Perception and experience of altruism in graduate nursing students

Introduction

Nursing is regarded as a profession that values compassion and altruism. Flexible approaches that place the needs and best interests of others above personal interests are at the core of the professionalism of nursing. ¹ Therefore, there is a need to raise the status of altruism in nursing values, and it is important to educate nursing professionals about professional values such as altruism throughout the specific curriculum and nursing practice. However, postgraduate nursing education in China started late, the curricula of various nursing schools are not yet well designed, and there is no relevant research that has been conducted on the expanding group of graduate nursing students in China. This study attempts to explore the perceptions and experiences of altruism among nursing graduate students in China.

Background

The French social philosopher Auguste Comte, coined the term altruism. According to Comte, ² altruism means putting the interests of others ahead of one’s own. In the Merriam–Webster dictionary, the word altruism has two interpretations: altruism is an “unselfish regard for or devotion to the welfare of others”; it is “behavior by an animal that is not beneficial to or may be harmful to itself but that benefits others of its species.” ³ Altruists are able to increase their genetic long-term success by reducing the temporal variability in the number of offspring produced by their relatives, driving the evolution of sociality. ⁴ From a biological point of view, although altruism is detrimental to individual organisms, it is beneficial to the continuation of biological species. ⁴ Therefore, altruism is indispensable for both the continuation of species in nature and in the daily interactions of social life.

The main problem facing the evolutionary theory of genetically determined altruistic behavior is that altruists face greater life risks than non-altruists and are therefore more likely to be eliminated by natural selection. ⁵ To solve the altruistic dilemma, Darwin later proposed the theory of group selection. This theory explains how group structure supports higher-level natural selection, and how the evolution of groups requires that they be embedded in a variety of relational structures, that is, altruistic behavior is justified only when it is evaluated in the context of group interests. According to Marx, ⁶ man must maximize his interests through reciprocal mechanisms within a network of social relations. Thus, altruistic behavior is divided into three types. The first is kin altruism, which is a kind of sacrifice for relatives without utilitarian purposes, with blood ties as a bond, ⁷ the second is Reciprocal altruism, in which individuals without blood ties provide some kind of help to receive a corresponding reward in the future,^8–10 the third is pure altruism, which is the behavior of an individual creature without blood ties and without seeking any reward. Between patients and nurses, there are few opportunities for kin altruism, but more for reciprocal altruism and pure altruism. ¹¹

American Association of Colleges of Nursing explains altruism in the nursing profession as the nurse’s concern for the welfare of patients, other nurses, and other health care providers. ¹² Of the more than 60 words or concepts used to describe and define the professional nurse, altruism ranks in the top 10¹. Previous studies found high levels of altruism among nursing students.^13,14 Nurses spontaneously show understanding and care to patients and their families because of pure altruism, without expecting anything in return, reflecting the nature of the nursing profession ¹⁵

A developed graduate nursing education system has been formed in nations including the United States, the United Kingdom, and Australia. Chinese graduate nursing education started late, and the Master of Science degree in Nursing wasn’t established until 2010, which enabled medical universities to quickly establish a curriculum system for nursing graduate education. However, the curricula of the nursing schools are not yet well designed and focus more on cultivating students’ research ability rather than caring character, which is also indispensable in clinical practice. ¹⁶ Due to the various cultural contexts between China and other nations, understanding the current level of altruistic behavior and the perceived experience of altruism among graduate nursing students in China may offer various viewpoints and implications.

Methods

Participants

Purposive sampling was used to recruit participants with varying degree types, grade levels, and demographic characteristics to enrich the diversity of the data.^19,20 Sampling ceased when data saturation (no new information or categories) was reached. A total of 17 nursing students enrolled in a master’s program made up the population of this study, 15 from the School of Nursing, Yangzhou University, 1 from the School of Nursing, Dalian University, and 1 from the School of Nursing, Huzhou University. Table 1 shows the detailed participant demographic characteristics.

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Table 1.

Participant demographic data.

Characteristics	n
Gender
Female	14
Male	3
Age (years)
20–29	12
30–39	5
Grade levels
Year 1	6
Year 2	9
Year 3	2
Marital status
Single	11
Married	6
Number of years employed as nurse (including internship)
<5	12
≥5	5

Results

Four themes emerged from the data: “Definition of altruism,” “Altruism in the nursing profession,” “Altruism applied in practice,” and “Factors influencing altruistic behavior,”

Theme 1

Definition of altruism

According to knowledge accumulation and experience, participants believed that “altruism” has the following characteristics: (1) it aims to help others; (2) it does not expect a return; (3) it is voluntary; and (4) the altruist may have something to lose. Participants described their understanding of altruism:

I think altruism is helping others voluntarily, but without the luxury of material rewards, the first prerequisite being voluntariness (in a very positive tone). (M5)

Theme 2

Altruism in the nursing profession

This theme includes the following categories: the Relevance of Nursing and Altruism, basic altruistic behavior needed in nursing profession, and altruism is not just a professional necessity.

Category 1: The Relevance of Nursing and Altruism

Participants pointed out that the nursing profession is closely related to altruism, as nurses are supposed to practice the professionalism of saving lives and helping the injured through practical actions:

I think it is closely related. As a nurse, there is definitely more altruism than self-interest, because this nursing profession is all about altruistic behavior to help others, and the relationship between nurses and patients is that of fish and water. (M12)

When asked what basic altruistic behaviors need to be practiced in the field of nursing, participants’ responses involved the need for medical staff to protect patients’ dignity and privacy, protect patients’ right to informed consent, put patients’ health first in the nursing process, avoid putting patients’ physical and mental health in jeopardy, and treat every patient equally:

The basic altruistic behavior is that nurses should respect and care for patients, protect patients’ privacy, be patient-centric, use our professional knowledge and experience to promote patients’ recovery, and not harm patients’ life and health. (M13)

Participants said their altruistic behavior is not only due to professional needs but their values and moral qualities should not be ignored:

There are many tasks that are not really part of my professional duties, but I still go the extra mile to help patients whenever I can, and I think that part of that dedication is because of my values. (M16)

Theme 3

Altruism applied in practice

This theme shows the following three categories: what was done, work-family conflict, and volunteerism.

Category 1: Altruistic behavior in the workplace

The participants’ responses became active when they were asked to share their experience in altruistic behaviors during their work or internship. The first thing they talked about was some altruistic behaviors they usually saw other nurses doing, such as humanistic care, protecting patients’ privacy, donating money to poor patients, and participating in epidemic prevention and control during the COVID-19 pandemic. They also said that if they were in the same situation, they would be willing to help the patients as much as they could as other nurses:

I saw that the teachers would draw the curtain to protect the patient’s privacy when doing perineal care, and would pay attention and comfort the patient when he or she was depressed. (M2)

The participants were a bit humble when talking about the altruistic behaviors they had done, saying that they had only helped in small ways and that they would be willing to give more help to others if they had the opportunity in the future. Male participants said they would take on more physical work, and sometimes when female patients refused care from male nurses, female colleagues would be willing to help them to complete some work tasks:

In gynecological department, there are female patients who refuse my care and want female nurses to care for them. This is when my colleagues help me with some of my work and is a demonstration of altruism from them to me. (M12)

When it comes to the choice between family and work, that is, the choice between altruism and self-interest, married and unmarried participants appeared to handle the situation differently. When married participants encountered family emergencies, especially when their children were sick, they chose to explain the situation to the chief nurse and ask other colleagues to continue working in their place; unmarried participants preferred to continue working and wait until the end of the day to deal with the problem unless there was a very critical situation.

If something were to happen to my child, I would request a family leave. My family is important to me, but work is something that my colleagues can help. (M4)

All 17 interviewees had participated in volunteer services, such as community service, health checkups for the elderly in nursing homes, and nucleic acid testing during the COVID-19 period, and expressed their willingness to volunteer again in the future.

During the COVID-19 pandemic, I volunteered within the community, distributing brochures, explaining how to prevent the virus, and calling for people to stay at home and watch their body temperature as much as possible. (M16)

Theme 4

Factors influencing altruistic behavior

This theme consisted of six categories: societal factors, the impact of Education, recipient factors, occupational factors, gains and losses, and personal factors.

Category 1: Societal factors

Participants mentioned the influence of the socio-cultural background and people around them, the power of role models, the support of their schools, and the COVID-19 pandemic as triggers that made them transform their altruistic motives into altruistic behaviors.

However, the news about patients or their relatives hurting medical staff would make them feel uneasy and hesitate to perform their altruistic behaviors:

During the COVID-19 pandemic, I have a deeper understanding of altruism, that suffering can make people more willing to help others because everybody is on the same boat. (M11)

Degree, empathic tendency, political affiliation, and their own experiences and perceptions were all cited as personal factors that influence altruistic behavior. However, notions of hating dirty things that can turn participants off when they encountered situations such as needing to clean up patients’ urine and stool, prevent them from performing altruistic behaviors with patients:

Sometimes when I see patients in the hospital who are the same age as my parents, I may think of my parents which makes me more willing to do altruistic acts. (M1)

Education, whether at home, school, or hospital, influenced the implementation of altruistic behaviors among participants:

Usually, there will be many lectures but we won’t listen carefully … The way of education is boring, and the school should use some ways to educate that is more close to young people. (M16)

Recipients who provide positive feedback or show appreciation would motivate altruistic behaviors:

Receiving positive feedback when I help others makes me more willing to help others next time. (M16)

Participants with less than five years of work experience were very unconfident about their operational abilities, and they believed that they were often not competent enough to help others. In addition, better professional ethics and good doctor-nurse relationships both promoted them to help others:

I think I am not good enough to help the patients, and I might make it worse. (M8)

Participants took into account the potential gains and losses associated with altruistic behavior. When altruistic behavior can bring psychological satisfaction, make the participant a role model, or bring some reward, it will promote their altruistic behavior; when doing altruistic behavior will bring losses instead, they may hesitate to do it:

Nurses work hard every day, and they need to stay up late on night shifts, so if the hospital offers lower pay, it can affect our mindset. (M2)

Discussion

To the best of our knowledge, this is the first study to investigate graduate nursing students’ perceptions and experiences with altruism. Overall, the participants did not have a very clear understanding of altruism, but altruistic behavior was prevalent in their work or lives. At this stage, nurses’ income is low, the public has misconceptions about nurses’ work, and they feel that they are not as altruistic as their predecessors, but from the conversations with them, it is clear that they want to go on in the path of medicine and desire to be recognized and respected.

This study found that all participants were aware of the professional responsibilities of nursing and had compassion and responsibility for their patients. During the COVID-19 pandemic, nurses were the most front-line health care workers, and new media and other multiple channels promoted the positive professional image of nurses and strengthened the public’s recognition of the profession ²⁶ Hero worship, however, could result in an oppressive moral standard and a sense of oppression. ²⁷ The nursing community was valued and admired by the public, but they simultaneously experienced the feeling of being morally abducted. A sense of oppression can also be present in ordinary work, as caregivers are always taken for granted for their efforts, even if they are “extra” efforts outside of hospital rules. Undoubtedly, altruistic professionalism needs to be supported by multiple values. The COVID-19 pandemic is an opportunity to raise the social status of nurses, and the government and hospitals need to improve the praise and incentive mechanisms for nurses. While externalized altruistic incentives are important, it is also essential to seek endogenous incentives. Continuously explore the mechanisms that generate the altruistic pleasure of nursing staff, internalize altruistic behavior as the core value of professionalism, and realize a “win-win” situation for nursing staff and patients.

During their internship or work, graduate nursing students will notice the altruistic behaviors of their clinical teachers or other nurses and add them to their “checklist” to lend a helping hand if they encounter similar situations in the future. Thus, the concept of altruism should be learned and developed by students from the role models of faculty or others and from clinical and classroom interactions where they can feel the altruistic atmosphere. Altruistic behavior is contagious, and teachers play a guiding role in the development of students’ altruistic behavior. Under the authoritative guidance of teachers or the influence of others, graduate nursing students are more likely to truly transform the cognition of altruistic behavior into action, form the will to altruism, and constantly reproduce altruistic behavior, thus reducing the disconnect between cognition and behavior in the reality of altruism education.

Most nursing graduate students are very enthusiastic about volunteering, especially in fields related to medicine. And in contrast to ordinary volunteer activities, some medical-related volunteering is often considered an act requiring risky decision-making, as volunteers are sometimes exposed to contamination such as viruses and may become patients at any time. Pure altruism is the highest level of volunteerism, which is often harder to achieve because, although volunteering is non-profit, volunteers still benefit from it, which is actually crucial to cultivating personal volunteerism and promoting long-term, stable volunteerism. On the one hand, volunteers voluntarily give their personal time and energy to create value for society and others, promoting human development, social progress, and welfare advancement; on the other hand, volunteers enjoy the growth of their personal abilities and discover their potential through volunteering and may gain channels of emotional expression and release that are difficult to obtain in daily life, and emotional needs that are neglected in the formal system can often be met through volunteering. Emotional needs that are neglected in the formal system can often be satisfied through volunteerism, such as the satisfaction of pride, security, and belonging, as well as the expression and release of emotions such as sympathy, trust, emotion, and grief.

A study that explored the stress of health care workers from an altruistic perspective when caring for COVID-19 patients found that married health care workers were more stressed than unmarried individuals because they had families to worry about ²⁸ In the present study, married respondents also tended to prioritize their families when family and work conflicted, but unmarried respondents preferred to continue to hold on to their jobs. This conflicting choice between altruism and self-interest is frequently influenced by gender-related sociocultural factors (the degree of national gender equality) and national-level policies, in addition to marriage status. The Global Gender Gap Report Index ²⁹ shows that Chinese women are currently subject to significant inequalities and are in a contradictory situation between the pursuit of modern values and traditional ethical norms. At the same time, China’s “three-child policy,” which supports three children per couple in response to an aging population, has implications for how the nursing profession, which has a high proportion of women, balances family and work.

Chinese society has always been a social and cultural system that emphasizes the collective over the individual and promotes the spirit of willingness to give and to help others. Not only socio-cultural factors but also major disasters can stimulate altruistic tendencies, which Staub and Vollhardt ³⁰ refer to as “altruism born of suffering.” During the COVID-19 pandemic, Chinese healthcare workers showed great professional dedication out of altruism, with 86.2% of college students, including medical students, volunteering to participate in epidemic preparedness efforts. ³¹ COVID-19 has a significant impact on people’s lives, work, and even lives, enhancing the emotional connection between people and promoting altruistic behaviors when exposed to this externally threatening stimulus. However, violence against health professionals is a global concern, and in China, the scale, frequency, and viciousness of attacks against health workers are particularly severe. ³² Nurses are sometimes the victims of this Nurses are sometimes the victims of this violence because they are the link between patient and doctor. ³³ With the current intensification of conflicts between health workers and patients and frequent incidents of injury to health workers in society, nursing staff are prone to identity confusion and structural fragmentation of their sense of self, which inhibit their altruistic behavior and even affect their psychological health.

The empathy-altruism hypothesis suggests that empathy is an important source of motivation and a mediator of altruistic behavior, and that people with strong empathy are more likely to help others.^34,35 Altruistic behavior can be based on empathy for the emotions and thoughts of others, so it is recommended that nursing teachers incorporate role-playing, scenario discussion, shared experience, and empathy training into the classroom. By creating situations, students’ internal thought processes are made external; they think from different perspectives, experience different emotions from different characters, and are guided to improve their empathy skills through emotional empathy.

There was a high degree of consistency in the decision-making mechanisms used by graduate nursing students when deciding whether to engage in altruistic behavior. When someone asks for assistance, nursing graduate students first consider whether the request is within their capabilities. If they believe that they are not capable of fulfilling the request, they will reject the person; if they believe that the request is within their capabilities, they will move on to the next stage of altruistic behavior decision-making: benefit judgment, where respondents will consider the benefits as well as the disadvantages that altruistic behavior can bring them. Therefore, both the results of self-competence judgment and benefit judgment are related to the altruistic behavior of nursing graduate students, and even if the marginal benefits are compromised, they will not affect the implementation of altruistic behavior if the core benefits are not offended. In terms of recipient factors, factors such as charisma, gender, post-assisted feedback, and relationship with the helper can have an impact on the helper’s altruistic behavior. The recognition and pleasure gained from altruistic behavior motivate the helper to continue being altruistic and to apply the successful altruistic experience gained to future interaction situations. Feedback from the recipient plays an important role in the altruistic motivation of the helper, and gaining respect and recognition from the recipient and gaining a good reputation are important antecedents to the altruistic motivation of the helper.

China’s strategy for humanistic education for graduate nursing students is largely consistent with the undergraduate nursing teaching model and fails to reflect the strengths and characteristics of graduate teaching. Few nursing faculty have received training on how to teach such courses, and most graduate nursing students are only passive listeners during classes. ¹⁶ Therefore, schools and hospitals need to pay attention to altruism education, establish a scientific training mechanism for faculty groups on altruism education, and implement altruism education not only in the classroom but also in clinical teaching to deepen students’ understanding of altruism theory and improve their ability to deal with clinically relevant problems. It should also pay attention to students’ interests, improve the teaching atmosphere, and use some methods of education that are more relevant to young people rather than being limited to ordinary courses and lectures. Schools can join with hospitals to set up standardized, scientific, and systematic teaching courses in altruism by comparing horizontally with foreign countries in terms of training objectives, training programs, and assessment and evaluation.

Each country or race has its own history as well as socio-cultural context. This study explores the perceptions and experiences of altruism among Chinese nursing students. Confucian altruism, with benevolence at its core, has been a representative altruistic ideology in China for a long period of history, and many Asian countries in addition to China have been influenced by Confucian culture, so this study has a degree of universal application. The emergence of altruistic ethical thought is rooted in the soil of culture, both in China and in other countries. However, in either cultural context, altruistic ethical advocacy is necessary and inevitable for human society to exist and develop. Although the results of this study cannot be fully applied to other countries or races with different socio-cultural backgrounds, there are many commonalities in the connotation of altruism, so the results of this study can be selectively applied or some ideas can be based on this study for future research.

Limitations

There were some limitations in this study. First, most of the participants were students from the School of Nursing at Yangzhou university, with only two from other schools, which limits the representativeness of the sample and the generalizability of the results. Second, since the percentage of a minority population in the School of Nursing of Yangzhou University is very small and none of the students are religious, all participants were Han ethnicity and non-religious, which may have overlooked the influence of some unique ethnic and religious cultures.

Conclusions

The concept of altruism is high on the list of nursing values, and although the concept of altruism is vague among graduate nursing students, altruistic behaviors are prevalent in their work or life. Environment, personal factors, education, recipient factors, occupational factors, and gains and losses all influence the altruistic behaviors of graduate nursing students. In general, they desire public recognition from society and hope that the government will improve the praise and incentive mechanism for nurses. Families, schools, hospitals, and even society as a whole should pay attention to altruism-related education and create favorable environments to foster students’ altruistic tendencies.