Teaching Core Values


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Teaching Core Values

  1. 1. 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 actualized within the baccalaureate nursing curricu- empathy for and connection with people. Teaching lum through the purposeful teaching and student- and role-modeling caring is a nursing curriculum centered learning of core values. This article presents challenge. Caring is best demonstrated by a nurse’s ability to embody the five core values of professional an innovative and integrative approach to value-based nursing. Core nursing values essential to baccalau- education in a baccalaureate nursing program. reate education include human dignity, integrity, autonomy, altruism, and social justice. The caring professional nurse integrates these values in clinical Theoretical Perspective on Value-Based practice. Strategies for integrating and teaching core Nursing Education values are outlined and outcomes of value-based nursing education are described. Carefully integrated Value-based nursing education appeals to the values education ensures that the legacy of caring moral and character development of students. Teach- behavior embodied by nurses is strengthened for the future nursing workforce. (Index words: Professional ing values requires a conscious connection between values; Nursing education; Curriculum) J Prof Nurs 21: the knower and the known (Liaschenko, 1999). This 46 – 51, 2005. A 2005 Elsevier Inc. All rights reserved. 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 C URRICULUM GUIDELINES FROM the American Association of Colleges of Nursing (AACN, 1998) espouse that baccalaureate education universalist view and a particularist view of moral development (Fahrenwald, 2003). The universalist view specifies that moral reasoning is grounded in programs facilitate the development of professional principles that are impartial and disinterested. These nursing values. The five core values embraced by the universalities are understood and accepted within a AACN (1998) include human dignity, integrity, professional and societal context. Value-based educa- autonomy, altruism, and social justice. Definitions tion from a universalist view requires moral character of these values are listed in Table 1. Behaviors that that does not give weight to self-interest. Nursing reflect these core values characterize the caring, values are understood as a universality that can be professional nurse (AACN, 1998). Caring is a described by the learner (Liaschenko, 1999). Helping multidimensional nursing concept that can be 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 *Assistant Professor and Undergraduate Curriculum Chair- Interpretive Statements is one way to facilitate moral person, College of Nursing, South Dakota State University, SD character development and ultimately, caring profes- 57007. sional behavior. yInstructor, College of Nursing, South Dakota State Univer- sity, SD 57007. Faculty members can also influence the moral z Assistant Professor, College of Nursing, South Dakota State character of students through a particularist approach University, SD 57007. to value-based education. The particularist view Address correspondence and reprint requests to Dr. Fahren- wald: Assistant Professor of the College of Nursing and allows personal issues and emotions to influence Undergraduate Curriculum Chairperson, 2000–2003, South and guide moral action. In this case, self-interest can Dakota State University, Box 2275, Brookings, SD 57007. determine value-based behavior (Liaschenko, 1999). E-mail: nancy_fahrenwald@sdstate.edu This approach allows the student to generate caring 8755-7223/$30.00 n 2005 Elsevier Inc. All rights reserved. behavior from personal or vicarious experiences that doi:10.1016/j.profnurs.2004.11.001 generate an emotional connection with value-based 46 Journal of Professional Nursing, Vol 21, No 1 (January–February), 2005: pp 46–51
  2. 2. TEACHING CORE NURSING VALUES 47 TABLE 1. Definitions of the Five Core Professional HUMAN DIGNITY: SEMESTER I Nursing Values Unrestricted respect for the dignity, worth, and Value Definition uniqueness of every individual is the first statement in the Code of Ethics with Interpretive Statements (ANA, Human Dignity bRespect for the inherent worth and uniqueness of individuals and populationsQ 2001). The essence of caring in nursing is respect for Integrity bActing in accordance with an appropriate human dignity (Jacobs, 2000, 2001). Because of its code of ethics and accepted standards of significance to nursing practice, human dignity is the practiceQ Autonomy bThe right to self-determinationQ first value introduced in the curriculum. In the initial Altruism bA concern for the welfare and well being of professional course, students analyze the concept othersQ of human dignity as described in The Essentials of Social Justice bUpholding moral, legal, and humanistic principlesQ Baccalaureate Nursing Education document (AACN, 1998). The students then define human NOTE. From The Essentials of Baccalaureate Education: For dignity in their own words and anticipate how Professional Nursing Practice by the AACN, 1998, pp. 8 – 9. Copyright 1998 by the American Association of Colleges of they will apply the value in clinical practice. This Nursing. assignment helps to ground students in concrete aspects of human dignity that are derived from both a universalist view and a particularist issues (Fahrenwald, 2003). Student experiences in the perspective on moral development. clinical setting or personal encounters with faculty Human dignity is learned through vicarious expe- members, peers, and other health-care professionals rience in a sensory deficit laboratory within a are formative in the particularistic approach to value- communications course. Students experience the life based education. of clients with vision, hearing, and mobility prob- lems. Discussion of personal feelings follows the Organization of the Undergraduate Curriculum experience. Key learning includes the importance of empathy and sensitivity when working with sensory- The conceptual framework for the undergraduate impaired people. Another key learning activity is an program is derived from The Essentials of Bacca- interpersonal communication process recording, laureate Nursing Education (AACN, 1998). Caring which is completed after a clinical experience. is described as professional behavior that uses both art Concepts that exemplify human dignity are incorpo- and science to address all dimensions of the client in rated within the assignment guidelines and evaluation nursing practice. Caring bencompasses the nurse’s criteria, including provision of privacy, confidential- empathy for and connection with the patient (i.e., ity, sensitivity to special needs, and competent client), as well as the ability to translate these affective communication skills. characteristics into compassionate, sensitive, appro- Human dignity is an abstract concept that is priate careQ (AACN, 1998, p. 8). The profes- difficult to evaluate using standard clinical assessment sional values provide the foundation for caring tools. Clinical conferences in the first semester provide professional practice. an opportunity to share experiences and observations One undergraduate program outcome specifies of human dignity. Students reflect on the aspects of that students will apply nursing values that exemplify human dignity observed through communication the caring, professional nurse. Level outcomes within patterns among health-care providers. Students also the nursing major stipulate that students will reflect on human dignity as applied in their own demonstrate caring behavior, with particular empha- performance of health assessment and interventions sis on one value during each of the five semesters. such as maintenance of safety, provision of privacy, Core values are examined conceptually within each of sensitivity to ethnic and cultural differences, and five professional perspectives courses. Value-based professional accountability. professional behaviors are practiced and evaluated within the clinical and theory courses offered each INTEGRITY: SEMESTER II semester. The following section provides an overview of this integrative approach to value-based education. The value of integrity is integrated in the second Strategies for teaching caring through value-based semester of the nursing major. In the professional learning within the undergraduate curriculum are course, integrity is introduced as bacting in accor- summarized in Table 2. dance with an appropriate code of ethics and accepted
  3. 3. 48 FAHRENWALD ET AL TABLE 2. Strategies for Teaching Caring Through Value-Based Learning Within the Undergraduate Curriculum Semester I: Semester II: Semester III: Semester IV: Semester V: Human Dignity Integrity Autonomy Altruism Social Justice Documents Code of Ethics Standards of Clinical Code of Ethics With Code of Ethics With Scope and Standards With Interpretive Nursing Practice Interpretive Statements Interpretive Statements of Public Health Statements (ANA, 1998) (ANA, 2001) (ANA, 2001) Nursing Practice (ANA, 2001) (ANA, 1999) Video Patient Confidentiality: Crossing the Line: A Nurse’s Residents Have the A Calling to Care Opening Doors: Public It’s Everybody’s Job Guide to the Importance of Answers: Improving Krals, 2001) Health Nursing in its (Costal Video Appropriate Professional Quality of Life in 100th Year (Washington Communications Boundaries (NCSBN, 1997) Long-Term Care State Public Health Corporation, 1997) (Terra Nova Association, 1993) Films, 2001) Age-Specific Care: Professional Boundaries It’s Relative (Costal [Brochure] (NCSBN, 1996) Video Communications Corporation, 1999) Assignment Personal definition Family project Critique of World Wide Wed Altruism definition Social justice issue of human dignity health information project project Interpersonal process Elderly client home visits Design of a living Will Altruism definition Journaling on social recording project justice issues Sensory laboratory 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 relationship, students are introduced to the concept of review ANA’s (2001) Code of Ethics then match professional boundary crossing. Students learn to statements describing nurse behaviors with respective avoid establishing socially focused relationships when statements from the code. The course professor, who providing home visits to pregnant women who are recently completed 10 years of services as a member often similar in age. The framework for this applica- of the state board of nursing, provides examples of tion of integrity and accountability in professional nurse behaviors that violated the ethical code and relationships is exemplified in a video and printed resulted in disciplinary action. These vicarious brochure prepared by the National Council of State illustrations assist students with application of the Boards of Nursing (NCSBN) (Table 2). These re- abstract language within the professional code. sources provide clear examples of the risks associated In a clinical course, students review the Standards with boundaries violations through well-intended ac- of Clinical Nursing Practice, 2nd ed. (ANA, 1998), tions, especially in community-based clinical settings. then describe how they implement each standard in the care of a community-based elderly client. During AUTONOMY: SEMESTER III four elderly client visits, students perform a health history, physical assessment, environment safety The third semester of the nursing major focuses on assessment, activities of daily living review, and a the value of autonomy, defined as bthe right to self medication review. Students analyze their nursing determinationQ (AACN, 1998, p. 8). This nursing care plan in relationship to the standards of practice. value is two-dimensional, including both patient An essential aspect of professional integrity is autonomy and nurse autonomy. Patient autonomy accountability for one’s own actions. Accountability focuses on respect for the patient’s right to make is evaluated throughout the semester, but receives decisions, even when those decisions conflict with the particular emphasis within a clinical assignment. Each values of the nurse. Nurses have a moral obligation to student visits a pregnant family during their pre-, the profession and to society to advocate for a patient’s peri-, and postnatal experience. In this nurse–family rights to self-determination.
  4. 4. TEACHING CORE NURSING VALUES 49 Learning experiences emphasize how to facilitate the A course module on liability changes the focus from patient’s right to make informed health-related choices. patient autonomy to nurse autonomy. Learning Nurse autonomy reflects a moral obligation to provide activities relate to the nurse’s obligation to not only competent care to clients and to protect clients from promote safe practice, but also to challenge the unsafe unsafe practice. Clinical nursing practice often occurs practice of other health-care providers. Case studies within a hierarchical health-care system that places help the student process how to intervene in situations social and environmental constraints on freedom of that require moral action on the part of the nurse to action (Scott, 1998). Consequently, it is critical that protect clients from unsafe care situations. nursing students practice how to exert influence for The third semester includes theory and clinical autonomous decision-making in practice. courses that focus on acute and chronic health prob- In the third of the five professional courses, a lems across the life span. Emphasis on the professional course objective specifies that students will recognize role of provider of care provides the platform for the value of autonomy and its relationship to nursing developing caring skills related to the value of care. The intent is to provide the conceptual basis for autonomy. Students are challenged to confront and autonomy in clinical practice. Within a module on respond to simulated unsafe care practices. A video information technology, students learn the nurse’s called Residents Have the Answers (Terra Nova Films, role in helping patients to independently gather and 2001) provides compelling evidence for allowing interpret health information. Autonomous behavior long-term care residents to maintain autonomous includes the provision of information so patients can decision-making. make informed choices (AACN, 1998). The most efficient means of facilitating choices and selecting ALTRUISM: SEMESTER IV new pathways is through knowledge development (Waller, 2001). Information empowers the patient to The value of altruism is integrated in the fourth make autonomous choices and vastly expands alter- semester of the nursing major. In the professional natives. To ensure that students are prepared to course, altruism is introduced as ba concern for the facilitate the selection of sound health-care alterna- welfare and well being of othersQ (AACN 1998). tives, students critique health-related World Wide Caring behaviors associated with altruism are often Web sites to determine (a) appropriateness for use by the reason that students choose the nursing profession patients, (b) credibility of the source, and (c) accuracy (Altun, 2002). Nurses extend altruistic caring beyond of the information. Each student leaves the course the traditional boundaries of family and friends to with a list of web sites that can be used to facilitate provide care to virtual strangers (Gormley, 1996; patient autonomy through informed, optimal, health- Grypma & Jamison, 2003). Altruistic caring behavior care decisions. involves self-sacrifice in its expression (Altun, 2003; A course module on ethics further develops the White, 2002). concept of patient autonomy because it applies to A course assignment in the fourth professional the process of informed consent. After classroom course assists students in recognizing the value of discussion and learning activities, students recognize altruism as a dimension of caring. The personal the nurse’s role and responsibility in assuring that definition of altruism project is designed to support consent for health care is an autonomous decision of analysis of altruistic behavior. Students consider how the patient or the patient’s legal guardian. In one the behaviors of high-profile public figures, such as learning activity, students create a living will or Princess Diana, Mahatma Gandhi, and Mother durable power of attorney. A values questionnaire Teresa, typified definitions of altruism. Reading and adapted from the Vermont Ethics Network (Teno & reflecting on materials that describe the altruistic Lynn, 1996) is then used to examine personal values actions of these public figures raises awareness of about these life issues. These learning activities help altruistic behavior. Students are also exposed to a the students to realize that autonomy is expressed video entitled A Calling to Care (Krals, 2001). This within each individual client’s value system (Doukas video tells the story of a successful professional nurse & McCullough, 1991). Creating a living will or who left her career to teach nursing to women in durable power of attorney provides an opportunity to Pakistan. After these learning activities, the students exercise personal autonomy and to experience the are guided to question and seek out examples of sometimes-difficult process of facilitating autono- altruistic acts performed by self and others. Each mous decisions. student explores the literature for references that
  5. 5. 50 FAHRENWALD ET AL exemplify and define altruism. Two references that Two additional nursing courses are taught in the last best relate critical attributes of a personal definition of semester of the program. Directed Study in Nursing is altruism are selected. The personal definition of a clinical and seminar course where students partici- altruism is then compared and contrasted with pate in 160 hours of clinical practicum under the literature-based definitions. The outcome of this supervision of a preceptor. As part of a required learn- concept analysis is a professional self-identity ing journal experience, students examine social justice grounded in altruism. Each student anticipates altru- issues observed in the practicum setting. istic behaviors that relate to their chosen career path The fifth semester also includes a population-based in nursing. public health nursing course. A course objective Within the fourth semester, there are two clinical specifies that students will apply the value of social and theory courses that focus on mental health and justice in nursing practice. Social justice is analyzed acute medical–surgical care. In clinical, students within the context of the Scope and Standards of become aware of the resources necessary to effectively Public Health Nursing Practice (ANA, 1999). Stu- manage altruistic care for a number of individuals dents also view the video Opening Doors: Public with complex mental and physical health problems. Health Nursing in its 100th Year (Washington State Clinical conference time is used to discuss caring Public Health Association, 1993). The vicarious decisions that support nurses’ altruistic values as well experience of observing public health nurses advocat- as the well-being of individuals with diverse back- ing for poor, substance-abusing, rural, and minority grounds and health issues. Altruistic behaviors of self populations is a particularistic approach to teaching and others are analyzed within the context of caring the value of social justice. for clients with extremely complex health concerns. 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 SOCIAL JUSTICE: SEMESTER V project. The purpose of the social justice issues project In the fifth and final semester of the nursing major, is to apply social justice principles to population the students are introduced to the value of social health problems. Students are encouraged to recall a justice in the professional perspectives course. Social clinical practice episode or life experience in which justice implies that there is a fair and equitable social justice issues specific to health were encoun- distribution of benefits and bearing of burdens in a tered. Students are encouraged to examine the type of society (Kneipp & Snider, 2001). Nurses who deeply oppression evident in these experiences and to value social justice may experience value-based discover ways to address the issue through a popula- conflict when working in a market justice health-care tion-based public health intervention. Students gen- system. Our profession embraces social justice (ANA, erate their social justice issue either inductively 2001), yet nurses continue to tolerate disparities in through experience and self-analysis or deductively health status and health care, especially as they exist in through reading the literature, examining issues, and minority and vulnerable populations on local, state, selecting one issue of interest. Project objectives national, and international levels (Fahrenwald, 2003). specify that the student describe the oppression In the professional perspectives course, students are evident in the social justice issue and present the exposed to local, national, and international social historical context for the injustice. The student is also justice issues. These issues are accessed from the World asked to provide evidence that supports this issue as Health Organization, the American Public Health important to the health of a particular population. Association, state and local health status indicators, The student develops and implements a public health and even local newspapers. To role-model the value of intervention to address the social justice issue. social justice, the instructor provides a compelling Examples of interventions that are appropriate for personal example of a social justice derived from the the social justice issue project are provided (e.g., clinical practice. Students view slides that portray the advocacy, coalition building, community organizing, population health inequities of AIDS orphans in and policy development). Malawi, Africa. Specific examples of the instructor’s To reduce student fear of receiving a poor grade if continued involvement in the social justice issue are the social justice issue is not congruent with the provided, including participation in a coalition that instructor’s value system, a peer evaluation mecha- builds orphanages in Malawi using local resources nism is used. Peer evaluation ensures accountability and personnel. for the assignment criteria while empowering stu-
  6. 6. TEACHING CORE NURSING VALUES 51 dents to critically evaluate whether peer projects met education throughout all nursing courses in a the assignment guidelines. As part of the assignment, baccalaureate education program is essential to ensure the student anticipates future involvement in that nursing students apply the abstract values of the issue. human dignity, integrity, autonomy, altruism, and social justice in clinical practice. Values integration Conclusion throughout the curriculum provides the conceptual, moral, and practical learning necessary to ensure that Nursing faculty members are challenged to teach the future nursing workforce is grounded in the core nursing values that embody the caring profes- concept of caring and actualizes this caring through sional nurse. Purposeful integration of value-based the application of value-based behavior. References Altun (2002). Burnout and nurses’ personal and theory and practice through consilience of knowledge. professional values. Nursing Ethics, 9, 269 –278. Advances in Nursing Science, 24, 17 – 35. American Association of Colleges of Nursing. (1998). Kneipp, S., & Snider, M. J. (2001). Social justice in a The essentials of baccalaureate education for professional market model world. Journal of Professional Nursing, 17, nursing practice. Washington, DC: Author. 113. American Nurses Association. (1998). Standards of Krals, B. J. (2001). A calling to care. Documentary film clinical nursing practice. 2nd ed. Washington, DC: Author. (Available from producer Documentary Educational American Nurses Association. (1999). Scope and stand- Resources, 101 Morse Street, Watertown, MA 02472). ards of public health nursing practice. Washington, DC: Liaschenko, J. (1999). Can justice coexist with the Author. supremacy of personal values in nursing practice? Western American Nurses Association. (2001). Code of ethics for Journal of Nursing Research, 21, 35– 50. nurses with interpretive statements. Washington, DC: National Council of State Boards of Nursing. (1996). Author. Professional boundaries: A nurse’s guide to the importance of Costal Video Communications Corporation (Producer). appropriate professional boundaries [Brochure]. Baltimore, (1997). Patient confidentiality: It’s everybody’s job. Video MD: Author. (Available from Coastal Training Technologies Corpora- National Council of State Boards of Nursing (Producer). tion, 3083 Brickhouse Court, Virginia Beach, VA 23452). (1997). Crossing the line: A nurse’s guide to the importance of Costal Video Communications Corporation (Producer). appropriate professional boundaries. (Available from pro- (1999). Age-specific care: It’s relative. Training video ducer, 526 Cole Lane, Baltimore, MD 21220). (Available from Coastal Training Technologies Corpora- Scott, P. A. (1998). Morally autonomous practice? tion, 3083 Brickhouse Court, Virginia Beach, VA 23452). Advances in Nursing Science, 21, 69. Doukas, D. J., & McCullough, L. B. (1991). The values Teno, J. M., & Lynn, J. (1996). Putting advance-care history: The evaluation of the patient’s values and advance planning into action. The Journal of Clinical Ethics, 7, directives. The Journal of Family Practice, 32, 145 –153. 205– 214. Fahrenwald, N. L. (2003). Teaching social justice. Nurse Terra Nova Films, Inc. (2001). Residents have the Educator, 28, 222 –226. answers: Improving quality of life in long-term care. Video Gormley, K. J. (1996). Altruism: A framework for (Available from producer, 9848 South Winchester Avenue, caring and providing care. International Journal of Nursing Chicago IL 60643). Studies, 33, 581 –588. Waller, B. N. (2001). Patient autonomy naturalized. Grypma, S., & Jamison, L. (2003). Caring for strangers. Perspectives in Biology and Medicine, 44, 584 –593. Journal of Christian Nursing, 20, 9 –13. Washington State Public Health Association. (1993). Jacobs, B. B. (2000). Respect for human dignity in Opening doors: Public health nursing in its 100th year. nursing: Philosophical and practical perspectives. Canadian (Available from author, 11414 26th Place SE, Everett, WA Journal of Nursing Research, 32, 15 –33. 98205 – 2586). Jacobs, B. B. (2001). Respect for human dignity: A White, K. (2002). Nursing as vocation. Nursing Ethics, central phenomenon to philosophically unite nursing 9, 279 – 290.