The level of development of nursing assistants’ value system predicts their views on paternalistic care and personal autonomy

Main Article Content

Sofia Kjellström
Per Sjölander


The quality of care is substantially influenced by the staff‘s value priorities. The purpose of this study was to identify and characterize value systems among nursing assistants and nurses’ aides, and to assess relations between their value systems and views on good care. A cross-sectional, quantitative study in a Swedish municipality was performed (N=226). Three distinct value systems were identified, and they corresponded to early (n=121), middle (n=88), and late (n=17) conventional stages ofego development. Early conventional value systems emphasized strict rules, routines and working conditions of staff, while middle and, in particularly, late conventional value systems stressed individualization and autonomy of older people. Assessment of value system, socio-demographic, and occupational variables showed that the value systems had a stronger predictive impact on views on care ethics, participation, and autonomy. The results indicate that staff with late conventional value systems prioritized older persons’ exercise of autonomy, while paternalism held priority in staff with early conventional value systems.


Metrics Loading ...

Article Details



Adler, A. (1964). Problems of Neurosis. Oxford: Harper Torchbooks.

Akrivou, K. (2008). Differentiation and integration in adult development: The influence of self complexity and integrative learning on self integration. Academic dissertation. Department of Organizational Behavior, Case Western Reserve University.

Anderson, R. A., Ammarell, N., Bailey, D., Colo´n-Emeric, C., Corazzini, K. N., Lillie, M., Piven, M. L., Utley-Smith, Q. & McDaniel, R. R. (2005). Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents. Qualitative Health Research 15(8): 1006–1021.


Blasi, A. & Glodis, K. (1995). The development of identity. A critical analysis from the perspective of the self as subject. Developmental Review 15(4): 404–433. DOI: 10.1006/drev.1995.1017


Bowers, B. & Becker, M. (1992). Nurse’s aides in nursing homes: The relationship between organization and quality. The Gerontologist 32(3): 360–366. DOI: 10.1093/geront/32.3.360


Chung, G. (2013). Understanding nursing home worker conceptualizations about good care. The Gerontologist 53(2): 246–254. DOI: 10.1093/geront/gns117


Commons, M. L. (1989). Adult Development. Vol. 2, Comparisons and Applications of Developmental Models. New York: Praeger.

Commons, M. L. (1990). Adult Development. Vol. 1 Models and Methods in the Study of Adolescent and Adult Thought. New York: Praeger.

Cook-Greuter, S. (1999). Postautonomous ego development: A study of its nature and measurement. PhD. Cambridge, MA: Harvard University.

Dauwerse, L., van der Dam, S. & Abma, T. (2012). Morality in the mundane: Specific needs for ethics support in elderly care. Nursing Ethics 19(1): 91–103. DOI: 10.1177/0969733011412102


Erikson, E. (1968). Identity: Youth and Crisis. New York: Norton.

Eyers, I., Arber, S., Luff, R., Young, E. & Ellmers, T. (2012). Rhetoric and reality of daily life in English care homes: The role of organized activities. International Journal of Ageing and Later Life 7(1): 5378. DOI: 10.3384/ijal.1652-8670.11132

Gilligan, C. (1982). In a Different Voice: Psychological Theory and Women’s Development. Cambridge, MA: Harvard University Press.

Grosch, K., Medvene, L. & Walker, D. (2011). Using a measure of personperception skills to identify outstanding home care workers. Home Health Care Services Quarterly 30(1): 24–41. DOI: 10.1080/01621424.2011.545738

Helson, R. & Roberts, B. W. (1994). Ego development and personality change in adulthood. Journal of Personality and Social Psychology 66(5): 911. DOI: 10.1037/0022-3514.66.5.911


Helson, R. & Wink, P. (1987). Two conceptions of maturity examined in the findings of a longitudinal study. Journal of Personality and Social Psychology 53(3): 531. DOI: 10.1037/0022-3514.53.3.531


Johnson, V. A. (2000). The concept of differentiation as a contribution to the psychology of maturity. Thesis. Harvard Graduate School of Education, Harvard University.

Joiner, W. B. & Josephs, S. A. (2006). Leadership Agility: Five Levels of Mastery for Anticipating and Change. San Francisco, CA: Jossey-Bass.

Juujärvi, S., Myyry, L. & Pesso, K. (2012). Empathy and values as predictors of care development. Scandinavian Journal of Psychology 53(5): 413–420. DOI: 10.1111/j.1467-9450.2012.00961.x


Kegan, R. (1994). In Over Our Heads: The Mental Demands of Modern Life. Cambridge, MA: Harvard University Press.

Kjellström, S. & Ross, S. N. (2011). Older persons’ reasoning about responsibility for health: Variations and predictions. International Journal of Aging and Human Development 73(2): 99–124. DOI: 10.2190/AG.73.2.a


Kohlberg, L. (1971). Stages of moral development. Moral Education 23–92.


Kohlberg, L. (1981). Essays on Moral Development (Vol. 1). The Philosophy of Moral Development. San Francisco, CA: Harper & Row.

Kolb, D. A. (1984). Experiential Learning: Experience as the Source of Learning and Development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

Labouvie-Vief, G., Hakim-Larson, J. & Hobart, C. J. (1987). Age, ego level, and the life-span development of coping and defense processes. Psychology and Aging 2(3): 286–293. DOI: 10.1037/0882-7974.2.3.286


Leibovich, V., Keilikhis, Y., Barzilay, A., Cohen, D., Shoval, G., Schapir, L., Libman, A., Kigli, R. S., Marcus, I., Weizman, A., Merrick, J.& Zalsman, G. (2011). Level of training of nursing staff and the autonomy given to psychiatric inpatients: A multicenter study. International Journal of Adolescent Medicine and Health 23(1): 45–50. DOI: 10.1515/ijamh.2011.008


Loevinger, J. (1979). Construct validity of the sentence completion test of ego development. Applied Psychological Measurement 3(3): 281–311. DOI: 10.1177/014662167900300301


Loevinger, J. (1998). Technical Foundations for Measuring Ego Development: The Washington University Sentence Completion Test. Mahwah, NJ: Lawrence Erlbaum.

Loevinger, J. & Blasi, A. (1976). Ego Development: Conceptions and Theories (1st ed). San Francisco, CA: Jossey-Bass.

Loevinger, J. & Hy, L. X. (1996). Measuring Ego Development (2nd ed). Mahwah, NJ: L. Erlbaum Associates.

Mahler, M. S., Pine, F. & Bergman, A. (2008). The Psychological Birth of the Human Infant Symbiosis and Individuation. New York: Basic Books (AZ).

Manners, J. & Durkin, K. (2001). A critical review of the validity of ego development theory and its measurement. Journal of Personality Assessment 77(3): 541–567. DOI: 10.1207/S15327752JPA7703_12

Manners, J., Durkin, K. & Nesdale, A. (2004). Promoting advanced ego development among adults. Journal of Adult Development 11(1): 19–27. DOI: 10.1023/B:JADE.0000012524.32002.8d


Mattiasson, A.-C. & Andersson, L. (1995). Nursing home staff attitudes to ethical conflicts with respect to patient autonomy and paternalism. Nursing Ethics 2(2): 115–130. DOI: 10.1177/096973309500200204


McCrae, R. R. & Costa, P. T. (1980). Openness to experience and ego level in Loevinger’s Sentence Completion Test: Dispositional contributions to developmental models of personality. Journal of Personality and Social Psychology 39(6): 1179. DOI: 10.1037/h0077727


Medvene, L., Grosch, K. & Swink, N. (2006). Interpersonal complexity: A cognitive component of person-centered care. The Gerontologist 46(2): 220–226. DOI: 10.1093/geront/46.2.220


Pals, J. L. & John, O. P. (1998). How are dimensions of adult personality related to ego development? An application of the typological approach. In M. P. Westenberg, A. Blasi & L. D. Cohn (eds.), Personality Devleopment: Theoretical, Empirical, and Clinical Investigations of Loevininger’s Conceptions of Ego Development (pp. 113–131). London: Lawrence Erlbaum Associates.

Persson, T. & Wästerfors, D. (2009). Such Trivial Matters:’’ How staff account for restrictions of residents’ influence in nursing homes. Journal of Aging Studies 23(1): 1–11. DOI: 10.1016/j.jaging.2007.09.005


Pfaffenberger, A. H. (2005). Optimal adult development: An inquiry into the dynamics of growth. Journal of Humanistic Psychology 45(3): 279–301. DOI: 10.1177/0022167804274359


Piaget, J. (1954). The Construction of Reality in the Child. New York: Basic Books. DOI: 10.1037/11168-000


Pratt, M. W., Diessner, R., Hunsberger, B., Pancer, S. M. & Savoy, K. (1991). Four pathways in the analysis of adult development and aging: Comparing analyses of reasoning about personal-life dilemmas. Psychology and Aging 6(4): 666. DOI: 10.1037/0882-7974.6.4.666


Rokeach, M. (1973). The Nature of Human Values. New York: Free Press

Schwartz, S. H. (1992). Universals in the content and structure of values: Theoretical advances and empirical tests in 20 countries. Advances in Experimental Social Psychology 25(1): 1–65. DOI: 10.1016/S0065-2601(08)60281-6


SFS (2001: 453). Socialtjänstlag [Social services act]. Stockholm: Socialdepartementet [Ministry of Health and Social Affairs].

SFS (1982: 763). Hälso- och sjukvårdslag [Swedish health and medical services act]. Stockholm: Socialdepartementet [Ministry of Health and Social Affairs].

Sheridan, J. E., White, J. & Fairchild, T. J. (1992). Ineffective staff, ineffective supervision, or ineffective administration? Why some nursing homes fail to provide adequate care. The Gerontologist 32(3): 334–341. DOI: 10.1093/geront/32.3.334


Sinnottt, J. D. (2003). Postformal thought and adult development. In J. Demick & C. Andreoletti (eds.), Handbook of Adult Development (pp. 221–238). New York: Kluwer Academic /Plenum.

Sjölander, P., Lindström, N., Ericsson, A. & Kjellström, S. (2014). A pattern recognition method for disclosing different levels of value system from questionnaire data. Behavioral Development Bulletin 19(3): 114–127. DOI: 10.1037/h0100596


Skoe, E., Pratt, M. W., Matthews, M. & Curror, S. E. (1996). The ethics of care: Stability over time, gender differences, and correlates in mid- to late adulthood. Psychology and Aging 11(2): 280–292. DOI: 10.1037/0882-7974.11.2.280

Skoe, E. E. & von der, L. (2002). Ego development and the ethics of care and justice: The relations among them revisited. Journal of Personality 70(4): 485–508. DOI: 10.1111/1467-6494.05016


Torbert, W. R. (2004). Action Inquiry: The Secret of Timely and Transforming Leadership. San Francisco, CA: Berrett-Koehler.

Torbert, W. R. & Rooke, D. (2005). Seven transformations of leadership. Harvard Business Review 83(4): 66–76.

Trydegård, G.-B. (2012). Care work in changing welfare states: Nordic care workers’ experiences. European Journal of Ageing 9(2): 119–129. DOI: 10.1007/s10433-012-0219-7


Westenberg, M. P., Blasi, A. & Cohn, L. D. (eds.). (1998). Personality Development: Theoretical, Empirical, and Clinical Investigations of Loevininger’s Conceptions of Ego Development. Mahwah, NJ: Lawrence Erlbaum Associates. DOI: 10.1037/0022-3514.65.4.792

Westenberg, M. P. & Block, J. (1993). Ego development and individual differences in personality. Journal of Personality and Social Psychology 65(4): 792.


White, M. S. (1985). Ego development in adult women. Journal of Personality 53(4): 561–574. DOI: 10.1111/j.1467-6494.1985.tb00383.x

Wold, S., Sjöström, M. & Eriksson, L. (2001). PLS-regression: A basic tool of chemometrics. Chemometrics and Intelligent Laboratory Systems 58: 109–130. DOI: 10.1016/S0169-7439(01)00155-1