Abstract
Aim
The aim is to understand current research into the impact of undergraduate nursing education on the development of professional values.
Background
Values are evident in the professional standards for nurses and the guidelines and healthcare policies of many countries. These professional values guide decisions and behaviour and are recognised as an essential component in the professions ability to provide safe and professional care. This literature review presents the current research on the impact of education on professional values in undergraduate nurse education.
Design
An integrative review of the findings was conducted to provide insight into the current research on the professional value development in undergraduate nurses.
Data sources
CINAHL, PubMed and Scopus.
Review methods
A literature search was undertaken within defined date parameters 2010–2021 using a systematic approach. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guide PRISMA was used to guide and illustrate the process. Papers were assessed for quality using the Mixed Methods Appraisal Tool.
Results
Two distinct areas of inquiry were identified. (a) Changes in professional values as an outcome of undergraduate nursing education or (b) changes in professional values as an outcome of specifically designed educational content. These areas were further explored to better understand the influences of undergraduate education on students’ professional values.
Conclusion
There is a lack of evidence in the literature to support the premise that professional values develop in line with academic year progression; however, there is strong evidence to support the inclusion of explicit learning in undergraduate education that engages students in education specifically designed to explore and develop professional values.
Introduction
Nursing is a profession deeply rooted in values. Values articulate the purpose and requirements of the profession by describing the expected attitudes and behaviours of nurses and conceptualising them as professional values. Research tells us that these professional values support quality care by guiding the actions of care givers. 1 The importance of values is increasingly recognised as a lynch pin in the profession’s ability to provide safe and professional care.2,3 There is also evidence that a crucial aspect of the development of professional role identity is the internalisation of professional values during undergraduate nursing education. 4 It is during these formative years of student nurse education that formation of the professional identity occurs 5 and students begin, what is referred to in some research, as their ‘values journey’. 6 This journey begins at commencement of in first year when the reality of healthcare is first experienced and continues as they learn and grow in their professional education. This literature review was undertaken to advance our understanding of the current research into the development of professional value development that occurs as an outcome of undergraduate nurse education.
Background
Competencies in ethical behaviour and expectations of professional practice are linked to development and internalisation of professional values. 7 In Australia these professional values align with the legislative requirements of the Nursing and Midwifery Board of Australia (NMBA) ‘Registered nurse standards for practice’ 8 which inform and regulate professional behaviours of all registered nurses. They were developed using the International Council of Nurses Code of Ethics as guiding documents to align Australian with international nursing standards. 9 The literature demonstrates an exponential increase in research internationally that seeks to explore the values of undergraduate (UG) nurses. In the United Kingdom (UK) and Australia, the Francis 10 and Garling 11 reports into the state of healthcare demonstrated the consequences of practices that did not align to professional values. This gave rise to re-evaluation of the role of nursing in the provision of safe healthcare. Attention also turned to the way in which the values of the profession are developed in student nurses and the influence of UG education.
It is accepted that professional values should be taught as part of nursing education12,13 and pedagogically nursing education is designed to provide students with the skills and knowledge to perform in ways that are safe, effective and align with the values of the profession.1,12,14 It is achieved with a combination of theoretical education and clinical experiences, both integral to the acquisition of the knowledge and skills required. Clinical practice is considered crucial to the development of professional values as students learn and internalise behaviours role modelled.7,15,16 While much has been written and observed about the overall impact of clinical experiences on student learning, there is little evidence of the impact this has specifically on the development of professional values. A small amount of research that looks specifically at the impact on professional values through the participation in clinical placements that are specifically chosen for their potential to positively influence this development was identified and is included in this review.17,18 Notwithstanding these examples, the research that dominates this field is that which looks at the impact of UG education overall, combining both theory and practice on the development of professional values.
Also evident in the literature is a large body of exploratory quantitative research that reflects a desire to deepen the professions understanding of the student nurses’ professional values by identifying, measuring and in some instances tracking and comparing them through the years of education. This research uses contexts for these measurements such as age, gender, culture and education; however, for the purpose of this review, only research related to education was considered.
Although it is beholden upon institutions to provide education on values and ethics,4,14 there are no standardised programmes evident in nursing education. There are examples of programmes designed to support this learning, which are often offered as additional or extracurricular programmes.14,19–22 There is also research on the influence that curricular or theoretical design exerts on professional value outcomes.23,24 Evaluation of such programmes is evident in the literature, exploring the learning from the perspective of the participant and determining the effectiveness of these programmes.
Nursing education broadly is designed to achieve theoretical learning and skill competency, areas that are consistently measurable and formally assessable. The desire to measure and assess professional values is reflected in much of the quantitative research evident in the literature. The most commonly used quantitative research tool used to measure values is the Nurses Professional Values Scale (NPVS) 25 and its later iterations, Nurses Professional Values Scale-Revised (NPVS-R) 26 and Nurses Professional Values Scale-3 (NPVS-3) 27 which were developed to align with the ANA Code of Ethics. 28 The codes were interpreted in terms of a value statement and were ranked from most to least important, providing a measurement that was described as a ‘value orientation’. 29 The language around values ‘increasing or decreasing’ or being ‘higher of lower’ is evident throughout the literature and describes movements in scores when using these tools. This terminology will therefore also be used in this review.
Aims of the literature review
The aim of this review is to examine recent research to determine the profession’s current understanding of professional value development in UG nursing education. It reviews research into the overall impact of nursing education as well as the influence of programmes specifically designed to support professional values development by addressing the following questions: (1 )How is professional value development evident when considering years of education and various types of educational levels and courses? (2 )What is the impact of education, which is specifically designed to support professional value development, on student nurses’ professional values?
Literature search methods
Design
An integrative review was undertaken using the Whittemore and Knafl framework 30 which was chosen as it allows for analyses of a diverse range of data. Searches were carried out in Cinahl, Pubmed and Scopus using a systematic approach as outlined in Polit and Beck. 31 Boolean phrases were used to perform searches: student nurs* AND professional values AND education AND curriculum.
Search Outcome
The initial search identified 1796 papers that met the search criteria (n = 1796). Duplicates were removed (n = 14). Titles were screened for relevancy (n = 1782) and 1622 were removed (n = 174). These articles were screened by either abstract or full text reading and the reference lists of each article were checked for grey literature yielding a further 20 articles (n = 194). Articles were assessed for eligibility against the inclusion and exclusion criteria by author one initially and any papers that were not immediately conclusive were discussed within the author team. Overall, 168 papers were excluded leaving 26 papers (n = 26). The PRISMA 2020 flow diagram (Figure 1) was developed to illustrate the outcomes of these searches. 32
Quality
Studies included in the review.
Methods
Articles were read several times for familiarisation. Papers were first categorised depending on the design and aim of the research as guided by the integrative review framework, 30 where similar data are grouped to allow for a comparisons and synthesis to take place. Due to the complexity of the data, a matrix was developed that allowed for extracting and coding of data to identify outcomes with commonalities and patterns. Colour coding was used to identify and organise findings in categories or themes. Primary sources were revisited numerous times to ensure accuracy. The categories and themes were developed in consultation with the author team. There were no contested themes or outcomes.
Inclusion criteria
(1) Studies which presented research into professional value development related to nurse education. (2) Publication date 2010–2021. This range captures recent research in line with the aims of the literature review. (3) English language and full text available.
Exclusion criteria
(1) Studies where professional values were only addressed as part of a larger focus such as ethics and did not offer any specific research on professional values. (2) Studies which focussed on one specific value such as caring or compassion. (3) Studies which described and/or evaluated UG nursing values however did not additionally include the impact of education on value development.
Results
The data analysis identified two distinct areas of inquiry representing the two main purposes of the research. The first was research that seeks to identify, measure and compare student nurses’ professional values, often conducted to discern differences related to years of experience, types of programmes and other socio-demographic factors. UG nursing education requires mastery of both theory and practice and research in this area did not make a distinction between these aspects when considering the impact of education. The second purpose was to explore the impact of educational experiences that are specifically designed to influence professional value development for students participating in such programmes. In this area, there was evidence of both specifically designed classroom experiences as well as clinical experiences evident in the literature. These two purposes have been categorised as follows: (a) Changes in professional values as an outcome of undergraduate nursing education and (b) Changes in professional values as an outcome of a specifically designed educational content.
a) Changes in professional values as an outcome of undergraduate nursing education
Research that identified changes to professional values was not conclusive and in some instances contradictory. There was research that demonstrated changes to professional values was either evident either in line with academic year progression or evident however not in line with academic progression. There was also research where there was no change identified. Exploration of each of these findings follows.
Professional values increased relative to students’ academic year progression
Professional value development evidenced as positive increases in student’s perception of their professional values between commencing and graduating students were demonstrated in studies in several countries. Longitudinal studies gave researchers the ability to track changes in professional values. One such study in Taiwan demonstrated students perceived increase in the importance of all listed professional values in 94 nursing students measured at the beginning and end of their education using NPVS-R. 34 Similarly, a Spanish study of 315 students across 4 years found significant correlation with progression in academic years to increasing importance of professional values. 35 Research using the same tool in Israel with 261 students from all years confirmed this, with clear increases noted from junior to senior students. 36 While this research does not include information on educational programmes, it does demonstrate the impact of a shared educational experience and supports the notion of nursing education contributing to professional value development. Similar studies from Turkey demonstrated the increased importance with which students regarded professional values over the course of their nursing education. The first, a comparative cohort study of 59 first year students and 83 students in the same cohort 4 years later, demonstrated a mean score increase of all professional values using quantitative surveys as well as a reprioritising of some values. 37 The second study, also using quantitative methods found progression in most areas when measuring both professional and personal values of 123 students over each of the 4 years of their education. The higher scores represented the higher importance attributed to each value and increases in this study were most notable from second to fourth year, with a dip in second year values. 15 The researchers felt this warranted future investigation and this phenomenon was evident in several other studies as discussed in the following section.
Changes in professional values evident however no increase in line with academic year progression
The apparent ‘dip’ that occurred was evidenced as a decrease in values from first to second year students with a subsequent increase in senior years. Researchers propose this phenomenon is attributable to students’ idealism being lost as they grapple with the realities of the work environment.6,35 Professional values then rise again as students adjusted to the pressures and expectations of their role ,35,38,39 progressed in their confidence and skills and gained the ability to delegate.40,41
Insight into these changes is provided in a longitudinal study published over three papers which explored the values of students who have been part of values-based recruitment (VBR) in the UK.6,40,41 VBR has been adopted to recruit students whose values are congruent with those of the National Health Service (NHS), Constitutional Values. 6 The researchers introduced the idea of a ‘values journey’ and used semi-structured focus groups to explore how the pressures of clinical experience might alter the values of students. They revealed that challenging clinical experiences had resulted in ‘value attrition’ at the end of year one. In year two, while overall values were unchanged, there was evidence of reprioritisation of their values to adapt to the practice environment. Student responses revealed that this was an outcome of their increased experience and confidence, despite the challenges faced in the clinical environment.6,40,41 There was also evidence of increasing understanding of professional values with senior student nurses demonstrating a more sophisticated conceptual grasp of professional values relevance, illustrating value development being more than an appreciation of a particular aspect of values. 7 It is worth noting that this research is unique as development of professional values based solely on clinical experiences was not widely evident in this review of the literature.
Anomalies were apparent in some research that recorded increased importance of the justice and acitivism category for second year student nurses when measured using NPVS-R.
26
An increase in the justice category was also noted by Fisher
4
who compared 351 junior and senior students in three levels of education, associate degree, diploma and Bachelor of Science in nursing programmes. The researchers hypothesised that professional values would increase in line with Benner’s ‘Novice to Expert’ model
5
Professional values did not change in relation to academic year progression
While the impact of nursing education was able to be demonstrated in some research, in others, no changes were identified. Research conducted using NPVS-R 26 was unable to determine increasing values when comparing junior and senior students across a number of studies.2,4,16,38,43 Research conducted in South Korea, Turkey, Israel and Iran demonstrated strong professional values across all years as well as statistically significant differences based on demographic variables such as gender and whether nursing was their preferred choice of profession, with no changes related to years of education.2,16,36,38 The inconsistency in findings is demonstrated in Turkey where the research by Donmez 2 did not demonstrate differences in professional values whilst Kantek et al. 37 and Kaya et al. 15 revealed increases in line with years of education. This was particularly interesting considering the research was conducted within the same time period, confounding any attempts to draw conclusions on the impact of nursing education that is reliable and replicable.2,44 Impact on professional values was demonstrated in line with personal values in qualitative research by McSherry et al. 44 in the USA using focus groups and also in line with socialisation in Egypt 39 using ‘Ochsner’s Inventory of Professional Values’. 45 Outcomes in both studies noted consistency between students personal and professional socialisation; however, there was no identifiable change in professional values in line with education that would support the theory that values increased with time and experience in the degree.39,44
b) Changes in professional values as an outcome of specifically designed educational content
Research in this category demonstrated similarities around the way in which programmes were designed and the teaching and learning processes used, identifying three key themes: the use of reflection, the use of stimulus and engagement in service learning. Despite consensus that educational resources related to value development be purposefully embedded in nursing education,12,14 there is little commonality in how this is achieved. Programmes are built into the curriculum or extracurricular, compulsory or voluntarily, online or face to face or as a service learning clinical experience. Despite the wide variations, there were some common concepts identified. The first commonality was that a stimulus or challenging environment or scenario was provided to encourage deep thinking and engagement with the educational experience. This was achieved through such things as online programmes, experience sharing, excerpts from novels, engaging in case studies and role playing. The second commonality was that reflection was built into the process. This research is less concerned with measuring values and provides outcomes related to the learning and development from participation in specific programmes. The following descriptions provide an overview of the innovations that are evident in the literature.
Stimulus/engagement
The process of engagement in learning opportunities is highlighted as an important first step in the professional value development programmes. The stimulus provided was often linked to real-life situations where students could imagine themselves exploring their own and other participant reactions and behaviour.
Such processes are demonstrated by Hanson 21 where extracts from a novel were used for an integrated values-based learning activity specific to high acuity nursing. Learners were supported to critically examine written accounts of nursing experiences, immersing them in an acute care setting in a controlled way by exploring the experiences of the writer. Students reported deepening understanding of the complexity of care including considering values they had not previously recognised and felt this would improve their practice. Based on transformative learning principles of Mezirow, 46 integrated values-based learning activities were employed to develop affective domain learning and support the socialisation of students into the nursing role.21,46 Similarly, McAllister et al. 22 incorporated transformative learning principles, using a television period-drama related to nursing as a case study, to captivate students’ attention. Feedback revealed the potential improvements to practice they foresaw from their deep engagement in the material.
Day 19 evaluated the implementation of ‘The Power of Nursing: Embracing the Healers Art’, an elective course used in four Universities which used affective domain learning in small group settings. The stimulus was a ‘seed talk’ where a faculty member shared an experience, allowing students to relate to their teachers in a uniquely personal way, an engaging activity that students felt contributed positively to their professional development. Lynch et al. 14 reported findings of a pilot study using an action-oriented approach based on the theories in ‘Giving Voice to Values’ (GVV) 47 which aimed to empower students to identify and articulate their values and act on them. Stimulus was a purposeful and often scripted role play which provided opportunities to explore and rehearse actions and conversations that may occur in challenging healthcare situations, allowing them to act in alignment with professional values in a safe environment before using the techniques in real life. 14
The use of stimulus through specifically designed online programmes was evident in two studies. The Values Exchange (VX) web-based programme in New Zealand nursing degree programme 20 provided provocative or challenging online scenarios. Students were asked to explore and examine their own values and engage with other people’s points of views, challenging their own ideas and developing the ability to discuss differences with tolerance and acceptance. In feedback, students reported an increased awareness of the impact of their values on the decisions they make in health care. Knecht et al. 48 used an online ethics programme aligned to the American Nurses Association Code of Ethics for 119 students completing an online Bachelor of Science in Nursing to registered nurse conversion programme. Results using pre-post NPVS-R26 demonstrated a measurable increase in overall values for students who had completed the ethics programme prior to the first pre-test compared to those who had not and found a demonstrable increase in professional values as an outcome of the programme, greater than that of the entire course.
Reflection/support
The importance of including reflection to consolidate learning was consistently evident in the qualitative research. It was used as a tool for exploration and deeper understanding with the provided stimulus, often as part of a supported or guided approach. In ‘The Power of Nursing: Embracing the Healers Art’, trained facilitators, using transformational learning processes, enabled reflections to promote new understanding and new knowledge. 19 Similarly, in the GVV programme 47 role play of difficult situations was followed by facilitated reflections in both small and large groups and enabled self-assessment and reflection on values. 14
The way in which reflection activities were implemented varied; however, the intent was always to explore meaning and embed learning that was personal and relevant to the individual. Haugland et al. 23 used written reflections of final year students to evaluate a suite of programmes designed to support the Universities Christian values. Evidence of integration of personal values and professional formation was clearly demonstrated and supported the use of various educational process that included a strong emphasis on facilitated reflection. It was evident that reflection allowed students to explore their own values and make discoveries that would impact care decisions into the future. 23
In the year two, finding of the study by Callwood 40 students themselves identified the importance of reflection in their value development. The researchers draw on the alignment with Mezirow 46 as the student embarks on self-discovery through critical reflection to self-correct and transform their understanding and behaviour, recommending the inclusion of supported reflective spaces in healthcare education programmes. 40 In other studies, transformational learning principles were central to guiding structured reflective discussions with academic staff 22 and developing questions to support critical reflection on both personal and professional values. 21 In these studies, reflection was purposefully employed to gain insights into students own experiences, deepen their understanding of complex situations and consolidate professional identity.
In combination with guided reflections, individual reflections were also supported as being an important aspect of professional value development in nursing education. Owen et al. 24 used reflection to demonstrate insights that can be achieved where a strong emphasis on values is integrated into every aspect of a curriculum. Using excerpts of a student reflection, the internalisation of professional values was evident in development of a deepening understanding of person-centred care.
Service learning
The only interventions that did not demonstrate an impact on professional development were those connected to service learning (SL). It is noted that the purpose of SL is not specifically to increase professional values; however, two research projects included in this review were designed to track changes resulting from these unique clinical experiences. Research by Fowler 18 used NPVS-R in randomised control which included reflective activities. Findings demonstrated a slight increase in value development of the control group although they hypothesise this may be related to the non-clinical nature of the SL placement. Ferrillo 17 found no difference in values using a pre-post NPVS-R, 26 in either a SL or a traditional clinical placement. They hypothesised the impact of SL would increase in line with Kolb’s 1984 model of experiential learning; however, this was not demonstrated. Notably, an increase in the caring subscale of both groups supported the importance overall of clinical experience in professional value development. While previous research has supported the use of SL as a valuable tool for professional development there is, thus far, no evidence to support direct impact on professional value development.
Discussion
The current research suggests that simply participating in nursing education does not predict professional value development. Values are not demonstrably influenced by the level of education attained, although research identifies the importance of educational components being specifically designed to transition the individual through the process of adopting and internalising professional nursing values.7,14,22,40,41 Current research which evaluates educational programmes is overwhelmingly positive although there is no consistency that allows the profession to assess the effectiveness of the interventions that were identified in this review of the literature. Indeed, in the context of many other aspects of nursing education, there is little evidence overall that measures the effectiveness of educational methods that support values development. 48
Opportunities to engage in learning with values embedded is an important aspect of nursing education2,14,22
Despite variations in educational processes there was an alignment with Mezirow’s transformational learning theory evidenced in much of the research emphasising the combination of thought, creativity, psychology and reflexivity to create new learning and insights. 46 It is evident in the consistent inclusion of stimulus and engagement to challenge students to think critically, combined with reflection and self-discovery to create new understanding. Educational processes that included reflection were evident as recommendations in the literature 42 and manifest in programmes as both embedded written activities14,21,23 and formally organised, face to face or group processes.6,40,41
Research further supported the development of reflective skills which were guided and supported.14,24 The literature demonstrates that while individual insights were personal, there needed to be a sense that there was space to think, discuss or practice that was safe and supportive. Furthermore, facilitation of reflection that provided guidance, allowed students to be honest and inquisitive about their beliefs and learning 14 with some research concluding that critical reflection should be a formal process that is embedded in nurse education to support the development of professional values. 41
Professional identity development is evident in the literature. It is the learning of skills alongside the behaviours and attitudes of the profession. As these attributes develop, professional values are adopted and internalised. Benner refers to this process as formation.5,19,23,43 Despite this alignment, Benner’s ‘Novice to Expert’ 5 theory was less readily applied to professional value development.4,7,24,43 It is clear from the literature that the development of professional values does not occur in a straight line. All students commence with a set of personal values, some of which will align with those of the profession so in a sense, there is no novice when it comes to values. There is however evidence of adjustment that occurs throughout the educational experience, when students’ personal values and their theoretical education are challenged in the real world of health care experiences. The finding of notable changes in the values of students that do not align with years of experience has been observed by several researchers.15,34,38,40 There is some consensus that this is due to students commencing with altruistic ideals which are then challenged and students are compelled to adapt. The longitudinal study by Callwood et al.6,40 and Groothuizen 41 is particularly helpful in developing our understanding of this finding. As the students themselves recount, the reprioritising of professional values evolves as a deepening understanding of the meaning of professional values in the context of their increasingly demanding roles. The understanding of values, rather than a change in values, is evident as an increased ability to apply learning to decision making and work prioritisation.6,40,41 It is here that we see the development of values, not in the scores but in students transformational learning, and in their formation as they adopt and internalise the values of the profession.
Throughout the literature the extensive use of quantitative methods to measure or assess values is notable and demonstrates the profession’s desire to quantify students’ professional values, compare and track them. Potential limitations of these results are described by Knecht 48 who speculate that surveys that do not demonstrate an increase or change in students’ professional values may be attributable to the high priority that students gave to values on entering nursing education. Research suggests that students are often drawn to a nursing career as they feel an alignment with their personal values6,14 which creates a reasonable assumption that the desirable professional values will be high on commencement of the education. Tools that ask students to prioritise professional values do not necessarily account for the students deepening understanding or reconceptualising of professional values. This would limit the opportunity for scores to increase across years and potentially account for some results where little or no professional value development was demonstrated. What was broadly lacking in the literature was research that used a mixed methodology to allow understanding of how professional values develop in conjunction with tools to track and measure progress. Another notable absence is research that follows student stories to create narratives about this development as individuals, how they experience this development in the context of their lives and the impact this may have on the care they give.
Professional value development remains an ongoing area of research and investigation. Regardless of the values, a student holds at the commencement of their education, there can be an impact on student’s values simply by participating in education; however, the nature of this development means that it is not a reliably predictable and measurable process. It needs to be supported by educational content that is purposefully designed and delivered in supported and enabling ways to develop behaviour that aligns with nursing professional values. While the research does not provide consensus on the most effective way to do this, essential core elements are identified. These are opportunities for exploration of values, developing awareness of ones’ own values, challenging previously held values and beliefs and supporting new learning with facilitated and guided reflection on new knowledge.
Limitations
There continues to be extensive research into the development of values internationally and the use of professional values as key words excluded potential research that would have included values more broadly; however, this was outside the scope of this review. More detailed investigation into the specific themes that arose from this review is warranted.
Conclusion
This integrative review has enabled understanding of the impact of educational experiences on the development of the professional values for UG nurses over recent years. It demonstrates the importance with which the nursing profession holds the development of professional values in student nurses internationally. Central to this research is the understanding that professional values are an integral part of professional nurse identity and essential to the provision of high-quality care.
The review identifies two dominant areas of research that currently exist. One seeks to identify and track professional values through UG nursing education. The second describes and evaluates programmes specifically designed to facilitate the development of professional values within the educational system. This review demonstrates that the premise that professional values are developed as an outcome of participation in UG nursing education is inconclusive. It does however provide compelling support for the inclusion of specifically designed educational programmes to promote the development of professional values. The use of both qualitative and quantitative research methods provides information on the impact to students from such education as well as the essential aspects that are required to facilitate this development. The inclusion of education, which is specifically designed to support professional value development is supported both in the research. The review supports the inclusion of explicit learning that engages students in a stimulative and supportive way to develop values which are recognised as being essential to the provision of safe and high-quality health care. This learning can be provided through various educational course designs or specific programmes and activities. The findings in this review demonstrate the diversity of thought, innovation and effort that is currently being generated to support the essential development of professional values in UG nursing education. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
