- Email: [email protected]
Teaching Core Nursing Values
Teaching Core Nursing Values NANCY L. FAHRENWALD, PHD, RN,* SUSAN D. BASSETT, MS, RN,y LOIS TSCHETTER, EDD, RN, IBCLC,z PAULA P. CARSON, PHD, RN,z LANI WHITE, MS, RN,y AND VENITA J. WINTERBOER, MS, RNy
Nursing is a caring profession. Caring encompasses empathy for and connection with people. Teaching and role-modeling caring is a nursing curriculum challenge. Caring is best demonstrated by a nurse’s ability to embody the five core values of professional nursing. Core nursing values essential to baccalaureate education include human dignity, integrity, autonomy, altruism, and social justice. The caring professional nurse integrates these values in clinical practice. Strategies for integrating and teaching core values are outlined and outcomes of value-based nursing education are described. Carefully integrated values education ensures that the legacy of caring behavior embodied by nurses is strengthened for the future nursing workforce. (Index words: Professional values; Nursing education; Curriculum) J Prof Nurs 21: 46 – 51, 2005. A 2005 Elsevier Inc. All rights reserved.
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URRICULUM GUIDELINES FROM the American Association of Colleges of Nursing (AACN, 1998) espouse that baccalaureate education programs facilitate the development of professional nursing values. The five core values embraced by the AACN (1998) include human dignity, integrity, autonomy, altruism, and social justice. Definitions of these values are listed in Table 1. Behaviors that reflect these core values characterize the caring, professional nurse (AACN, 1998). Caring is a multidimensional nursing concept that can be
*Assistant Professor and Undergraduate Curriculum Chairperson, College of Nursing, South Dakota State University, SD 57007. yInstructor, College of Nursing, South Dakota State University, SD 57007. z Assistant Professor, College of Nursing, South Dakota State University, SD 57007. Address correspondence and reprint requests to Dr. Fahrenwald: Assistant Professor of the College of Nursing and Undergraduate Curriculum Chairperson, 2000–2003, South Dakota State University, Box 2275, Brookings, SD 57007. E-mail: [email protected] 8755-7223/$30.00 n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2004.11.001 46
actualized within the baccalaureate nursing curriculum through the purposeful teaching and studentcentered learning of core values. This article presents an innovative and integrative approach to value-based education in a baccalaureate nursing program. Theoretical Perspective on Value-Based Nursing Education
Value-based nursing education appeals to the moral and character development of students. Teaching values requires a conscious connection between the knower and the known (Liaschenko, 1999). This principle requires students to connect with the faculty on value-based issues of importance to them, and visa versa. To do so, faculty members advocate for both a universalist view and a particularist view of moral development (Fahrenwald, 2003). The universalist view specifies that moral reasoning is grounded in principles that are impartial and disinterested. These universalities are understood and accepted within a professional and societal context. Value-based education from a universalist view requires moral character that does not give weight to self-interest. Nursing values are understood as a universality that can be described by the learner (Liaschenko, 1999). Helping students to experience the universalities of each core nursing value within the context of the American Nurses Association’s (ANA, 2001) Code of Ethics with Interpretive Statements is one way to facilitate moral character development and ultimately, caring professional behavior. Faculty members can also influence the moral character of students through a particularist approach to value-based education. The particularist view allows personal issues and emotions to influence and guide moral action. In this case, self-interest can determine value-based behavior (Liaschenko, 1999). This approach allows the student to generate caring behavior from personal or vicarious experiences that generate an emotional connection with value-based
Journal of Professional Nursing, Vol 21, No 1 (January–February), 2005: pp 46–51
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TABLE 1. Definitions of the Five Core Professional Nursing Values Value
Definition
Human Dignity
bRespect for the inherent worth and uniqueness of individuals and populationsQ bActing in accordance with an appropriate code of ethics and accepted standards of practiceQ bThe right to self-determinationQ bA concern for the welfare and well being of othersQ bUpholding moral, legal, and humanistic principlesQ
Integrity
Autonomy Altruism Social Justice
NOTE. From The Essentials of Baccalaureate Education: For Professional Nursing Practice by the AACN, 1998, pp. 8 – 9. Copyright 1998 by the American Association of Colleges of Nursing.
issues (Fahrenwald, 2003). Student experiences in the clinical setting or personal encounters with faculty members, peers, and other health-care professionals are formative in the particularistic approach to valuebased education. Organization of the Undergraduate Curriculum
The conceptual framework for the undergraduate program is derived from The Essentials of Baccalaureate Nursing Education (AACN, 1998). Caring is described as professional behavior that uses both art and science to address all dimensions of the client in nursing practice. Caring bencompasses the nurse’s empathy for and connection with the patient (i.e., client), as well as the ability to translate these affective characteristics into compassionate, sensitive, appropriate careQ (AACN, 1998, p. 8). The professional values provide the foundation for caring professional practice. One undergraduate program outcome specifies that students will apply nursing values that exemplify the caring, professional nurse. Level outcomes within the nursing major stipulate that students will demonstrate caring behavior, with particular emphasis on one value during each of the five semesters. Core values are examined conceptually within each of five professional perspectives courses. Value-based professional behaviors are practiced and evaluated within the clinical and theory courses offered each semester. The following section provides an overview of this integrative approach to value-based education. Strategies for teaching caring through value-based learning within the undergraduate curriculum are summarized in Table 2.
HUMAN DIGNITY: SEMESTER I
Unrestricted respect for the dignity, worth, and uniqueness of every individual is the first statement in the Code of Ethics with Interpretive Statements (ANA, 2001). The essence of caring in nursing is respect for human dignity (Jacobs, 2000, 2001). Because of its significance to nursing practice, human dignity is the first value introduced in the curriculum. In the initial professional course, students analyze the concept of human dignity as described in The Essentials of Baccalaureate Nursing Education document (AACN, 1998). The students then define human dignity in their own words and anticipate how they will apply the value in clinical practice. This assignment helps to ground students in concrete aspects of human dignity that are derived from both a universalist view and a particularist perspective on moral development. Human dignity is learned through vicarious experience in a sensory deficit laboratory within a communications course. Students experience the life of clients with vision, hearing, and mobility problems. Discussion of personal feelings follows the experience. Key learning includes the importance of empathy and sensitivity when working with sensoryimpaired people. Another key learning activity is an interpersonal communication process recording, which is completed after a clinical experience. Concepts that exemplify human dignity are incorporated within the assignment guidelines and evaluation criteria, including provision of privacy, confidentiality, sensitivity to special needs, and competent communication skills. Human dignity is an abstract concept that is difficult to evaluate using standard clinical assessment tools. Clinical conferences in the first semester provide an opportunity to share experiences and observations of human dignity. Students reflect on the aspects of human dignity observed through communication patterns among health-care providers. Students also reflect on human dignity as applied in their own performance of health assessment and interventions such as maintenance of safety, provision of privacy, sensitivity to ethnic and cultural differences, and professional accountability. INTEGRITY: SEMESTER II
The value of integrity is integrated in the second semester of the nursing major. In the professional course, integrity is introduced as bacting in accordance with an appropriate code of ethics and accepted
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TABLE 2. Strategies for Teaching Caring Through Value-Based Learning Within the Undergraduate Curriculum Semester I: Human Dignity
Semester II: Integrity
Semester III: Autonomy
Semester IV: Altruism
Semester V: Social Justice
Documents Code of Ethics With Interpretive Statements (ANA, 2001)
Standards of Clinical Nursing Practice (ANA, 1998)
Code of Ethics With Interpretive Statements (ANA, 2001)
Code of Ethics With Scope and Standards Interpretive Statements of Public Health (ANA, 2001) Nursing Practice (ANA, 1999)
Video Patient Confidentiality: It’s Everybody’s Job (Costal Video Communications Corporation, 1997)
Crossing the Line: A Nurse’s Guide to the Importance of Appropriate Professional Boundaries (NCSBN, 1997)
Residents Have the Answers: Improving Quality of Life in Long-Term Care (Terra Nova Films, 2001)
A Calling to Care Krals, 2001)
Opening Doors: Public Health Nursing in its 100th Year (Washington State Public Health Association, 1993)
Age-Specific Care: Professional Boundaries It’s Relative (Costal [Brochure] (NCSBN, 1996) Video Communications Corporation, 1999) Assignment Personal definition of human dignity Interpersonal process recording Sensory laboratory
Family project Elderly client home visits
Critique of World Wide Wed Altruism definition health information project Design of a living Will Altruism definition project
Social justice issue project Journaling on social justice issues
NOTE. All semesters use The Essentials of Baccalaureate Education: For Professional Nursing Practice by the AACN (1998).
standards of practiceQ (AACN, 1998, p. 8). Students review ANA’s (2001) Code of Ethics then match statements describing nurse behaviors with respective statements from the code. The course professor, who recently completed 10 years of services as a member of the state board of nursing, provides examples of nurse behaviors that violated the ethical code and resulted in disciplinary action. These vicarious illustrations assist students with application of the abstract language within the professional code. In a clinical course, students review the Standards of Clinical Nursing Practice, 2nd ed. (ANA, 1998), then describe how they implement each standard in the care of a community-based elderly client. During four elderly client visits, students perform a health history, physical assessment, environment safety assessment, activities of daily living review, and a medication review. Students analyze their nursing care plan in relationship to the standards of practice. An essential aspect of professional integrity is accountability for one’s own actions. Accountability is evaluated throughout the semester, but receives particular emphasis within a clinical assignment. Each student visits a pregnant family during their pre-, peri-, and postnatal experience. In this nurse–family
relationship, students are introduced to the concept of professional boundary crossing. Students learn to avoid establishing socially focused relationships when providing home visits to pregnant women who are often similar in age. The framework for this application of integrity and accountability in professional relationships is exemplified in a video and printed brochure prepared by the National Council of State Boards of Nursing (NCSBN) (Table 2). These resources provide clear examples of the risks associated with boundaries violations through well-intended actions, especially in community-based clinical settings. AUTONOMY: SEMESTER III
The third semester of the nursing major focuses on the value of autonomy, defined as bthe right to self determinationQ (AACN, 1998, p. 8). This nursing value is two-dimensional, including both patient autonomy and nurse autonomy. Patient autonomy focuses on respect for the patient’s right to make decisions, even when those decisions conflict with the values of the nurse. Nurses have a moral obligation to the profession and to society to advocate for a patient’s rights to self-determination.
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TEACHING CORE NURSING VALUES
Learning experiences emphasize how to facilitate the patient’s right to make informed health-related choices. Nurse autonomy reflects a moral obligation to provide competent care to clients and to protect clients from unsafe practice. Clinical nursing practice often occurs within a hierarchical health-care system that places social and environmental constraints on freedom of action (Scott, 1998). Consequently, it is critical that nursing students practice how to exert influence for autonomous decision-making in practice. In the third of the five professional courses, a course objective specifies that students will recognize the value of autonomy and its relationship to nursing care. The intent is to provide the conceptual basis for autonomy in clinical practice. Within a module on information technology, students learn the nurse’s role in helping patients to independently gather and interpret health information. Autonomous behavior includes the provision of information so patients can make informed choices (AACN, 1998). The most efficient means of facilitating choices and selecting new pathways is through knowledge development (Waller, 2001). Information empowers the patient to make autonomous choices and vastly expands alternatives. To ensure that students are prepared to facilitate the selection of sound health-care alternatives, students critique health-related World Wide Web sites to determine (a) appropriateness for use by patients, (b) credibility of the source, and (c) accuracy of the information. Each student leaves the course with a list of web sites that can be used to facilitate patient autonomy through informed, optimal, healthcare decisions. A course module on ethics further develops the concept of patient autonomy because it applies to the process of informed consent. After classroom discussion and learning activities, students recognize the nurse’s role and responsibility in assuring that consent for health care is an autonomous decision of the patient or the patient’s legal guardian. In one learning activity, students create a living will or durable power of attorney. A values questionnaire adapted from the Vermont Ethics Network (Teno & Lynn, 1996) is then used to examine personal values about these life issues. These learning activities help the students to realize that autonomy is expressed within each individual client’s value system (Doukas & McCullough, 1991). Creating a living will or durable power of attorney provides an opportunity to exercise personal autonomy and to experience the sometimes-difficult process of facilitating autonomous decisions.
A course module on liability changes the focus from patient autonomy to nurse autonomy. Learning activities relate to the nurse’s obligation to not only promote safe practice, but also to challenge the unsafe practice of other health-care providers. Case studies help the student process how to intervene in situations that require moral action on the part of the nurse to protect clients from unsafe care situations. The third semester includes theory and clinical courses that focus on acute and chronic health problems across the life span. Emphasis on the professional role of provider of care provides the platform for developing caring skills related to the value of autonomy. Students are challenged to confront and respond to simulated unsafe care practices. A video called Residents Have the Answers (Terra Nova Films, 2001) provides compelling evidence for allowing long-term care residents to maintain autonomous decision-making. ALTRUISM: SEMESTER IV
The value of altruism is integrated in the fourth semester of the nursing major. In the professional course, altruism is introduced as ba concern for the welfare and well being of othersQ (AACN 1998). Caring behaviors associated with altruism are often the reason that students choose the nursing profession (Altun, 2002). Nurses extend altruistic caring beyond the traditional boundaries of family and friends to provide care to virtual strangers (Gormley, 1996; Grypma & Jamison, 2003). Altruistic caring behavior involves self-sacrifice in its expression (Altun, 2003; White, 2002). A course assignment in the fourth professional course assists students in recognizing the value of altruism as a dimension of caring. The personal definition of altruism project is designed to support analysis of altruistic behavior. Students consider how the behaviors of high-profile public figures, such as Princess Diana, Mahatma Gandhi, and Mother Teresa, typified definitions of altruism. Reading and reflecting on materials that describe the altruistic actions of these public figures raises awareness of altruistic behavior. Students are also exposed to a video entitled A Calling to Care (Krals, 2001). This video tells the story of a successful professional nurse who left her career to teach nursing to women in Pakistan. After these learning activities, the students are guided to question and seek out examples of altruistic acts performed by self and others. Each student explores the literature for references that
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exemplify and define altruism. Two references that best relate critical attributes of a personal definition of altruism are selected. The personal definition of altruism is then compared and contrasted with literature-based definitions. The outcome of this concept analysis is a professional self-identity grounded in altruism. Each student anticipates altruistic behaviors that relate to their chosen career path in nursing. Within the fourth semester, there are two clinical and theory courses that focus on mental health and acute medical–surgical care. In clinical, students become aware of the resources necessary to effectively manage altruistic care for a number of individuals with complex mental and physical health problems. Clinical conference time is used to discuss caring decisions that support nurses’ altruistic values as well as the well-being of individuals with diverse backgrounds and health issues. Altruistic behaviors of self and others are analyzed within the context of caring for clients with extremely complex health concerns. SOCIAL JUSTICE: SEMESTER V
In the fifth and final semester of the nursing major, the students are introduced to the value of social justice in the professional perspectives course. Social justice implies that there is a fair and equitable distribution of benefits and bearing of burdens in a society (Kneipp & Snider, 2001). Nurses who deeply value social justice may experience value-based conflict when working in a market justice health-care system. Our profession embraces social justice (ANA, 2001), yet nurses continue to tolerate disparities in health status and health care, especially as they exist in minority and vulnerable populations on local, state, national, and international levels (Fahrenwald, 2003). In the professional perspectives course, students are exposed to local, national, and international social justice issues. These issues are accessed from the World Health Organization, the American Public Health Association, state and local health status indicators, and even local newspapers. To role-model the value of social justice, the instructor provides a compelling personal example of a social justice derived from the clinical practice. Students view slides that portray the population health inequities of AIDS orphans in Malawi, Africa. Specific examples of the instructor’s continued involvement in the social justice issue are provided, including participation in a coalition that builds orphanages in Malawi using local resources and personnel.
Two additional nursing courses are taught in the last semester of the program. Directed Study in Nursing is a clinical and seminar course where students participate in 160 hours of clinical practicum under the supervision of a preceptor. As part of a required learning journal experience, students examine social justice issues observed in the practicum setting. The fifth semester also includes a population-based public health nursing course. A course objective specifies that students will apply the value of social justice in nursing practice. Social justice is analyzed within the context of the Scope and Standards of Public Health Nursing Practice (ANA, 1999). Students also view the video Opening Doors: Public Health Nursing in its 100th Year (Washington State Public Health Association, 1993). The vicarious experience of observing public health nurses advocating for poor, substance-abusing, rural, and minority populations is a particularistic approach to teaching the value of social justice. Because social justice is a core nursing value and a core public health value, the public health nursing course is an appropriate place for a social justice issue project. The purpose of the social justice issues project is to apply social justice principles to population health problems. Students are encouraged to recall a clinical practice episode or life experience in which social justice issues specific to health were encountered. Students are encouraged to examine the type of oppression evident in these experiences and to discover ways to address the issue through a population-based public health intervention. Students generate their social justice issue either inductively through experience and self-analysis or deductively through reading the literature, examining issues, and selecting one issue of interest. Project objectives specify that the student describe the oppression evident in the social justice issue and present the historical context for the injustice. The student is also asked to provide evidence that supports this issue as important to the health of a particular population. The student develops and implements a public health intervention to address the social justice issue. Examples of interventions that are appropriate for the social justice issue project are provided (e.g., advocacy, coalition building, community organizing, and policy development). To reduce student fear of receiving a poor grade if the social justice issue is not congruent with the instructor’s value system, a peer evaluation mechanism is used. Peer evaluation ensures accountability for the assignment criteria while empowering stu-
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dents to critically evaluate whether peer projects met the assignment guidelines. As part of the assignment, the student anticipates future involvement in the issue. Conclusion
Nursing faculty members are challenged to teach core nursing values that embody the caring professional nurse. Purposeful integration of value-based
education throughout all nursing courses in a baccalaureate education program is essential to ensure that nursing students apply the abstract values of human dignity, integrity, autonomy, altruism, and social justice in clinical practice. Values integration throughout the curriculum provides the conceptual, moral, and practical learning necessary to ensure that the future nursing workforce is grounded in the concept of caring and actualizes this caring through the application of value-based behavior.
References Altun (2002). Burnout and nurses’ personal and professional values. Nursing Ethics, 9, 269 –278. American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Nurses Association. (1998). Standards of clinical nursing practice. 2nd ed. Washington, DC: Author. American Nurses Association. (1999). Scope and standards of public health nursing practice. Washington, DC: Author. American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author. Costal Video Communications Corporation (Producer). (1997). Patient confidentiality: It’s everybody’s job. Video (Available from Coastal Training Technologies Corporation, 3083 Brickhouse Court, Virginia Beach, VA 23452). Costal Video Communications Corporation (Producer). (1999). Age-specific care: It’s relative. Training video (Available from Coastal Training Technologies Corporation, 3083 Brickhouse Court, Virginia Beach, VA 23452). Doukas, D. J., & McCullough, L. B. (1991). The values history: The evaluation of the patient’s values and advance directives. The Journal of Family Practice, 32, 145 –153. Fahrenwald, N. L. (2003). Teaching social justice. Nurse Educator, 28, 222 –226. Gormley, K. J. (1996). Altruism: A framework for caring and providing care. International Journal of Nursing Studies, 33, 581 –588. Grypma, S., & Jamison, L. (2003). Caring for strangers. Journal of Christian Nursing, 20, 9 –13. Jacobs, B. B. (2000). Respect for human dignity in nursing: Philosophical and practical perspectives. Canadian Journal of Nursing Research, 32, 15 –33. Jacobs, B. B. (2001). Respect for human dignity: A central phenomenon to philosophically unite nursing
theory and practice through consilience of knowledge. Advances in Nursing Science, 24, 17 – 35. Kneipp, S., & Snider, M. J. (2001). Social justice in a market model world. Journal of Professional Nursing, 17, 113. Krals, B. J. (2001). A calling to care. Documentary film (Available from producer Documentary Educational Resources, 101 Morse Street, Watertown, MA 02472). Liaschenko, J. (1999). Can justice coexist with the supremacy of personal values in nursing practice? Western Journal of Nursing Research, 21, 35– 50. National Council of State Boards of Nursing. (1996). Professional boundaries: A nurse’s guide to the importance of appropriate professional boundaries [Brochure]. Baltimore, MD: Author. National Council of State Boards of Nursing (Producer). (1997). Crossing the line: A nurse’s guide to the importance of appropriate professional boundaries. (Available from producer, 526 Cole Lane, Baltimore, MD 21220). Scott, P. A. (1998). Morally autonomous practice? Advances in Nursing Science, 21, 69. Teno, J. M., & Lynn, J. (1996). Putting advance-care planning into action. The Journal of Clinical Ethics, 7, 205– 214. Terra Nova Films, Inc. (2001). Residents have the answers: Improving quality of life in long-term care. Video (Available from producer, 9848 South Winchester Avenue, Chicago IL 60643). Waller, B. N. (2001). Patient autonomy naturalized. Perspectives in Biology and Medicine, 44, 584 –593. Washington State Public Health Association. (1993). Opening doors: Public health nursing in its 100th year. (Available from author, 11414 26th Place SE, Everett, WA 98205 – 2586). White, K. (2002). Nursing as vocation. Nursing Ethics, 9, 279 – 290.
Nursing is a caring profession. Caring encompasses empathy for and connection with people. Teaching and role-modeling caring is a nursing curriculum challenge. Caring is best demonstrated by a nurse’s ability to embody the five core values of professional nursing. Core nursing values essential to baccalaureate education include human dignity, integrity, autonomy, altruism, and social justice. The caring professional nurse integrates these values in clinical practice. Strategies for integrating and teaching core values are outlined and outcomes of value-based nursing education are described. Carefully integrated values education ensures that the legacy of caring behavior embodied by nurses is strengthened for the future nursing workforce. (Index words: Professional values; Nursing education; Curriculum) J Prof Nurs 21: 46 – 51, 2005. A 2005 Elsevier Inc. All rights reserved.
C
URRICULUM GUIDELINES FROM the American Association of Colleges of Nursing (AACN, 1998) espouse that baccalaureate education programs facilitate the development of professional nursing values. The five core values embraced by the AACN (1998) include human dignity, integrity, autonomy, altruism, and social justice. Definitions of these values are listed in Table 1. Behaviors that reflect these core values characterize the caring, professional nurse (AACN, 1998). Caring is a multidimensional nursing concept that can be
*Assistant Professor and Undergraduate Curriculum Chairperson, College of Nursing, South Dakota State University, SD 57007. yInstructor, College of Nursing, South Dakota State University, SD 57007. z Assistant Professor, College of Nursing, South Dakota State University, SD 57007. Address correspondence and reprint requests to Dr. Fahrenwald: Assistant Professor of the College of Nursing and Undergraduate Curriculum Chairperson, 2000–2003, South Dakota State University, Box 2275, Brookings, SD 57007. E-mail: [email protected] 8755-7223/$30.00 n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2004.11.001 46
actualized within the baccalaureate nursing curriculum through the purposeful teaching and studentcentered learning of core values. This article presents an innovative and integrative approach to value-based education in a baccalaureate nursing program. Theoretical Perspective on Value-Based Nursing Education
Value-based nursing education appeals to the moral and character development of students. Teaching values requires a conscious connection between the knower and the known (Liaschenko, 1999). This principle requires students to connect with the faculty on value-based issues of importance to them, and visa versa. To do so, faculty members advocate for both a universalist view and a particularist view of moral development (Fahrenwald, 2003). The universalist view specifies that moral reasoning is grounded in principles that are impartial and disinterested. These universalities are understood and accepted within a professional and societal context. Value-based education from a universalist view requires moral character that does not give weight to self-interest. Nursing values are understood as a universality that can be described by the learner (Liaschenko, 1999). Helping students to experience the universalities of each core nursing value within the context of the American Nurses Association’s (ANA, 2001) Code of Ethics with Interpretive Statements is one way to facilitate moral character development and ultimately, caring professional behavior. Faculty members can also influence the moral character of students through a particularist approach to value-based education. The particularist view allows personal issues and emotions to influence and guide moral action. In this case, self-interest can determine value-based behavior (Liaschenko, 1999). This approach allows the student to generate caring behavior from personal or vicarious experiences that generate an emotional connection with value-based
Journal of Professional Nursing, Vol 21, No 1 (January–February), 2005: pp 46–51
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TEACHING CORE NURSING VALUES
TABLE 1. Definitions of the Five Core Professional Nursing Values Value
Definition
Human Dignity
bRespect for the inherent worth and uniqueness of individuals and populationsQ bActing in accordance with an appropriate code of ethics and accepted standards of practiceQ bThe right to self-determinationQ bA concern for the welfare and well being of othersQ bUpholding moral, legal, and humanistic principlesQ
Integrity
Autonomy Altruism Social Justice
NOTE. From The Essentials of Baccalaureate Education: For Professional Nursing Practice by the AACN, 1998, pp. 8 – 9. Copyright 1998 by the American Association of Colleges of Nursing.
issues (Fahrenwald, 2003). Student experiences in the clinical setting or personal encounters with faculty members, peers, and other health-care professionals are formative in the particularistic approach to valuebased education. Organization of the Undergraduate Curriculum
The conceptual framework for the undergraduate program is derived from The Essentials of Baccalaureate Nursing Education (AACN, 1998). Caring is described as professional behavior that uses both art and science to address all dimensions of the client in nursing practice. Caring bencompasses the nurse’s empathy for and connection with the patient (i.e., client), as well as the ability to translate these affective characteristics into compassionate, sensitive, appropriate careQ (AACN, 1998, p. 8). The professional values provide the foundation for caring professional practice. One undergraduate program outcome specifies that students will apply nursing values that exemplify the caring, professional nurse. Level outcomes within the nursing major stipulate that students will demonstrate caring behavior, with particular emphasis on one value during each of the five semesters. Core values are examined conceptually within each of five professional perspectives courses. Value-based professional behaviors are practiced and evaluated within the clinical and theory courses offered each semester. The following section provides an overview of this integrative approach to value-based education. Strategies for teaching caring through value-based learning within the undergraduate curriculum are summarized in Table 2.
HUMAN DIGNITY: SEMESTER I
Unrestricted respect for the dignity, worth, and uniqueness of every individual is the first statement in the Code of Ethics with Interpretive Statements (ANA, 2001). The essence of caring in nursing is respect for human dignity (Jacobs, 2000, 2001). Because of its significance to nursing practice, human dignity is the first value introduced in the curriculum. In the initial professional course, students analyze the concept of human dignity as described in The Essentials of Baccalaureate Nursing Education document (AACN, 1998). The students then define human dignity in their own words and anticipate how they will apply the value in clinical practice. This assignment helps to ground students in concrete aspects of human dignity that are derived from both a universalist view and a particularist perspective on moral development. Human dignity is learned through vicarious experience in a sensory deficit laboratory within a communications course. Students experience the life of clients with vision, hearing, and mobility problems. Discussion of personal feelings follows the experience. Key learning includes the importance of empathy and sensitivity when working with sensoryimpaired people. Another key learning activity is an interpersonal communication process recording, which is completed after a clinical experience. Concepts that exemplify human dignity are incorporated within the assignment guidelines and evaluation criteria, including provision of privacy, confidentiality, sensitivity to special needs, and competent communication skills. Human dignity is an abstract concept that is difficult to evaluate using standard clinical assessment tools. Clinical conferences in the first semester provide an opportunity to share experiences and observations of human dignity. Students reflect on the aspects of human dignity observed through communication patterns among health-care providers. Students also reflect on human dignity as applied in their own performance of health assessment and interventions such as maintenance of safety, provision of privacy, sensitivity to ethnic and cultural differences, and professional accountability. INTEGRITY: SEMESTER II
The value of integrity is integrated in the second semester of the nursing major. In the professional course, integrity is introduced as bacting in accordance with an appropriate code of ethics and accepted
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TABLE 2. Strategies for Teaching Caring Through Value-Based Learning Within the Undergraduate Curriculum Semester I: Human Dignity
Semester II: Integrity
Semester III: Autonomy
Semester IV: Altruism
Semester V: Social Justice
Documents Code of Ethics With Interpretive Statements (ANA, 2001)
Standards of Clinical Nursing Practice (ANA, 1998)
Code of Ethics With Interpretive Statements (ANA, 2001)
Code of Ethics With Scope and Standards Interpretive Statements of Public Health (ANA, 2001) Nursing Practice (ANA, 1999)
Video Patient Confidentiality: It’s Everybody’s Job (Costal Video Communications Corporation, 1997)
Crossing the Line: A Nurse’s Guide to the Importance of Appropriate Professional Boundaries (NCSBN, 1997)
Residents Have the Answers: Improving Quality of Life in Long-Term Care (Terra Nova Films, 2001)
A Calling to Care Krals, 2001)
Opening Doors: Public Health Nursing in its 100th Year (Washington State Public Health Association, 1993)
Age-Specific Care: Professional Boundaries It’s Relative (Costal [Brochure] (NCSBN, 1996) Video Communications Corporation, 1999) Assignment Personal definition of human dignity Interpersonal process recording Sensory laboratory
Family project Elderly client home visits
Critique of World Wide Wed Altruism definition health information project Design of a living Will Altruism definition project
Social justice issue project Journaling on social justice issues
NOTE. All semesters use The Essentials of Baccalaureate Education: For Professional Nursing Practice by the AACN (1998).
standards of practiceQ (AACN, 1998, p. 8). Students review ANA’s (2001) Code of Ethics then match statements describing nurse behaviors with respective statements from the code. The course professor, who recently completed 10 years of services as a member of the state board of nursing, provides examples of nurse behaviors that violated the ethical code and resulted in disciplinary action. These vicarious illustrations assist students with application of the abstract language within the professional code. In a clinical course, students review the Standards of Clinical Nursing Practice, 2nd ed. (ANA, 1998), then describe how they implement each standard in the care of a community-based elderly client. During four elderly client visits, students perform a health history, physical assessment, environment safety assessment, activities of daily living review, and a medication review. Students analyze their nursing care plan in relationship to the standards of practice. An essential aspect of professional integrity is accountability for one’s own actions. Accountability is evaluated throughout the semester, but receives particular emphasis within a clinical assignment. Each student visits a pregnant family during their pre-, peri-, and postnatal experience. In this nurse–family
relationship, students are introduced to the concept of professional boundary crossing. Students learn to avoid establishing socially focused relationships when providing home visits to pregnant women who are often similar in age. The framework for this application of integrity and accountability in professional relationships is exemplified in a video and printed brochure prepared by the National Council of State Boards of Nursing (NCSBN) (Table 2). These resources provide clear examples of the risks associated with boundaries violations through well-intended actions, especially in community-based clinical settings. AUTONOMY: SEMESTER III
The third semester of the nursing major focuses on the value of autonomy, defined as bthe right to self determinationQ (AACN, 1998, p. 8). This nursing value is two-dimensional, including both patient autonomy and nurse autonomy. Patient autonomy focuses on respect for the patient’s right to make decisions, even when those decisions conflict with the values of the nurse. Nurses have a moral obligation to the profession and to society to advocate for a patient’s rights to self-determination.
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Learning experiences emphasize how to facilitate the patient’s right to make informed health-related choices. Nurse autonomy reflects a moral obligation to provide competent care to clients and to protect clients from unsafe practice. Clinical nursing practice often occurs within a hierarchical health-care system that places social and environmental constraints on freedom of action (Scott, 1998). Consequently, it is critical that nursing students practice how to exert influence for autonomous decision-making in practice. In the third of the five professional courses, a course objective specifies that students will recognize the value of autonomy and its relationship to nursing care. The intent is to provide the conceptual basis for autonomy in clinical practice. Within a module on information technology, students learn the nurse’s role in helping patients to independently gather and interpret health information. Autonomous behavior includes the provision of information so patients can make informed choices (AACN, 1998). The most efficient means of facilitating choices and selecting new pathways is through knowledge development (Waller, 2001). Information empowers the patient to make autonomous choices and vastly expands alternatives. To ensure that students are prepared to facilitate the selection of sound health-care alternatives, students critique health-related World Wide Web sites to determine (a) appropriateness for use by patients, (b) credibility of the source, and (c) accuracy of the information. Each student leaves the course with a list of web sites that can be used to facilitate patient autonomy through informed, optimal, healthcare decisions. A course module on ethics further develops the concept of patient autonomy because it applies to the process of informed consent. After classroom discussion and learning activities, students recognize the nurse’s role and responsibility in assuring that consent for health care is an autonomous decision of the patient or the patient’s legal guardian. In one learning activity, students create a living will or durable power of attorney. A values questionnaire adapted from the Vermont Ethics Network (Teno & Lynn, 1996) is then used to examine personal values about these life issues. These learning activities help the students to realize that autonomy is expressed within each individual client’s value system (Doukas & McCullough, 1991). Creating a living will or durable power of attorney provides an opportunity to exercise personal autonomy and to experience the sometimes-difficult process of facilitating autonomous decisions.
A course module on liability changes the focus from patient autonomy to nurse autonomy. Learning activities relate to the nurse’s obligation to not only promote safe practice, but also to challenge the unsafe practice of other health-care providers. Case studies help the student process how to intervene in situations that require moral action on the part of the nurse to protect clients from unsafe care situations. The third semester includes theory and clinical courses that focus on acute and chronic health problems across the life span. Emphasis on the professional role of provider of care provides the platform for developing caring skills related to the value of autonomy. Students are challenged to confront and respond to simulated unsafe care practices. A video called Residents Have the Answers (Terra Nova Films, 2001) provides compelling evidence for allowing long-term care residents to maintain autonomous decision-making. ALTRUISM: SEMESTER IV
The value of altruism is integrated in the fourth semester of the nursing major. In the professional course, altruism is introduced as ba concern for the welfare and well being of othersQ (AACN 1998). Caring behaviors associated with altruism are often the reason that students choose the nursing profession (Altun, 2002). Nurses extend altruistic caring beyond the traditional boundaries of family and friends to provide care to virtual strangers (Gormley, 1996; Grypma & Jamison, 2003). Altruistic caring behavior involves self-sacrifice in its expression (Altun, 2003; White, 2002). A course assignment in the fourth professional course assists students in recognizing the value of altruism as a dimension of caring. The personal definition of altruism project is designed to support analysis of altruistic behavior. Students consider how the behaviors of high-profile public figures, such as Princess Diana, Mahatma Gandhi, and Mother Teresa, typified definitions of altruism. Reading and reflecting on materials that describe the altruistic actions of these public figures raises awareness of altruistic behavior. Students are also exposed to a video entitled A Calling to Care (Krals, 2001). This video tells the story of a successful professional nurse who left her career to teach nursing to women in Pakistan. After these learning activities, the students are guided to question and seek out examples of altruistic acts performed by self and others. Each student explores the literature for references that
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exemplify and define altruism. Two references that best relate critical attributes of a personal definition of altruism are selected. The personal definition of altruism is then compared and contrasted with literature-based definitions. The outcome of this concept analysis is a professional self-identity grounded in altruism. Each student anticipates altruistic behaviors that relate to their chosen career path in nursing. Within the fourth semester, there are two clinical and theory courses that focus on mental health and acute medical–surgical care. In clinical, students become aware of the resources necessary to effectively manage altruistic care for a number of individuals with complex mental and physical health problems. Clinical conference time is used to discuss caring decisions that support nurses’ altruistic values as well as the well-being of individuals with diverse backgrounds and health issues. Altruistic behaviors of self and others are analyzed within the context of caring for clients with extremely complex health concerns. SOCIAL JUSTICE: SEMESTER V
In the fifth and final semester of the nursing major, the students are introduced to the value of social justice in the professional perspectives course. Social justice implies that there is a fair and equitable distribution of benefits and bearing of burdens in a society (Kneipp & Snider, 2001). Nurses who deeply value social justice may experience value-based conflict when working in a market justice health-care system. Our profession embraces social justice (ANA, 2001), yet nurses continue to tolerate disparities in health status and health care, especially as they exist in minority and vulnerable populations on local, state, national, and international levels (Fahrenwald, 2003). In the professional perspectives course, students are exposed to local, national, and international social justice issues. These issues are accessed from the World Health Organization, the American Public Health Association, state and local health status indicators, and even local newspapers. To role-model the value of social justice, the instructor provides a compelling personal example of a social justice derived from the clinical practice. Students view slides that portray the population health inequities of AIDS orphans in Malawi, Africa. Specific examples of the instructor’s continued involvement in the social justice issue are provided, including participation in a coalition that builds orphanages in Malawi using local resources and personnel.
Two additional nursing courses are taught in the last semester of the program. Directed Study in Nursing is a clinical and seminar course where students participate in 160 hours of clinical practicum under the supervision of a preceptor. As part of a required learning journal experience, students examine social justice issues observed in the practicum setting. The fifth semester also includes a population-based public health nursing course. A course objective specifies that students will apply the value of social justice in nursing practice. Social justice is analyzed within the context of the Scope and Standards of Public Health Nursing Practice (ANA, 1999). Students also view the video Opening Doors: Public Health Nursing in its 100th Year (Washington State Public Health Association, 1993). The vicarious experience of observing public health nurses advocating for poor, substance-abusing, rural, and minority populations is a particularistic approach to teaching the value of social justice. Because social justice is a core nursing value and a core public health value, the public health nursing course is an appropriate place for a social justice issue project. The purpose of the social justice issues project is to apply social justice principles to population health problems. Students are encouraged to recall a clinical practice episode or life experience in which social justice issues specific to health were encountered. Students are encouraged to examine the type of oppression evident in these experiences and to discover ways to address the issue through a population-based public health intervention. Students generate their social justice issue either inductively through experience and self-analysis or deductively through reading the literature, examining issues, and selecting one issue of interest. Project objectives specify that the student describe the oppression evident in the social justice issue and present the historical context for the injustice. The student is also asked to provide evidence that supports this issue as important to the health of a particular population. The student develops and implements a public health intervention to address the social justice issue. Examples of interventions that are appropriate for the social justice issue project are provided (e.g., advocacy, coalition building, community organizing, and policy development). To reduce student fear of receiving a poor grade if the social justice issue is not congruent with the instructor’s value system, a peer evaluation mechanism is used. Peer evaluation ensures accountability for the assignment criteria while empowering stu-
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dents to critically evaluate whether peer projects met the assignment guidelines. As part of the assignment, the student anticipates future involvement in the issue. Conclusion
Nursing faculty members are challenged to teach core nursing values that embody the caring professional nurse. Purposeful integration of value-based
education throughout all nursing courses in a baccalaureate education program is essential to ensure that nursing students apply the abstract values of human dignity, integrity, autonomy, altruism, and social justice in clinical practice. Values integration throughout the curriculum provides the conceptual, moral, and practical learning necessary to ensure that the future nursing workforce is grounded in the concept of caring and actualizes this caring through the application of value-based behavior.
References Altun (2002). Burnout and nurses’ personal and professional values. Nursing Ethics, 9, 269 –278. American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Nurses Association. (1998). Standards of clinical nursing practice. 2nd ed. Washington, DC: Author. American Nurses Association. (1999). Scope and standards of public health nursing practice. Washington, DC: Author. American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author. Costal Video Communications Corporation (Producer). (1997). Patient confidentiality: It’s everybody’s job. Video (Available from Coastal Training Technologies Corporation, 3083 Brickhouse Court, Virginia Beach, VA 23452). Costal Video Communications Corporation (Producer). (1999). Age-specific care: It’s relative. Training video (Available from Coastal Training Technologies Corporation, 3083 Brickhouse Court, Virginia Beach, VA 23452). Doukas, D. J., & McCullough, L. B. (1991). The values history: The evaluation of the patient’s values and advance directives. The Journal of Family Practice, 32, 145 –153. Fahrenwald, N. L. (2003). Teaching social justice. Nurse Educator, 28, 222 –226. Gormley, K. J. (1996). Altruism: A framework for caring and providing care. International Journal of Nursing Studies, 33, 581 –588. Grypma, S., & Jamison, L. (2003). Caring for strangers. Journal of Christian Nursing, 20, 9 –13. Jacobs, B. B. (2000). Respect for human dignity in nursing: Philosophical and practical perspectives. Canadian Journal of Nursing Research, 32, 15 –33. Jacobs, B. B. (2001). Respect for human dignity: A central phenomenon to philosophically unite nursing
theory and practice through consilience of knowledge. Advances in Nursing Science, 24, 17 – 35. Kneipp, S., & Snider, M. J. (2001). Social justice in a market model world. Journal of Professional Nursing, 17, 113. Krals, B. J. (2001). A calling to care. Documentary film (Available from producer Documentary Educational Resources, 101 Morse Street, Watertown, MA 02472). Liaschenko, J. (1999). Can justice coexist with the supremacy of personal values in nursing practice? Western Journal of Nursing Research, 21, 35– 50. National Council of State Boards of Nursing. (1996). Professional boundaries: A nurse’s guide to the importance of appropriate professional boundaries [Brochure]. Baltimore, MD: Author. National Council of State Boards of Nursing (Producer). (1997). Crossing the line: A nurse’s guide to the importance of appropriate professional boundaries. (Available from producer, 526 Cole Lane, Baltimore, MD 21220). Scott, P. A. (1998). Morally autonomous practice? Advances in Nursing Science, 21, 69. Teno, J. M., & Lynn, J. (1996). Putting advance-care planning into action. The Journal of Clinical Ethics, 7, 205– 214. Terra Nova Films, Inc. (2001). Residents have the answers: Improving quality of life in long-term care. Video (Available from producer, 9848 South Winchester Avenue, Chicago IL 60643). Waller, B. N. (2001). Patient autonomy naturalized. Perspectives in Biology and Medicine, 44, 584 –593. Washington State Public Health Association. (1993). Opening doors: Public health nursing in its 100th year. (Available from author, 11414 26th Place SE, Everett, WA 98205 – 2586). White, K. (2002). Nursing as vocation. Nursing Ethics, 9, 279 – 290.