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: firstname.lastname@example.org This approach allows the student to generate caring
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
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
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
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
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
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
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)
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)
Age-Specific Care: Professional Boundaries
It’s Relative (Costal [Brochure] (NCSBN, 1996)
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
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.
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
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-
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.
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