Professional values education for undergraduate nursing students: developing a framework based on the professional values growth theory

Background

Education has been recognised as necessary in forming and internalising professional values. The system and instructors' content in existing educational institutions focus on developing students' knowledge, skills and practices. Still, the development of values has yet to achieve significant effects, leading to a crisis in students' professional identity.

Aims

To construct a professional values growth theory for undergraduate nursing students and develop a corresponding education framework.

Methods

Through the review, some databases(PubMed、CINAHL、Web of Science、Wiley and Google Scholars)were searched using a systematic search strategy to collect relevant literature on professional values education. Based on the nursing professional values growth theory (Li and Li, Nursing Ethics In press, 2022), a theory of professional values growth of nursing undergraduates was developed using the method of theory derivation. Two rounds of expert meetings were conducted to review and revise an education framework of professional values of nursing undergraduates derived from that theory.

Findings

A total of 10 studies were included. The contents of two themes were analysed: theories and models and the current status of the professional values development of nursing students. The resulting professional values growth theory for undergraduate nursing students consists of five parts: key aspects, decisive opportunities, drivers, embodiment (humanistic sentiments, moral emotions), and outcomes. A total of five experts in the relevant fields were invited to this study. After two rounds of expert meetings, an education framework for undergraduate nursing students was finally developed, which consists of four parts: education objectives, education process and content, environment and conditions, and evaluation.

Conclusion

The education framework developed in this study has practical implications for the development of professional values of undergraduate nursing students, providing educational strategies and methods for the growth and internalisation of professional values of undergraduate nursing students.

Introduction

With the rapid advances in various fields such as technology, economy, and culture, healthcare from an international perspective has witnessed the inclusive coexistence of multiple cultures and a deepening trend of globalization. China's nursing workforce has grown in numbers and qualifications since 2016. In 2020, China's National Nursing Career Development Plan (2021–2025) emphasises the need to fully mobilise the nursing workforce and improve the quality of nursing services [1]. The cultivation of nursing professionals has always been an essential mission of higher education institutions, in which the cultivation of nursing professional values has become an important element in the training of undergraduate nursing students [2]. In the context of global multiculturalism, the formation of good nursing professional values can not only enhance the professional satisfaction of undergraduate nursing students [3] and improve ethical decision-making ability [4], but also shape the profession's social image. Based on previous theoretical research, this study develops a framework for cultivating professional values among undergraduate nursing students and provides educational strategies and methods for the growth and internalisation of professional values among undergraduate nursing students.

Background

Values are the deeper meanings and perspectives on something that are developed by one's needs and experiences; they are ideologies of social life that are formed and maintained over time by individuals through their life experiences, and are not affected by changes in the organisation's social environmen [5]. Values influence individuals' behaviour in everyday life and guide their evaluation of themselves and others, choices, and actions [6]. Professional values are a specific choice of values based on the connotations and characteristics of a profession and are used as an element in shaping the identity of a professional group [7]. Although there is no unified definition of professional values to date, more scholars have stipulated and explained them [8, 9]. It is also clear that professional values are a product of the inevitable formation of the socialisation process [10].

In nursing, values become a breakthrough in establishing a unified and accepted model of behaviour within the profession [11]. In 2016, Bonnie J. Schmidt et al. conceptualised nursing professional values through Walker and Avant's concept analysis, which identified nursing professional values as Human dignity, Integrity, Altruism and Justice, which are crucial professional nursing principles and frameworks for clinical practice and assessment [12]. Nursing professional values are closely related to three themes, namely patients, the profession and society, and are agreed upon in a global perspective based on ethical guidelines [13]. Meanwhile, Derek Sellman identified rigid value propositions among administrators and policymakers at all levels of health care, contributing to the marginalisation of nursing discourse, as well as the subordination of nursing to the health care system, which has marginalised and homogenised its values [14]. A study by Cho S.H et al. also found that in the social–historical process, the deep-rooted stereotypes formed about the image of nurses have influenced students' perceptions and formation of professional values in choosing whether to pursue a nursing profession [15]. Therefore, when the socialisation process of nursing students is fraught with a professional identity crisis, transforming their perceptions of nursing from a widespread perception of the profession to an understanding of the professional profession can be challenging and obstructive.

In China, nursing students are demanding about the geographical location of their employment, the salary package, and the number of night shifts, and hospitals and local governments need to adopt more material incentives to be able to attract more nurses to work in rural areas [16]. Yi qi feng et al.'s study also found that nursing students generally have employment anxiety [17], and that professional identity is a key factor influencing the employment intention and career planning of nursing students [18]. This highlights the importance of nursing education in fostering good professional values and socialisation to prepare students for the demands of the nursing profession and bridge the gap between theory and practise. Students' beliefs that 'I am doing this to serve the health of others' and 'I deserve to be paid well for my work' often coexist, requiring education to guide, assist, and adequately support them in this process. Kaya et al. investigated the changes in undergraduate nursing students' professional and personal values over four years of study [19]. They found that the differences in the measures of professional values between the four years of undergraduate nursing education were statistically significant, showing that education has been identified as a crucial prerequisite for forming and internalising professional values.

Instructors often focus more on the external norms reflected in professional values and less on their complex internal nature [20], making teaching values easier. However, this strategy fails to provide nursing students with emotional education and prevents them from forming and internalising professional values. The existing institutional system and the content of lessons focus on developing students' knowledge, skills, and behaviours. Still, the development of professionalism and values has yielded insignificant results, thus creating more of a professional identity crisis [21]. Students can gain satisfaction from technical mastery, but working in nursing solely for money and status is not nursing. It may even lead to questioning the fairness of external benefits [14], creating a dilemma for nursing staff. Therefore, on top of the emphasis on technical competency in professional education, there is a greater need for professional values to be involved in professional socialisation in the form of internal rewards. Furthermore, personal experience influences individual values and behavioural choices. It argues that all values are not simply given from the outside but spontaneously formed in their growth and development and all socialisation experiences.

At present, research on nursing professional values has focused on the current situation and influencing factors of professional values among nurses and nursing students, as well as the study of their correlation with several factors such as work environment, job satisfaction, self-esteem, and nursing organisational climate [21, 22]. In-depth research has yet to be been conducted on the relevant development programmes and frameworks for nursing professional values of nursing students at the undergraduate level. Our research group has developed nursing professional values growth theory based on grounded theory research in previous studies [23]. Therefore, the purpose of this study is to explore the current problems in professional values education in nursing undergraduates, and a theory specific to the growth of professional values in undergraduate students based on pre-theory is developed to guide the construction of an educational framework and address the challenges that may arise in future healthcare professionals' development.

Aims

This study aims to develop a framework for the cultivation of professional values in nursing based on theories of professional values growth for undergraduate nursing students.

Methods

Theory derivation

In 2011, Walker and Avants introduced theory derivation in the methodology of theory construction, which refers to a theory (theory 1) that provides some new insights from an area of interest (domain 1). The theorist moves some of its content and structural features to another area of interest (domain 2), forming a new theory (theory 2).Theory derivation could notice two different domains and dimensions of similar phenomena and enables the redefinition and transformation of theories from domain 1 to domain 2. Theory derivation is the process by which a set of related concepts or overall structures is transferred from one domain to another and modified to fit the new domain. Furthermore, Walkers and Avants also emphasised that at least some modifications in content and structure cannot be borrowed directly. Theory derivation is an iterative process, and the order of the steps may change during the research process, but it basically consists of five steps: (i) understanding the level of theoretical development in one's field of interest and being able to assess its scientific value; (ii) reading extensively in nursing and other fields while allowing imagination and creativity to run free; (iii) selecting the parent theory for a derivation; (iv) determining the content and structure of the parent theory; and (v) developing or redefining new concepts and statements from the content and structure of the parent theory [24]. Theory derivation requires the researcher to be familiar with the field of interest, and the new theory must be empirically tested to verify its relationship to actual reality [25].

The theory of professional values growth in nursing developed in the pre-study of our research group is applicable in a wide range of contexts, from nursing students to senior nurses. In order to construct a professional values education framework for undergraduate nursing students, this study cannot directly use the theory of professional values growth in nursing. Still, it should instead focus on the growth of professional values at the undergraduate education level in a context. Therefore, it is necessary to derive the theoretical framework on which this study is based, namely the professional values growth theory for undergraduate nursing students, based on the structure and content of the pre-study theory.

Data sources

Given that a scoping review allows for a wide-ranging and comprehensive exploration of the research question, including the background, boundaries, and possible gaps [26], the inclusion of information collected from a systematic literature search to ensure the completeness and accuracy of the included literature, and the emphasis of the paragraph on an overall theme, it was chosen as the data collection method for theory derivation and the development of education frameworks.

A systematic search is conducted to understand the relevant theories and educational frameworks for professional values in nursing. The following two main questions were addressed: (i) What are the relevant theories and models of nursing professional values? (ii) What is the educational framework for professional values education for nursing students?

• (1) Search strategy

The search terms in this study were developed according to PCC [27], where population (P) is nursing student or undergraduate, concept (C) is nursing professional values, and context (C) is the theory, training programme, education framework. Two databases (CINAHL and PubMed) were first used to understand the basic research in the field and to identify further relevant search terms. The search terms used in this study were "professional", "profession", "nurses", "values", and "training". "values", "student", "undergraduate", "theory ", "education", and "training". The search databases included PubMed, CINAHL, Web of Sciences, and Wiley. Also, grey literature was accessed through the official nursing website, Google Scholars. The search time interval was 2000 ~ present. The search was conducted in March 2022. (See Appendix 1 for examples of the search strategy).

• (2) Inclusion and exclusion criteria

Inclusion criteria: articles published in English with access to the full text; the population was nursing students, with no restrictions on an academic background; the literature included theoretical models or training programmes for nursing professional values. Exclusion criteria: nursing students in the study population were midwifery.

• (3) Selection process

After excluding duplicates from the retrieved literature, one researcher (LJL) first screened the literature by reading the titles and abstracts. Then two researchers (LJL LXH) read the titles and abstracts of all the literature initially screened on this basis and jointly discussed the deletion of literature that was not relevant to the study. The two researchers then independently read the full text and excluded literature that did not meet the inclusion criteria of the study, and finally reached a consensus on consensus on the literature to be included in the study.

• (4) Collation and analysis of literature

In this study, the information was collated according to the literature extraction form designed in advance, which included author, year of publication, country, type, aims, methods, population, instrument, data collection methods and results. The literature extraction was first carried out by one researcher for the first three included papers and adjusted the literature inclusion form, after which two researchers completed it independently and discussed it after completion. According to the research questions, the analysis method used was thematic analysis.

Framework formation process

This study ‘s theoretical foundations included the professional values growth theory developed by the pre-study and constructivist learning theory. The education framework was developed through group discussions considering feasibility, including the following four parts: objectives, content and methods, environment and conditions, and evaluation.

Five experts in nursing ethics and education fields (see Appendix 2) were selected to discuss the cultivation framework in two rounds of expert meetings. The cultivation framework was revised and adjusted according to the experts' opinions and suggestions. The first round of expert meetings was conducted online. A consultation questionnaire was sent to the experts by email before the meeting, including a letter to the experts, a professional values theory and cultivation framework for undergraduate nursing students, and an expert information list. The second round of the expert meeting was used to review the revised framework by email.

Ethical consideration

The Ethics Committee of China Medical University approved this study under approval number [2022] 86.

Findings

Literature review results

A total of 98 pieces of literature were retrieved, 15 duplicates were removed, and the remaining 83 were screened, of which 64 had titles and abstracts that did not meet the inclusion criteria for this study. The remaining 18 were read, and 8 were removed. The final 10 articles were included in this study, see Fig. 1, of which 5 were reviews, 8 were experimental studies, and 1 was an action study, the details of which are in Appendix 3 and 4.

Fig. 1

PRISMA-ScR flow diagram

A total of six nursing professional values theories or models were included, collated, and summarised in this study. The context of their theory construction, the theories' paradigmatic origins, and the theories' internal dimensional analysis were analysed according to Meleis' theoretical analysis strategy, as shown in Table 1.

Table 1 Analysis of theories and models included in the study

The content of the existing nursing professional values education framework is summarised according to the included literature. The analysis revealed that existing nursing professional values education is divided into two forms of organisation: classroom teaching, where the school sets the professional values course content and syllabus, and extra-curricular teaching, where students choose whether or not to participate in extra-curricular teaching programmes, such as intercultural education and international service projects. See Table 2 for details.

Table 2 Nursing students' professional values development studies summary

Theory derivative results

This study used the theory of professional values growth in nursing as a derivative of the parent theory through the Walk and Avant theory derivation. It developed a theory of professional values growth for undergraduate nursing students about the literature review findings.

Theory description

The content of the professional values growth theory for undergraduate nursing students includes five parts, key aspects, decisive opportunities, drivers, embodiment and outcomes, see Fig. 2.

Fig. 2

The professional values growth theory for undergraduate nursing students

• (1) Key aspects

  The core of the professional values growth theory is the key aspect, which includes four stages: the initial stage, the consciousness stage, the core stage, and the action stage. However, undergraduate nursing students are in the professional learning stage and have not yet engaged in clinical nursing practice as nurses; therefore, their professional values at growth stage represent a preliminary professional value system.

  • 1) The initial stage: The initial stage of the growth of professional values is to build the foundation of professional values, including respect for life and family culture immersion. ①Respect for life: At the early stage of entering the nursing profession, students need to fully understand and appreciate the nature of the nursing profession, the pursuit of which is closely related to life. Respect for life is, therefore, a prerequisite for the growth of professional values in nursing, in which a sense of professional mission is developed, and a correct attitude towards human life and dignity is formed. ②Family culture immersion: virtue education in the family culture is part of forming their values. The family environment enables students to learn how to communicate and interact appropriately with others not part of the family. When the student is exposed to the nursing profession, the personal values acquired from the family culture that are compatible with professional values are perpetuated and integrated into the personal value system.

  • 2) The consciousness stage includes identity and finding professional role models. ①When students first encounter the nursing profession, they are full of unknowns about everything in the profession. However, individuals need to be understood, supported, respected, and helped within a whole group that has always been characterised by discourse: standards of practice, human attitudes, values, and goals; and to empathise with common interests, thus creating a sense of belonging within the group and among individuals. ②There will always be trusted predecessors or peers along the way, but the presence of role models is not the key to the growth of their professional value; instead, students should actively seek out role models and believe they can strengthen their personal future professional development. Role models convey professional values and career beliefs by word and example and translate their professional values into practice, thus exposing students to subtle influences.

  • 3) The core stage includes immersive experiences and reflective learning. ①Practical and applied professions require professional practice experience to gain a deep professional emotional education. Essential to the growth of professional values is the experience of authentic clinical nursing practice. Without an immersive practice experience, the humanistic and ethical sentiments in professional values will not be accurately felt. ②For professional values to grow and be internalised, constant reflection and self-reflection are required during the experience so that personal values that contradict professional values can be adjusted and attitudes and behaviours consistent with professional values can be gradually clarified. Active reflection and introspection are, therefore, inevitable processes in internalising professional values.

  • 4) The action stage is the final stage of the key aspects, including reflexivity and planning the future. ①As students grow in their professional values, their personal values are also influenced, thus bringing an "invisible sense of responsibility" to all aspects of professional practice. Secondly, when the professional values of nursing, which have grown through education, are "merged" with personal actions, the values assigned by the student's profession enable him or her to determine exactly when and how to present their professional roles and actions, even when temporarily removed from the professional environment. ②When students consider their profession or future career desirable, they are hopeful for the future and want to define their career aspirations further. Therefore, students create a professional future by setting short-term and long-term pursuits to give them professional confidence and motivation to move forward, taking purposeful action, and providing the possibility of other internalising professional values.

• (2) Decisive opportunities: The growth of professional values in undergraduate nursing students needs appropriate support and determinants. When individuals capture opportunities for the growth of professional values in nursing, they play a supportive role in their personal development and professional values. Furthermore, decisive opportunities are somewhat out of control but can be created through the environment and through one's actions and reflections to determine opportunities for professional values growth. These include organisational and personal opportunities.

Organisational decisive opportunities are the interpersonal processes of student-staff and student–student interaction within the campus culture and interpersonal environment in which students learn and live. These provide decisive opportunities to promote the growth of professional values in nursing. Companionship is the form of support that needs to be given in the interpersonal environment in which the student lives. Not only are students in the early stages of the development of their professional values, but they are also in the early stages of forming their value systems. They may encounter difficulties in their lives and studies that they cannot overcome.

Personal decisive opportunities are actions initiated and engaged in by individuals in the process of growing professional values. Such actions provide individual motivation for the growth of professional values and strengthen the link between personal feelings and professional values. As students become aware of professional nursing values, their growth requires them to use critical thinking, balance personal ideals with professional realities, integrate personal and professional emotions, gain self-recognition, and integrate self-fulfilment with professional development pursuits.

• (3) Drivers: A variety of factors, particularly social culture and self-trait, influence and drive the development of students' professional values.

The recognition of the profession in social culture influences students' confidence in the value of the profession and their future careers in the related profession. The growth of professional values in undergraduate nursing students requires encouragement from social health policies, support for nursing talent development, access to professional autonomy, decision-making, and voice, as well as recognition and respect from patients and society.

In addition, the individual's subjective initiative in self-trait plays an important role. Individuals with solid subjective initiative who are able to proactively deal with and cope with the complex world and break out of the confusing situations they find themselves in can play a self-motivating role in the growth of their professional values. When students enter the nursing profession with a frustrating personal dilemma from stereotypes can cause them to become confused when it is vital to break through the harmful confusion and rethink the pursuit of nursing professional values through spontaneous introspection and reflection.

• (4) Embodiment: Embodiment includes humanism and ethical emotions. Humanism refers to nursing professional values centred on human health, respect for human dignity and values, humanitarianism, consciously caring for others, loving others, and safeguarding the health of others. In the professional values growth of undergraduate nursing students, humanism is concretely reflected in fraternity, empathy, and care. Fraternity means that the nursing profession treats all patients and others with any health need with a spirit of non-discriminatory fraternity, treating them equally and giving care services to others selflessly. Empathy means putting oneself in the shoes of others, understanding and responding empathetically to the emotional problems caused by illness, and having the ability to empathise and feel empathy. Caring is motivated by "goodness" and demonstrates altruism in the care of patients. Caring is transferable and contagious, and when students receive care as part of developing their professional values, they will spontaneously want to give care to others in their profession or their lives.

Ethical emotions refer to the embodiment of moral obligations and ethical responsibilities in nursing professional values, which can transform different professional events into inner moral experiences and help individuals and groups to judge the rightness or wrongness of professional actions, specifically responsibility, discretion, kindness, sincerity, and equality. Responsibility refers to the ability of individuals in the nursing profession to take an active and positive attitude towards their obligations to maintain health and save lives and to fulfil them consciously. Discretion is the expression of ethical values in the form of self-discipline in nursing practice. Kindness means treating the lives of others well, providing timely care to help maintain or recover from health problems, and not harming others. Sincerity refers to an altruistic spirit of seeking truth and truthfulness in the treatment of those we serve. Equality refers to maintaining equality in health care by providing professional care to patients without discrimination or prejudice.

• (5) Outcome: The growth and internalisation of professional nursing values continue with the change of role; therefore, at the stage of undergraduate nursing students, in conjunction with the requirements and objectives of talent training, the embryonic professional value system at this stage needs to be formed. In the process of receiving higher education, students are able to understand the nature of professional values, remain loyal to their profession, direct their clinical nursing practice activities in a spontaneous, active, and non-coercive manner, have their beliefs and value pursuits about the nursing profession ingrained in their hearts, take technical excellence and emotional firmness as the criteria for professional interpretation, and are able to infect others through their behaviours and attitudes in line with their professional values; this process is the key to the initial formation of a professional value system.

Education framework

Education framework includes four components, namely education objectives, education process and content, environment and conditions, and evaluation, as shown in the Table 3.

Table 3 Education framework of professional values for undergraduate nursing students

Discussion

The education framework is grounded in the theory of professional values growth for undergraduate nursing students and constructivist learning theory. The four stages, which comprise the key aspect of the theory, articulate the core development events and structure them in professional values education, fully demonstrating how the structured education framework is a process to achieve the growth and internalisation of professional values. Recent studies also argue that the current nursing education should clarify at which stage of development learning styles and professional values are developed [22]. The education framework under development integrates professional education and professional values cultivation throughout the undergraduate nursing program in an organic and seamless manner.. The four components of the education framework are permeably integrated with the existing education model for undergraduate nursing students. The content takes complete account of student-centred teaching and learning activities, uses available resources to mobilise students' independent participation, it also embeds cumulative, reflective, and collaborative learning among peers in the education framework to develop professional values. Therefore, based on the characteristics of the professional values growth theory for undergraduate nursing students, this study integrates professional values cultivation with undergraduate nursing education in an embedded way and adopts multiple perspectives to evaluate the cultivation effects comprehensively.

The nursing professional values growth theory for undergraduate nursing students is the basis for the formation of this education framework, which centres on key aspects and consists of four phases. In the initial stage, professional values growth is to develop attitudes and beliefs that honour life and are influenced by the subtle influence of family virtue education. Ingrid Snellman et al. [28] suggest that nursing's values are grounded in the principle of human worth and the power to experience a meaningful life, which emphasises the equality of human worth and respect for human rights, which is a reflection of the nursing professional values that identify with the equal right to life. In the consciousness stage, the formation of a sense of professional community is critical to the growth of professional values in nursing. For the power of role models, Bandura's [29] social learning theory points out that individuals need to learn through observation and imitate the exemplary behaviours and activities of role models to complete the process of individual social learning. The growth of professional values itself is the process of professional socialisation, which cannot be separated from social learning, and following role models and imitating them becomes the way to grow their professional values [30]. In addition, a study by Aimei Mao et al. [31] pointed out that nurses' professional identity is influenced by personal and professional values. In the core stage, in the process of growing professional values, people will actively or passively find out that there are contradictions in their understanding of the profession and find out how they can act by their professional values amid the contradictions, gradually clarifying their understanding of personal and professional values and clarifying what attitudes and behaviours are right and wrong in their professional values, what can be imitated, and what can be resolutely resisted, to achieve the internalisation of their professional values during their clarification process [32]. In the last action stage, the individual's professional values have the basic formation conditions; combined with other research on professional values [33], it can be found that the individual's interpretation of professional values ultimately needs to be embodied in the professional action. The formation of professional values needs to come from personal reflection and the support of the external environment. In the education process, students need to be aware of their personal and professional values and focus on their expressions of relevant behaviours, such as empathy and fraternity. Students engage in active or instructor-led reflection during ongoing values infusion education, identify the gap between themselves and practitioners in terms of professional values, and gradually grow and narrow the gap through continuous learning to develop mature professional values. A study suggests that the process of growing one's professional values is a journey of self-discovery and argues that what is "learned" does not influence what students "become" and "be" in the future [34]. At the same time, education also needs to provide space and opportunities for reflection, providing a supportive environment for instructors and peers to exchange and discuss. There are numerous strategic approaches to providing reflective teaching and learning, and a research demonstrates that film teaching can better help learners to enter professional contexts and also provide interventions and methods for their reflection [35].

In the current healthcare environment, the nursing profession often exists in a marginal or subordinate role, and active engagement in healthcare and demonstrating professional values are often weak [36]. It is more important for students to strengthen the development of professional values during education to deal with the threat of neglected professional values and the dilemma of ethical practice [37]. The development of professional values in the current research has usually been based on an unstructured hidden curriculum as a teaching model, but the hidden curriculum is defined as an informal course with no clear objectives and faces the problem that it is difficult to evaluate and give feedback on the effectiveness of the teaching in its unstructured framework. Therefore, a formal emotional education framework should be established to develop professional values and integrate them into the undergraduate nursing curriculum in an embedded manner [38]. In-class needs to be combined with the characteristics of the various types of nursing courses to develop professional values in a focused manner. Out-of-class is combined with the implicit curriculum and is not restricted by the materials. It is based on carrying out various types of thematic activities, with the students being the centre and participating actively, giving full play to their subjective initiative. In this study, the education framework is closely integrated with the professional nursing curriculum and the teaching design based on the objectives of the professional curriculum is combined with the professional values development objectives so that the professional values development will have a significant effect on the formation and internalisation of students' professional values.

Conclusion

This study was a structured and systematic education framework for cultivating professional values among undergraduate nursing students based on preliminary systematic theoretical research. The education framework formed in this study has a solid academic foundation, and the content design takes account of student-centred teaching activities and makes use of available resources to mobilise students' independent participation, and adopts a multi-faceted perspective to comprehensively evaluate the development effects, ultimately forming a professional values education framework for undergraduate nursing students with structural and practical significance, providing educational strategies and methods for internalisation of professional values for nursing students, and enriching the values development strategies in undergraduate nursing education. However, the study has not yet been validated, and our research group will explore the feasibility and practicality of this educational framework through experimental studies in the future.