; SD: standard devia-
tion; ICU: intensive care unit.
*Special unit includes ICU, operating room and emergency room.

the order of the average scores were professionalism of nursing, self-concept of the profession, the roles of
nursing services and social awareness.

ProQOL by demographic characteristics

Table 2 presents the differences in the ProQOL scores according to the demographic characteristics of
the participants. The level of compassion satisfaction for the participants was statistically significant for
age (F ¼ 16.87, df ¼ 2, p < 0.001), marital status (t ¼ 4.39, p < 0.001), religion (t ¼ 3.37, p < 0.001), edu-
cational status (F ¼ 13.17, df ¼ 3, p < 0.001), position (F ¼ 15.92, df ¼ 2, p < 0.001) and number of years as a
clinical nurse (F ¼ 5.04, df ¼ 3, p ¼ 0.001). The level of nurses’ burnout was statistically significant for age

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Kim et al. 7

Table 3. Correlation among ProQOL, ethical dilemma and nursing professional values (N ¼ 476).

ProQOL

CS, r (p) BO, r (p) STS, r (p)

Ethical dilemma
Human life domain 0.17 (<0.001) 0.01 (0.843) 0.22 (<0.001)
Client domain 0.15 (0.001) 0.05 (0.284) 0.32 (<0.001)
Professional work domain 0.09 (0.056) 0.15 (<0.001) 0.32 (<0.001)
Supporter domain 0.08 (0.099) 0.15 (<0.001) 0.29 (<0.001)
Nursing professional values
Self-concept of the profession 0.49 (<0.001) 0.34 (<0.001) 0.00 (0.995)
Social awareness 0.48 (<0.001) 0.36 (<0.001) 0.04 (0.436)
Professionalism of nursing 0.41 (<0.001) 0.23 (<0.001) 0.04 (0.342)
The roles of nursing services 0.47 (<0.001) 0.32 (<0.001) 0.02 (0.616)
ProQOL: professional quality of life; CS: compassion satisfaction; BO: burnout, STS: secondary traumatic stress.

(F ¼ 12.75, df ¼ 2, p < 0.001), marital status (t ¼ 4.70, p < 0.001), religion (t ¼ 4.22, p < 0.001), educational
status (F ¼ 7.58, p < 0.001), position (F ¼ 12.37, p < 0.001) and number of years as a clinical nurse (F ¼ 6.69,
df ¼ 3, p ¼ 0.001). However, secondary traumatic stress did not show differences in age, gender, marital sta-
tus, religion, educational status, type of department, position or the number of years as a clinical nurse.

Correlations among the ProQOL scores, ethical dilemmas and professional nursing values
Table 3 presents the correlations among the scores of the ProQOL, ethical dilemmas and professional nur-
sing values questionnaires. Compassion satisfaction showed a weak positive correlation with the human life
and client domains; both the domains are sub-factors of ethical dilemmas. The sub-factors of professional
nursing values, including self-concept of the profession, social awareness, professionalism of nursing and
the role of nursing services, were positively correlated with compassion satisfaction. While burnout also had
a weak positive correlation with the professional work domain and the supporter domain of the ethical
dilemmas sub-factor, it had a negative correlation with self-concept of the profession, social awareness,
professionalism of nursing, the roles of nursing services and the sub-factor of professional nursing values.
Secondary traumatic stress was positively correlated with the human life, client, professional work and sup-
porter domains.

Multiple regression analysis showing the influencing factors of the ProQOL

Table 4 shows the factors influencing the participants’ ProQOL. The analyses of the influencing factors of
the nurses’ compassion satisfaction found that age, client domain of the ethical dilemmas, social awareness
of professional values, professionalism of nursing and the role of nursing services influenced participants’
ProQOL. The results indicated that compassion satisfaction increases as age increases; in other words,
nurses have greater experience with ethical dilemmas of the client domain, higher professional nursing val-
ues of the role of nursing services and higher nursing professionalism and social awareness as their age
increases. The factors influencing nurses’ burnout were marital status, religious status, social awareness,
the human life and professional work domains of ethical dilemmas and the roles of nursing services of pro-
fessional nursing values. These findings suggest that the level of nurses’ burnout is reduced when they are
religious, have more experience with ethical dilemmas of the human domain and when their recognition of
professional values about social awareness and the roles of nursing services is higher. They also suggest that

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8 Nursing Ethics

Table 4. Multiple regression analysis showing the influencing factors of ProQOL (N ¼ 476).

ProQOL

CS BO STS
b (p) b (p) b (p)

Age 0.13 (<0.001)

Marital status (married) 1.65 (<0.001)
Religion (yes) 1.11 (0.002)
Ethical dilemma
Human life domain 0.16 (0.007) 0.19 (0.031)
Client domain 0.14 (0.011) 0.35 (0.002)
Professional work domain 0.18 (<0.001) 0.20 (<0.001)
Nursing professional values
Social awareness 0.30 (<0.001) 0.22 (<0.001)
Professionalism of nursing 0.34 (0.007)
The roles of nursing services 0.52 (0.001) 0.34 (<0.001)
R2 0.31 0.24 0.12
ProQOL: professional quality of life; CS: compassion satisfaction; BO: burnout; STS: secondary traumatic stress.

the level of nurses’ burnout increases when they are married and have more experience with ethical dilem-
mas in the professional work domain. The influencing factors of secondary traumatic stress were the human
life, client and professional work domains. This finding revealed that nurses with much experience with
ethical dilemmas of the client and professional work domains have a higher level of secondary traumatic
stress and that those with more experience with ethical dilemmas in the human life domain have lower lev-
els of secondary traumatic stress.

Discussion
This is the first study investigating the relationships between the ProQOL of clinical nurses in Korea, level
of ethical dilemmas they experience and professional nursing values they perceive. In this study, the level of
the nurses’ ProQOL was low on the positive concept of compassion satisfaction compared with other med-
ical professionals and high on the negative concept of burnout. This study did not examine the influence of
cultural differences on these variables; perhaps they should be explored in participants who have similar
positions as clinical nurses working in different countries to serve as comparison groups. Further research
exploring the expression of cultural differences of different countries might inform us of ways to improve
nurses’ ProQOL.
This study found significant differences in compassion satisfaction and burnout of ProQOL by age, mar-
ital status, religion, educational status, position and number of years as a clinical nurse. These findings are,
in part, similar to prior findings12 that targeted oncology nurses in Korea and reported that compassion satis-
faction was high in the nurses who were 40 years or older, had a graduate degree or higher, worked in an
outpatient department as a general-duty clinician or had more than 10 years of clinical experience. The level
of burnout was high in nurses working on inpatient wards and in general-duty clinics. However, this finding
was similar to the findings of a previous study29 in which compassion satisfaction was associated with the
demographic characteristics of mental-health services staff in Italy. However, this finding was different
from a study29 reporting high levels of burnout among nurses with graduate degrees. In a previous study13
on American oncology nurses, compassion satisfaction and burnout were divided into high- and low-risk
groups. There were no differences associated with the demographic characteristics of the participants

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Kim et al. 9

except for the type of nursing department. None of the variables revealed differences in secondary traumatic
stress in relation to the general characteristics of the participants, and this finding corresponded to the find-
ings of a study,12 which targeted Korean oncology nurses. As the prior study suggests, with different out-
comes, it is more difficult to generalize research results. This study also implies that factors such as age,
marital status, religion, educational status, position and the number of years as a clinical nurse are the ones
that are difficult, if not impossibly hard, to change through intervention. Nevertheless, the proposal to ana-
lyse basic data to predict nurses’ quality of life is a meaningful one. Low compassion satisfaction and high
burnout rates of nurses with less than 3 years of clinical experience indicate that the individuals and their
organizations are at a high risk of developing a low ProQOL.2,30 Care programmes to solve the difficulties
of these high-risk groups are highly recommended.
One of the results of this study was that the nurses’ compassion satisfaction had a weak positive correla-
tion with the experience level of ethical dilemmas in the human life and client domains. We expected the
lower level of experience in ethical dilemmas to result in a higher compassion satisfaction of nurses as com-
passion fatigue was positively correlated with difficulty controlling emotions during abortion care.8 How-
ever, the correlations between compassion satisfaction and ethical dilemmas in human life and client
domains were very low, albeit statistically significant; the outcomes of this research were contrary to the
findings of the study of the nurses who provided abortion care. The ethical dilemmas of the human life
domain include making decisions associated with respect for human life and rights, and dilemmas of the
client domain concerning life and death. These findings are related to the duty to tell the patient the truth
and ensure their right to know the truth in order to make informed choices. Therefore, the results of this
research indicate that the nurses’ compassion satisfaction is not merely the number of times they experience
an ethical dilemma, but the recognition that they made an effort to maintain their patient’s rights and did so
based on their values and beliefs. Nurses facing ethical dilemmas may find that their work provides a sense
of personal happiness in helping others, thereby affecting their compassion satisfaction. The nurses’ com-
passion satisfaction showed a positive correlation with all the sub-factors of professional nursing values,
which was similar to previous findings.27,31 Those studies reported that individuals with more positive pro-
fessional values had higher levels of professional satisfaction.
Burnout of the nurses in this study was positively correlated with the experience of ethical dilemmas in
the professional and supporter work domains and negatively correlated with the sub-factors of professional
nursing values. Similar to previous research,14 the frequency of ethical dilemmas was negatively correlated
with skill level. Nurses place importance on meeting patients’ needs and having a holistic view of quality
care. Challenges to this professional value were believed to influence burnout. In the ethical dilemmas, mat-
ters of the professional work domain positively correlated with nurses’ burnout.
Ethical dilemmas of the professional work domain include how nurses should distribute insufficient
resources, whether they should use a restraining band for safety, and the conflicts resulting from their role
as a professional. Ethical dilemmas in the supporter domain include conflicts related to evaluating or sup-
porting colleagues. A major finding of this research was that the ethical dilemmas in human life and client
domains had a positive effect on the nurses’ compassion satisfaction, even though it was the same ethical
dilemma. Conflicts caused by work or relations with colleagues had a negative effect on nurses’ burnout. In
matters of financial resources, problems with government systems and the hospitals involved should be
responsible for handling certain issues. In some situations, the hospitals should allocate labour resources
in an appropriate manner. To deal with the ethical conflicts of medical personnel, the government and hos-
pitals must generate ideas to form a foundation for the establishment of an ethical environment. These activ-
ities would include the best use of an ethics commission and other paths to problem solving, such concerns.
It is difficult to find studies on the relationship between professional values and burnout in the nursing field
because of the scarcity of research.32 This study found a negative correlation between nurses’ burnout and
professional values. If we implement a strategy to strengthen their professional values, we may be able to

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10 Nursing Ethics

manage nurses’ burnout. In short, the study suggests that professional organizations, such as hospitals, pro-
fessional organizations at the national level (e.g. the Hospital Nurses Association of Korea) and universities
with nursing departments conduct continuing education programmes to enhance the professional values of
nurses and decrease the degree of exhaustion of individual nurses.
The secondary traumatic stress of the nurses was positively correlated with the experience of ethical
dilemmas. Secondary traumatic stress refers to work-related secondary exposure to people who have expe-
rienced extreme events2 and these results were similar to those of previous studies.8 Given these findings,
one may think that clients’ dilemmas exposed nurses to stressful events, thereby having a negative impact
on the nurses’ secondary traumatic stress. In order to generalize the results of this study, it is necessary to
replicate the process that nurses experience when they encounter ethical dilemmas. The qualitative data
generated by such a study may reveal a deeper level of knowledge of secondary traumatic stress in nurses.33
The results of this study indicated that the roles of nursing services, professionalism, social awareness,
professional values, experience with ethical dilemmas and age influence nurses’ compassion satisfaction.
The key concepts of nursing services roles, professionalism of nursing and professional values comprise the
professional qualities needed to solve problems swiftly and correctly. Similar to the ethical dilemma expe-
rience of the client domain, this can be interpreted as providing satisfaction to nurses when they offer ‘help’
to patients. Based on Maslow’s hierarchy of needs,34 nurses who value the social awareness of nursing
services have high compassion satisfaction and this is an indicator of self-actualization.35 Marital status
(married), religion (yes), the roles of nursing services and social awareness in professional nursing values
had a high influence on burnout. Ethical dilemma experience in the professional work domain and human
life domain were also high influencers of nurses’ burnout. Client domain, professional work domain and
dilemma experience in human life were higher influencers of nurses’ secondary traumatic stress. These out-
comes suggest that an increased risk of burnout in married nurses is most probably due to the stress of bal-
ancing hospital duties and work at home.11 Furthermore, the risk of burnout is lower in religious nurses as
religious behaviour may act as a buffer against these stressors. The more they experience problems, such as
properly distributing the insufficient medical resources, using restraining bands for safety, and dealing with
conflicts incurred as part of the role of a professional (professional work domain), the more nurses will face
an increasing amount of negative influences. In turn, they will suffer from compassion fatigue, including
burnout or secondary traumatic stress. This study found that nurses’ compassion satisfaction and compas-
sion fatigue were influenced by the specific domain to which the ethical dilemma belonged. As stated ear-
lier, there are no previous studies on nurses’ ProQOL, ethical dilemmas and professional nursing values.
Based on the relationship that we found between the ProQOL and the ethical dilemmas of the nurses, it
is apparent that the frequency of ethical dilemmas faced by clinical nurses, and the types of ethical dilemmas
that they judge to be the least and most difficult, must be reclassified. If these variables were recategorized
according to their frequency and relevance in the actual clinical setting, the results of future investigations
might be more generalizable.

Study limitations
As this study used a convenience sample of nurses working at four university hospitals in Korea, the results
must be interpreted with caution. In the light of what has been discussed so far, a follow-up study that con-
siders the hospital’s size might generate a more representative study sample. If the characteristics of the
working conditions (e.g. severity of illness, number of nurses and workload) are representative, then the
findings should be more easily generalized and replicated. As a cross-sectional study, this investigation does
not provide causal explanations about the factors affecting the ProQOL of nurses. A sub-factor had to be
excluded from this research because of the low reliability of nursing professional values among the research
instruments. A replication of the study in the future that uses instruments with established reliability and

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Kim et al. 11

validity should be conducted. As the ProQOL of nurses is a very complicated phenomenon, the replication
of qualitative and quantitative studies of the relevant variables, and further studies of intervention pro-
grammes to improve ProQOL, would be worthwhile endeavours.

Conclusion
Nursing is a profession with a high probability of experiencing a low ProQOL. A low ProQOL has a neg-
ative effect on a nurse’s mental and physical health and it reduces the quality of nursing care. Therefore,
measures to improve the ProQOL of nurses are imperative. The results of this study show that nurses’ Pro-
QOL was affected by ethical dilemmas and professional nursing values. Therefore, an intervention has a
greater chance of success if it is based on the nurses’ values and beliefs about the ethical dilemmas they
face and fosters the establishment of positive professional values. To accomplish this objective, we can use
this study as a basis to examine compassion satisfaction and fatigue in relation to the domains of ethical
dilemmas. Thereafter, we may integrate our findings to develop curricula for the ethics education of clinical
nurses. In addition, professional organizations related to hospital administrators and nurses should continue
to conduct educational programmes to enhance nursing professional values, which might lower the serious-
ness of the ethical dilemmas that the nurses could experience and reduce the degree of exhaustion of nurses.

Acknowledgements
The authors appreciate Dr BH Stamm for providing the ProQOL tool.

Conflict of interest
The authors declare that there is no conflict of interest.

Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.

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