Research ArticleAbstract
Background: Professional values provide a context for appraising beliefs and
attitudes that guide behaviors and considered as standards for acceptable actions by
professionals toward providing safe patient care.
Aim: This study aimed to assess professional values among Palestinian
undergraduate nursing and midwifery students and examine the relationship between
students’ demographics and professional values.
Materials and Methods: A cross-sectional design was used in this study. A
convenient sample of 370 undergraduate nursing and midwifery students from the
Islamic University of Gaza, Palestine completed an electronic version of the revised
nursing professional values scale, which consists of 26 items covering five domains
(caring, trust, justice, activism and professionalism).
Results: Age of participants ranged between 18 and 36 years with a mean of
21.1 years. The majority of them were females (60.7%), regular students (87.3%),
were enrolled in the nursing program (95.4%). The top caring statement rated by the
participants was “Maintain confidentiality of patient” (4.41) while the statement “Protect
rights of participants in research” received the lowest score (3.62). The mean total scores
of the domains of revised nursing professional values scale ranged between 3.610 for
the “professionalism” domain and 4.133 for the “justice” domain. The variables related
to age, gender, grades cumulative average, study year did not impact the scores of the
revised nursing professional values scale or its domains.
Conclusion: This study found that professional values were relatively high among
Palestinian nursing and midwifery students. Justice and caring domains were rated
highest by participants, while activism and professionalism domains were rated low.
These results should alert nursing educators to their roles in improving these values
among nursing and midwifery students. This could be approached by empowering, role
modeling and engagement of students in more activities to enhance these values.
Keywords: Professional Nursing Values; Undergraduate Nursing Students; Undergraduate Midwifery Students; Perception; Gaza; Palestine
Abbreviations: NPV: Nursing Professional Values; NPVS: Nurses Professional Values Scale; ANA: American Nurses Association; SPSS: Statistical Package for Social Science; ANOVA: Analysis of variance
Introduction
Professional values provide a context for appraising beliefs
and attitudes that guide behaviors and considered as standards
for acceptable actions by professionals [1]. Values are essential
to the nursing practice, determining priorities and creating the
relationships with clients. Specific values have been known as
needed to professional nursing practice and should be considered vital in any baccalaureate nursing program [2]. Nurses around the
world follow a shared set of professional values but terminology may
differ, however basic principles of beliefs and attitudes are similar.
These professional values include respect for protection of client
rights such as privacy, beneficence and non-maleficence, human
dignity, responsibility and accountability [3]. In a qualitative study
done by [4]. The participants’ described a range of professional
values and behaviors, but only four main professional values were
identified, included: being person-centered; kindness and caring;
being in control; and commitment to learning. Attaining Nursing
Professional Values (NPV) is vital to professional development
because of increasing quality of care; improve patient satisfaction,
nurses job satisfaction and retention of staff [5]. Since such values
are important and significant factors for quality care, so developing
professional values among undergraduate nursing and midwifery
students is central.
Worldwide, there have been a numerous studies in the issues
of professional values. One was done by Parandeh, Khaghanizade,
Mohammadi, and Nouri (2015) aimed to assess factors influencing
development of professional values among nursing students
and instructors. Researchers found that there is an influence
of many elements such as individual, culture and education on
developing nurses’ professional values; in accordance, nursing
programs should reflect that on the curriculum through valuebased
cares and in clinical training [6]. Another study explored
nursing students’ perception of NPV and compared the NPV scores
between participants according to demographic characteristics
in South Korea [7]. The NPV scores were significantly higher in
students who entered nursing schools following their desire and
students who were planning to pursue graduate study than in
those who entered because of their scores are sufficient and had
not yet decided their career future. The NPV scores were not
correlated with academic year, gender, or academic performance
[8]. Moreover, in a study aimed to assess the perspective of nursing
students from universities of medical sciences about professional
values of nursing in Iran. The most important and least important
items identified by the participants were the “maintain competency
in area of practice “and “participate in peer review”, respectively
[9].
Regionally, a few studies conducted to assess nursing student’s
professional values, such as R. S. Allari, Ismaile, and Househ (2017)
study to explore the perception of Saudi female nursing students
on professional values and to examine the relationship between
students’ and their year of academic studies. The results presented
that students have a positive perception of professional values
in relation to confidentiality, privacy, patients’ rights, safety, and
work environment. Whereas they have a low perception engaging
in professional nursing activities, evidence based practice, peer
review, public policy, and participating in self-evaluation. And there
was positive correlation between professional values and academic
years [10]. The need to teach professionals with competencies
that stand highly for the services that should be given to clients is
becoming an issue of increasing importance. Nursing education
and practice must be grounded on fixed high quality standards and
competencies. The development of a nursing code of conduct is to
guide nurses to make fitting clinical decision, when facing ethical
dilemma.
It is significance that nurse educators, faculty members and
instructors understand baccalaureate nursing students’ perceptions
of the importance of the code of conduct and the technical difficulties
in implementing it though preparing them for future practice of
nursing. According to the Palestinian Accreditation and Quality
Assurance Commission (2014), the Code of Conduct includes
the following principles: altruism, autonomy, human dignity,
integrity, and social justice [11]. In accordance, one of the major
nursing education standard or outcome in relation to professional
values in higher education in Palestine is aimed that students
and graduates should exhibit ethical behavior and understands
and follow professional values. This outcome can be achieved
by the help of nursing program who provides opportunities for
students to participate in professional organizations that advocate
for quality and health care, uses realistic scenarios for students
that address ethical, and legal patient care situations, provides
opportunities to participate in inter-professional service-learning
projects, uses reflective writing as assessment strategy to discuss
student perception of advocacy role and identifies the influence
of his/her attitudes, values, on practice, develops a student honor
code and professional values to be embraced, and demonstrates
professionalism [12].
Palestinian nursing and midwifery students need to know
that it is important to understand the nurses’ professional values
because they are in a specialty that carries great privilege and
responsibilities. On the other hand, Palestinian cultural values
are mostly generosity, selflessness, hospitality, and respect for
relatives, willingness, chastity and sexual modesty. These values
are greatly related in the essence to the professional values, so it
will not be so demanding for Palestinian nursing and midwifery
students to hold professional values. Nursing values is essential
globally and locally. Therefore, educating nursing and midwifery
students about the significance of nurses’ values and the need
to be committed to apply those values through their health care
practices, and decision making thus will improve patients out
comes. However, there were no papers about professional values
among Palestinian undergraduate nursing and midwifery students.
The purpose of this study is to assess professional values among
Palestinian undergraduate nursing and midwifery students and
examine the relationship between students’ demographics and
professional values.
Materials and Methods
Design, Setting and Sampling
A cross-sectional, descriptive design was used in this study. The target population comprised of undergraduate nursing and midwifery students enrolled in the second semester at the Faculty of Nursing at the Islamic University of Gaza. This included students who are upgrading from associate degree to bachelor’s degree. Data were collected after students had finished their final exams for the second semester. There were 1392 students enrolled in this semester, 920 of them were females and 412 males; 221 were enrolled in the midwifery department while the rest (1170) were in the nursing department. The sample size was calculated using sample size calculator Rao soft®. With a population size 1392, margin error 5%, confidential level 95%, distribution response 50% the recommended sample size given was 302 students, but all the population were targeted to compensate for missing responses and reach the intended sample size. A total of 370 students completed an electronic version of the questionnaire. Data were collected by electronic means due to the spread of COVID-19 pandemic. The link for the survey was sent to students through WhatsApp groups established by the faculty members to communicate with students during the COVID-19 pandemic.
Instrument
A self-administered electronic questionnaire was used in this
study. The Nurses Professional Values Scale (NPVS) was developed
by Schank and Weis (2000) to measure professional nursing values
based on the American Nurses Association (ANA) Code of Ethics for
Nurses [13]. The instrument was then revised by same authors and
now is known as Nurses Professional Values Scale-Revised (NPVS-R)
[14]. The NPVS-R is used to measure professional values and has
been translated and validated into the Arabic language by R. Allari.
The NPVS-R includes 26 items based on the nine provisions of the
Code of Ethics for Nurses [15]. Each item of the NPVS-R contains
expressive statement that reflects the interpretive statements
of the Code of Ethics of the American Nurses Association. Each
statement NPVS-R is rated on a five-point Likert scale. For each
item, the possible answers are:
a) not important
b) slightly important
c) important
d) very important
e) most important
The NPVS-R was designed with five factors supported by
psychometric evaluation done by Weis and Schank (2009).
Those factors were caring, activism, trust, professionalism, and
justice. The Arabic version [16] was tested for the reliability and
validity and the results revealed that the scale to be valid and highly
reliable to be used for assessing PNV among Arab nursing students.
Internal consistency reliability of the five factors were significantly
high ranging from 0.71 to 0.91. Internal consistency reliability
reported from this study for NPVS-R was 0.950 and ranged between
0.766 and 0.899 for its domains.
Data Analysis
The Statistical Package for Social Science (SPSS), version 18, was used to compute and analyze the data. Data was analyzed using descriptive statistics (frequency, percentage, mean and standard deviation). Analysis of variance (ANOVA), t-test and Pearson’s correlation coefficient were used to examine impact of study variables on professional values. Statistical significance was established at the 0.05 level.
Ethical Considerations
Prior to conducting this research study, ethical clearance was obtained from the Research Ethics Committee Board at the Islamic University of Gaza. Participants were informed about the purpose of the study at the opening statement of the electronic questionnaire and were assured that their participation is completely voluntary and that participant one has the right to refuse to complete the questionnaire. Participants were assured that if they decided to refuse to be involved in the study, this decision would not affect their grades. Data was collected anonymously from all participants. In the final report, confidentiality and anonymity will be maintained.
Results
Characteristics of Participants
A total of 370 nursing student completed the questionnaire. Table 1 represents the characteristics of participants. The majority of participants were females (60.7%, n = 258). Age ranged between 18 and 36 years with a mean of 21.1 years (± 2.78). The majority of participants were regular students (87.3%, n = 323) while the rest were upgrading student from associate degree to a bachelor’s degree. Most of the respondent were from student in the third year (40.8%, n = 151) while the least were from students in the second year (12.7%, n= 47). The great majority of our participants (95.4%, n = 353) were enrolled in the nursing program while the rest came from the midwifery program. Grade accumulative average ranged between 50.2 and 98.4 with a mean of 79.51(± 7.7). Finally, the great majority of participants (83.2%, n = 308) were planning to study nursing at the time of enrollment.
Table 1: Descriptive statistics for participants’ characteristics.
NPVS-R and its Dimensions
The total score for the NPVS-R ranged from 26 and 130 with a mean of 100.68 (±16.55). Table 2 depicts the number of items, minimum, maximum, total score, standard deviation and mean for the NPVS-R and its subdomains. This is beside the Chronbach’s alpha for each of them. Chronbach’s alpha for the NPVS-R was 0.95 and for the subdomains, they ranged between 0.766 and.899; which all fall within the acceptable ranges. The domain Justice was ranked first by our participants with a mean of 4.133 while the professionalism domain received the lowest mean (3.610). The top caring factor statement rated by the participants was “Maintain confidentiality of patient” with a mean of 4.41 (±0.86) followed by “Safeguard patient’s right of privacy”. On the other hand, participants rated “Protect rights of participants in research” as the lowest statement with a mean of 3.62 (±1.04) (Table 3). The statement “Advance the profession through active involvement in health related activities” received the highest mean among the activism domain with a mean of 4.07 (±0.96). Moreover, the statement “Participate in public policy decisions affecting distribution of resources” received the least score with a mean of 2.94 (±1.04) (Table 4).
Table 2: Descriptive statistics for NPVS-R and its domains.
Table 3: Mean and ranking of statements of caring dimension.
Table 4: Mean and ranking of statements of activism dimension.
Table 5 depicts the means for the trust dimension. The statement “Maintain competency in area of practice” received the highest rank with a mean of 4.20 (±0.89). Moreover, the statement “Engage in on-going self-evaluation” was ranked last with a mean of 3.49 (±0.89). Table 6 represents the means for the statements related to professionalism dimension. The means ranged between 4.13 (±0.92) for the “Initiate actions to improve environments of practice” statement and 2.88 (±1.06) for the “Participate in peer review” statement. Finally, the top statement rated by the participants in the justice dimensions was “ Protect health and safety of the public” as it received a mean of 4.37 (±0.84). On the other hand, participants rated the statements of “Assume responsibility for meeting health needs of the culturally diverse population” as the lowest rated statement with a mean of 3.85 (±0.97) (Table 7).
Table 5: Mean and ranking of statements of “Trust” dimension.
Table 6: Mean and ranking of statements of Professionalism dimension.
Table 7: Mean and ranking of statements of Justice dimension.
Influencing Factors on NPVS-R and its Subdomains
Results of correlation coefficient revealed no significant
correlation between age nor grades cumulative average and total
score of NPVS-R and its domains. Results of t test showed that
gender did not affect means of NPVS-R and its subdomains. On the
other hand, when test for significance difference between regular
student and upgrading students, it was found that there was a
statistically significant difference between the means of the two
groups in the domain of professionalism as the mean for regular
students was 14.33 and for upgrading students 15.17 (p = 0.38).
There was slight difference between the means of justice domain of
nursing student (mean 12.6) and midwifery students (mean 13.39)
with a p value of 0.48. One way ANOVA did not show any difference
in the means of NPVS-R and its subdomains among students from
different levels of study.
While ANOVA test did not show any difference if the means of
activism and justice subdomains according to students planning at
enrolment time, there were some difference in the means of total
score of NPVS-R and the other subdomains (Table 8). Differences
were found to be statistically significant between the means of
student who planned to enroll at the faculty of nursing and those
who did not know in the total score of NPVS-R (p = 0.033), trust
domain (p= 0.039) and professionalism domain (p = 0.038), while
the significance in differences in the caring domain was due to the
difference in the means of students who planned to enroll at the
faculty of nursing and those who did not (p = 0.023).
Table 8: Descriptive statistics to NPVS-R and its domains in relation to the variable whether students plan to study nursing the time of enrollment.
Discussion
The present study aimed to assess professional values from the
perception of undergraduate Palestinian nursing and midwifery
students. The top caring factor statement rated by the participants
was “Maintain confidentiality of patient” (4.41) while the statement
“Protect rights of participants in research” received the lowest
score (3.62). On the other hand, the mean total scores of the
domains of PNV-R ranged between 3.610 for the “professionalism”
domain and 4.133 for the “justice” domain. While the variables age,
gender, grades cumulative average, study year did not impact the
scores of PNV-R or its domains, results of upgrading students were
higher in the domain of professionalism. Moreover, there was slight
difference between the means of justice domain among nursing
students (mean 12.6) and midwifery students (mean 13.39). The
high scores of nursing professional values reported in this study are
congruent with many other findings from other studies conducted
in different countries [17-29]. The relatively high scores of NPVS-R
reflects adherence of nursing programs to providing nursing
and midwifery students the essential standards of preparing
nursing and midwifery students for practice and support in their
professional values [19]. This argument is supported by Sibandze
and Scafide (2018) who found, in an extensive literature review,
that nurses pursuing a Bachelor of Nursing had a more awareness
and application of professional values than nurses with lower levels
of academic or non‐academic education.
Participants of this study rated “Justice” and “caring” as the
highest domains of NPVS-R. Other studies ranked the domain
“Justice” as the highest or the second highest domain [25].
The justice domain is considered the “basis for all professional
interactions across all care settings” [26] and it reflects nurses’ duty
to provide equal care to all patients regardless of diversity issues
[30]. A potential cause for rating “justice” as the highest domain by
Palestinian nursing and midwifery students is the fact that Palestine
is one of the few countries that are still under occupation, which
enhances feelings of injustice among Palestinians; therefore, they
do their best to provide justice for their clients. The second most
important domain from participants’ perception was “caring.” This
domain was rated as the first or second most important domain in
many other studies [31]. Caring includes “having a concern or regard
for that which affects the welfare (of another)” and it is considered
central to nursing practice [32]. Furthermore, dimensions of caring
are considered as the most fundamental values and commitments
of the nurse in the ANA code of ethics [33]. Begum and Slavin
(2012) argued that nurturing a caring attitude in nursing education
is important as this is the first place for students to learn about the
most significant values and essence of their profession.
Moreover, giving high scores by nursing participants to
items related to “caring” dimension could be due to that caring is
considered by students as the major role of nurses and the spirit
of nursing practice. Another reason for rating high scores for the
items of “caring” could be due to the fact that nursing programs
may have an impact on students’ caring values and behaviors
and that students are evaluated in their practice mostly for their
skills of caring during their practice. The statement “maintain
confidentiality of patient” from the “caring” domain received
the highest score of the NPVS-R items with a mean of 4.41. This
reflects the high attention students pay for safeguarding patients’
rights for privacy and maintaining confidentiality, which are core
competences of caring. This goes in line with other studies which
ranked this item in the top items of the NPVS-R the caring domain.
R. S. Allari considered the issue of maintaining privacy as an
essential right since it is a part of the Islamic doctrine which is the
main religion in Palestine and influencing the actions and cultural
believes of the participants.
The low scores of our participants related to public policy,
professional organizations and peer review is not unique to our results. Other studied reported similar results. This could be due
to the political chaos that prevails in the region where people,
including nurses and nursing and midwifery students, are not
really involved in such activities. Finally, the scores of the domains
“activism” and “professionalism” were rated with the lowest scores
by our participants, which goes in line with other studies. These
results should alert nursing educators to their roles in improving
these values among nursing and midwifery students. This could
be approached by empowering, role modeling and engagement
of students in more activities to enhance these values. Moreover,
faculties of nursing may help to enhance these values through
arranging meetings and forums with faculty members, national
nursing pioneers in research, activities in public policy and engaging
students in peer reviews, self-evaluations, and lead professional
nursing events and activities.
Conclusion
This study found that Palestinian nursing and midwifery students’ perceptions of the importance of professional values were relatively high. Items related to justice and caring domains were rated highest by participants, while items related to activism and professionalism domains were rated low. While the variables age, gender, grades cumulative average, study year did not impact the scores of PNV-R or its domains, results of upgrading students were higher in the domain of professionalism and midwifery students reported slightly higher score in justice domain than nursing students. These results should alert nursing educators to their roles in improving these values among nursing and midwifery students. This could be approached by empowering, role modeling and engagement of students in more activities to enhance these values. Furthermore, nursing educator need to focus on enhancing facilitating factors which include personal factors (such as stimuli, believe in God, inner beliefs and acting on values) and environmental factors (such as cooperation, order and discipline) ensure avoiding inhibiting factors which include personal inhibitors (the lack of professional motivation and enthusiasm, negative emotions) and environmental inhibitors (unfavorable work environment, society’s negative attitude toward nursing, the violation of rights).
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