Comparison of professional values between nursing students in Taiwan and China

Abstract

Background:

People in both Taiwan and China originally descended from the Han Chinese, but the societies have been separated for approximately 38 years. Due to different political systems, variations exist in healthcare and nursing education systems in Taiwan and China.

Objective:

The purpose of this study was to examine the professional values of nursing students in Taiwan and China.

Design:

A cross-sectional design was applied in this study. The Nursing Professional Value Scale–Revised was used to measure the professional values of the students. The questionnaire was distributed to eligible undergraduate students in a classroom setting.

Ethical considerations:

This study was approved by the Institutional Review Board at the first investigator’s university. Participants were informed that completion and return of the questionnaire was voluntary, and confidentiality was ensured by keeping the responses anonymous.

Participants:

A convenience sample included 292 Taiwanese students and 654 Chinese students.

Findings:

A total of 11 individual Nursing Professional Value Scale–Revised items showed significant differences between the two groups. These results reflect the differences in the perceived importance of these items between the groups. There was no significant difference between the two groups in the mean overall scores for the Nursing Professional Value Scale–Revised (p = .766) and three subscales (all p > .05).

Conclusion:

There are some differences in professional values between nursing students in Taiwan and China. Given the increasingly frequent and close interactions between Taiwan and China and the globalization of nursing, understanding these differences may help nursing educators identify students’ perceptions of their professional values and support the development of strategies to improve weaknesses in professional values.

Keywords

China nursing student professional values Taiwan

Introduction

While the people of Taiwan and China largely share the same ethnic origin of the Han Chinese, they have been ruled under different political regimes with no cross-strait exchange since the founding of the People’s Republic of China in 1949.^1,2 Along with the opening policy of the Chinese mainland, professional exchange activities between China and Taiwan began in 1987. Modern Chinese nursing education started in 1920 at Peking Union Medical College (funded by the Rockefeller foundation) initially as a 5-year nursing program, but was revised in 1952.^1
–3 The Taiwanese nursing practice and education system were established and developed by mainland nursing educators who immigrated to Taiwan after 1949 and merged with Japan’s medical system under colonial rule.^3,4 Different types of political systems (democracy vs communism) caused variations in their healthcare and nursing education systems. Due to the 38 years of separation and the destruction by the Cultural Revolution of mainland China from 1966 to 1976, the younger Chinese generation lost educational opportunities. So, China began extensive recruitment of nursing undergraduates in 1985.⁵ Furthermore, this generation’s intellectual capacity and its moral and ethical systems were underdeveloped.^6,7 Snellman and Gedden⁸ state that all values emerge from individuals’ perceptions and experiences. Some practitioners believe that universal values can be established for nursing, such as Alfred et al.⁹ who state that professional nursing values direct our practice, but our values are culturally grounded.

The values of nursing are influenced by cultural change, globalization, and progress in technology and medicine.¹⁰ Ethical values in healthcare and the nursing profession demonstrate cultural differences in both developed and developing countries.^11,12 Therefore, there should be some moral and ethical differences between nursing students in Taiwan and China.

Since 1987, when the government of Taiwan allowed its citizens to go to China, the interaction between the two locations became more frequent. Members of nursing-related associations and institutes visited each other, and academic conferences held in the two countries facilitated further communication and globalization. Since 2007, many nursing education schools have recruited students from China. In nursing, several hospitals have established branches in China so that their hospital nurses can travel abroad and rotate to work at branches in China. Although nurses’ professional values are in accordance with the codes of the International Council of Nursing (ICN) in two sites,^13,14 it is unknown whether there is still a gap in professional values between China and Taiwan.

A study conducted by Alfred et al.⁹ found that nurses’ professional morals, ethics, and values are influenced by the cultures in which they live, learn, and practice. These values influence the profession to successfully integrate nurses and nursing students who travel abroad for education and employment. Barry and Ghebrehiwet¹⁵ stated that globalization can accelerate cultural development and discussed whether the development of a “universal” code of ethics for nursing is possible. Cross-cultural analysis has shown that cultural values play a substantial role in determining healthcare professionals’ moral experience.¹⁶ The need for a deeper understanding of culturally associated differences in approaches to the practice of these values was suggested by Alfred et al.⁹

Several studies have compared professional values among different cultures. Rassin¹⁷ compared the values of Israeli and Soviet-born students. Pang et al.¹⁶ conducted a study using the Role Responsibility Questionnaire to compare Chinese, American, and Japanese nurses’ perceptions. Alfred et al.⁹ used the Nursing Professional Value Scale–Revised (NPVS-R) to compare nursing students in Taiwan and the United States. Due to the increasingly frequent interactions between nurses and nursing students in Taiwan and China and to effectually work together in the universal world, it is necessary to understand the professional values held by nurses in these two areas; yet, studies about this topic are rare. Ethical thinking and professional values are essential concepts that are taught in undergraduate nursing programs in both Taiwan and China. The purpose of this study was to compare the professional values held by nursing students in Taiwan and China.

Methods

Participants and procedures

A cross-sectional and comparison design was used for this study. The study was approved by the Institutional Review Board of the first author’s school. Since Wǔhàn city is two to three times larger than Kaohsiung city, there were more participants from the Wǔhàn city. A convenience sample of 946 nursing students (292 from a university in southern Taiwan and 645 from three universities in Wǔhàn, China) was surveyed using the NPVS-R.

All the baccalaureate nursing education programs in Taiwan and China are 4-year program. The sophomore and junior students recruited for this study were studying in the nursing department and were willing to participate in this study. The researchers distributed questionnaires in the classroom. The purpose and context of the study were clarified to students, and it was emphasized that participation in the study was voluntary. The written and oral information distributed prior to the data collection clearly specified that participation was voluntary and that anonymity was guaranteed. If students did not want to participate, they could return a blank questionnaire. Sufficient time (15 min) was given to the students to answer.

Instrument

This study used the Chinese version of the NPVS-R, which was translated by Lin and Wang¹⁸ from Weis and Schank¹⁹ based on the American Nurses Association’s (ANA)²⁰ code of ethics with interpretive statements developed and revised in 2009.²¹ The Chinese version of the NPVS-R is composed of 26 items representing three subscales: professionalism (items 1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16), caring (items 17, 20, 21, 22, 23, 24, 25), and activism (items 4, 5, 13, 18, 19, 26).¹⁸ These factors were conceptualized by Weis and Schank as essential professional nursing values and were confirmed to fit the Taiwanese culture (which is also a Chinese descendant). The Professionalism subscale reflected the promotion of nursing competence, self-evaluation and reflection, and seeking professional growth. The Caring subscale reflected respect for clients and protection and safeguarding of clients’ rights. The Activism subscale reflected participation in professional activities and the resolution of professional problems. Nurses specified the importance of each item on a 5-point Likert scale ranging from 1 = not important to 5 = most important. The possible range of scores was between 26 and 130. Higher scores indicated stronger professional values. The subscale scores were divided by the number of items. Previous studies demonstrated good validity and reliability.^9,18,22 The internal consistency reliabilities of the overall scale Cronbach’s alpha were .91, and .92, .88, and .79 for the subscales, respectively (detail in Table 3); this indicated the scale had an overall high reliability in this study.²³

Demographic data included age, gender, and grade.

Statistical analysis

Statistical analysis was performed using SPSS version 20.0. Values were expressed as frequency, percentage, mean, and standard deviation (SD). Each NPVS-R item was treated as ordinal-level data on which we used nonparametric statistics. The Mann–Whitney U test was used to examine the difference in each item’s mean (SD) by group. The results of the Kolmogorov–Smirnov test showed that the sum of the NPVS-R and the subscale scores violated a statistically normal distribution (all p < .01). Statistical comparisons of data between the two groups were measured by a Mann–Whitney U test. All tests were two-tailed with significance defined by p < .05.

Results

Demographic data

Table 1 shows that there were 946 participants, 292 (30.9%) in Taiwan and 654 (69.1%) in China. The majority of the participants in both groups were female (84.2% vs 86.5%, respectively). The ages of the participants ranged from 19 to 26 years (mean = 21.0, SD = 1.5, median = 21) in the Taiwanese group and 18 to 27 years (mean = 21.3, SD = 1.4, median = 21) in the Chinese group. The majority of students in the study were sophomores (63.7% vs 60.9%, respectively).

Table 1.

Summary of demographic data (N = 946).

	Taiwan (n = 292)	China (n = 654)
Items	n (%)	n (%)
Age (years)	Range, M (SD), median 19–26, 21.0 (1.5), 21	Range, M (SD), median 17–27, 21.1 (1.4), 21
Gender
Female	246 (84.2)	566 (86.5)
Male	46 (15.8)	88 (13.5)
Grade
Sophomore	186 (63.7)	398 (60.9)
Junior	106 (36.3)	256 (39.1)

M: mean; SD: standard deviation.

Differences between nursing students’ professional values in Taiwan and China

The top five highest scored items were similar in both groups and included “item 21—safeguard patient’s right to privacy,” “item 25—maintain confidentiality of patient,” “item 24—practice guided by principles of fidelity and respect for person,” “item 14—accept responsibility and accountability for own practice,” and “item 9—seek additional education to update knowledge and skills.” Among these highest scored items, 21, 24, and 25 revealed statistically significant differences between the two groups. Nursing students in Taiwan had a higher mean score than nursing students in China, indicating that Taiwanese nursing students accepted the responsibility and accountability for their practice higher than China nursing students. The last three lowest scored items were also similar in both groups and included “item 4—participate in public policy decisions affecting distribution of resources,” “item 18—act as a patient advocate,” and “item 5—participate in peer review,” at both sites.

A summary of the NPVS-R items and mean scores is presented in Table 2 and shows that 11 of the individual NPVS-R items were significantly different between the two groups, reflecting differences in perceived importance. These items included the following: item 1 (engage in on-going self-evaluation) (p < .01), item 3 (protect health and safety of the public) (p < .05), item 4 (participate in public policy decisions affecting the distribution of resources) (p < .01), item 6 (establish standards as a guide for nursing practice) (p < .01), item 8 (initiate actions to improve practice environment) (p < .001), item 12 (promote equitable access to nursing and healthcare) (p < .05), item 18 (act as a patient advocate) (p < .05), item 19 (participate in nursing research and/or implement research findings appropriate to practice) (p < .001), item 21 (safeguard patient’s right to privacy) (p < .001), item 24 (practice guided by principles of fidelity and respect for person) (p < .05), and item 25 (maintain patient confidentiality) (p < .01). Six items (3, 4, 6, 8, 12, 19) revealed nursing students in China rated higher mean scores than nursing students in Taiwan, but the other five items (1, 18, 21, 24, 25) revealed nursing students in Taiwan rated higher mean scores than nursing students in China.

Table 2.

Comparison of NPVS-R between nursing students in Taiwan and China (N = 946).

Item	Taiwan		China		p-value
Item	Rank	M (SD)	Rank	M (SD)	p-value
1. Engage in on-going self-evaluation	19	3.64 (0.8)	23	3.44 (1.0)	.007
2. Request consultation/collaboration when unable to meet patient needs	6	4.08 (0.8)	14	3.92 (0.9)	.057
3. Protect health and safety of the public	14	3.83 (0.9)	11	3.94 (1.0)	.032
4. Participate in public policy decisions affecting distribution of resources	26	3.21 (0.8)	25	3.38 (1.1)	.008
5. Participate in peer review	23	3.55 (1.0)	24	3.39 (1.2)	.054
6. Establish standards as a guide for nursing practice	16	3.77 (0.9)	13	3.93 (1.0)	.005
7. Promote and maintain standards where planned learning activities for students take place	20	3.64 (0.9)	19	3.73 (1.0)	.089
8. Initiate actions to improve environments of practice	15	3.82 (0.8)	9	3.97 (0.9)	.005
9. Seek additional education to update knowledge and skills	5	4.10 (0.9)	4	4.11 (0.9)	.586
10. Advance the profession through active involvement in health-related activities	10	3.93 (0.9)	12	3.93 (0.9)	.902
11. Recognize role of professional nursing associations in shaping healthcare policy	18	3.66 (0.9)	21	3.69 (1.0)	.589
12. Promote equal access to nursing and healthcare	17	3.67 (0.9)	18	3.78 (1.0)	.049
13. Assume responsibility for meeting health needs of a culturally diverse population	24	3.48 (0.9)	21	3.59 (1.1)	.088
14. Accept responsibility and accountability for own practice	4	4.24 (0.9)	3	4.22 (0.9)	.094
15. Maintain competency in area of practice	7	4.08 (0.9)	6	4.02 (0.9)	.465
16. Protect moral and legal rights of patients	8	4.04 (0.9)	7	3.98 (1.0)	.485
17. Refuse to participate in care if in ethical opposition to own professional values	11	3.93 (1.0)	8	3.98 (1.1)	.301
18. Act as a patient advocate	25	3.40 (1.1)	26	3.24 (1.1)	.032
19. Participate in nursing research and/or implement research findings appropriately to practice	21	3.63 (0.9)	16	3.87 (0.9)	.000
20. Provide care without prejudice to patients of varying lifestyles	9	4.02 (0.9)	9	3.97 (1.0)	.702
21. Safeguard patient’s right to privacy	1	4.50 (0.8)	1	4.27 (0.9)	.000
22. Confront practitioners with questionable or inappropriate practices	12	3.89 (0.9)	17	3.86 (0.9)	.843
23. Protect rights of participants in research	13	3.87 (0.9)	15	3.90 (0.9)	.525
24. Practice guided by principles of fidelity and respect for person	3	4.25 (0.8)	4	4.11 (0.9)	.021
25. Maintain patient confidentiality	2	4.47 (0.8)	1	4.27 (0.9)	.001
26. Participate in activities of professional nursing associations	22	3.62 (0.9)	20	3.70 (1.0)	.165

M: mean; SD: standard deviation; NPVS-R: nursing professional value scale–revised.

Scoring: Likert-type scale from 1 = not important to 5 = most important.

The mean of the subscales (subscale score divided by number of items) showed the highest subscale was Caring (4.12 vs 4.05) and the lowest subscale was Professionalism (3.47 vs 3.53) in both groups. The Mann–Whitney U test revealed no significant differences between the two groups for the mean total scores on the NPVS-R (p = .766) and the three-subscale comparisons (p > .05) (shown in Table 3).

Table 3.

Comparison of NPVS-R subscale between nursing students in Taiwan and China (N = 946).

Items	Cronbach’s alpha	Taiwan	China	Z	p-value
Items	Cronbach’s alpha	M (SD)	M (SD)	Z	p-value
Overall scale	.91	99.10 (15.6)	100.47 (16.6)	−0.30	.766
Professionalism/13	.92	3.47 (0.7)	3.53 (0.7)	−1.09	.276
Caring/7	.88	4.12 (0.6)	4.05 (0.7)	−1.24	.215
Activism/6	.79	3.87 (0.6)	3.90 (0.7)	−0.73	.463

NPVS-R: nursing professional value scale–revised; M: mean; SD: standard deviation.

Tested by Mann–Whitney U test.

Discussion

The study results show that nursing students rated the same professional values with the highest scores, such as safeguarding patients’ right to privacy and maintaining the confidentiality of patients. These two items are included in the Caring subscale. These results are consistent with the results of Lin et al.,²² who found that nursing students in both Taiwan and China maintain a “patient-centered” focus in their work. Patient safety was a major issue in current nursing practice, and emphasized in nursing education. These results support the finding from LeDuc and Kotzer,²⁴ which focused on the importance of values related to patient care quality issues.

The results of this study also demonstrate similarity in the lowest scored items, which included participating in public policy decisions affecting the distribution of resources and acting as a patient advocate in both groups. These two items are included in the Activism subscale. These results are consistent with the results from Lin et al.²² and represent the lowest values on the Activism subscale. These results reveal that nursing students perceive a lack of influence in public policy decisions and as patient advocates. Wadensten et al.²⁵ compared Swedish and Chinese nurses’ ethical concerns and found that nurses facing a demanding workload still do their best, even if they perceive themselves as powerless and unable to influence medical decisions. This literature suggests that nurses perceive a lack of respect and inter-professional communication. Despite being a majority of the workforce in the healthcare system, they have a low social standing in the medical system hierarchy.²⁵

A total of 11 individual NPVS-R items showed significant differences between the two groups in this study. The mean score of six items (related to public, environment, standard guide, and promote equitable access issues) for the Chinese nursing students was higher than the mean score for the nursing students from Taiwan. Bullington²⁶ stated that students from China have experienced aggressive competition and are more resistant to everyday stress than Taiwanese students, and their attitude toward learning is often more serious than Taiwanese students. Chinese students will work to figure out something that they do not understand. Taiwanese students who follow the status quo will not improve their learning. Nursing students born between 1982 and 2000 are categorized as the Millennial Generation by Stokowski.²⁷ Characteristics of this generation include confidence, impatience, and a sociable nature. The mean score of the other five items (related to self-evaluation, protect patients’ right, and respect patients issues) for the Taiwanese nursing students was higher than the mean score for the nursing students from China. These differences may be related to Taiwan being a democratic country that protects human rights potentially more so than China. Nursing students in Taiwan seem more likely to attribute this characteristic to their democratic political system. The Yeh et al.²⁸ study found that Taiwanese nursing students experienced some ethical issues in clinical practice, such as frustration with an inability to help patients and domination by others subsequent from a low position and powerlessness. Taiwanese students cannot use justifications to conceal the ways in which they are less effective than Chinese students because Taiwan is a democratic country and should have more adequate resources than China to search for information.²⁶ China’s educational, moral, and ethical systems were destroyed by the Cultural Revolution of the mainland, but the participants in this study were part of China’s new youth generation, who were born and grew up after the Cultural Revolution. Thus, they should be educationally well prepared for nursing.

There are some limitations to this study. First, we recruited participants from one university in southern Taiwan and three universities in China, which may limit the ability to generalize these findings. Second, due to the cross-sectional research design, we cannot explain the difference in the development of professional values among nursing students in both groups. Third, some variables, such as religion and ethnic origin, may influence the formation of professional values but are not explored in terms of their association with nurses’ professional values in this study.

Conclusion and recommendations

This study showed that although China and Taiwan have been separated for 38 years and ruled by different political systems, the key nursing professional values (top five items) held by nursing students are similar. However, there are some differences in professional values between nursing students in Taiwan and China. Given the increasingly frequent and close interactions between Taiwan and China and the globalization of nursing, understanding these differences may help nursing educators identify students’ perceptions of their professional values and support the development of strategies to improve on weaknesses in the professional values of nursing students.

Our results are from a young cohort recruited from China and Taiwan. Future studies may involve diverse age generations and extend the sampling to registered nurses from multiple sites in both countries. Furthermore, future study is needed to explore the factors (e.g. ethnic origin and religion) that influence nurses’ professional values.

Footnotes

Acknowledgments

The authors thank the nursing students who participated for their contributions.

Conflict of interest

The authors declare no conflict of interest.

Funding

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

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