Attitudes and Values of Nurse Educators: An International Survey

International Journal of NursingEducation Scholarship

Volume 4, Issue 1 2007 Article 14

Attitudes and Values of Nurse Educators: AnInternational Survey

Carol Haigh∗ Martin Johnson†

∗University of Salford, UK, [email protected]†University of Salford, UK, [email protected]

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Attitudes and Values of Nurse Educators: AnInternational Survey

Carol Haigh and Martin Johnson

Abstract

Within the last two decades the holistic care of patients has become increasingly important tonurse practitioners and educators. This has led to a move from a wholly biological approach tocare to one that requires greater moral reasoning and value judgments by practitioners. There is asignificant body of literature suggesting that values developed by students throughout their educa-tion can be affected to varying degrees by the nurse educators to whom the student is exposed. Yet,there is a dearth of research into what the values held by such nurse educators may be. A ques-tionnaire was distributed to nurse educators from nineteen different countries at an internationalconference. Overall, educators reported high regard for the values of honesty and intellectualism,whilst maintaining a more cautious, although still positive, attitude toward altruism in health care.

KEYWORDS: nurse education, attitudes, spirituality



Within the last two decades the holistic care of patients has become increasingly important to health care practitioners and educators, and this has led to a move from a wholly biological approach to care to one that requires greater moral reasoning and value judgements on the part of the practitioner. There is a significant body of literature that suggests that values developed by students throughout their nurse training and later demonstrated in early career stages can be affected to varying degrees by the nurse educators to whom the student is exposed. Yet, there is a dearth of research into what the values held by such nurse educators may be. In this paper we report the results of a survey conducted at an international nurse education conference to complement a larger replication study whose purpose is to compare and contrast the values and attitudes of student nurses in 1983 and 2005. The focus of this study was to gain some insight into the values and attitudes of contemporary nurse educators from several countries.

LITERATURE REVIEW

Whilst there is increasing interest in exploring the values demonstrated by nurses of various grades and educational backgrounds, such exploration is hampered by difficulty in identifying and categorising such values. Fawcett, Watson, Neuman, Hinton Walker, and Fitzpatrick (2001) spoke of moral and nonmoral values in nursing but did not commit themselves to a clear articulation of the difference between them nor did they suggest what these values may be other, than to state that they could be found in standards of practice or within nursing philosophies.

Nurses’ Values

Gregg and Magilvy (2004) examined nurses’ values in clinical practice and developed 12 categories which reflected reported values. These categories were extremely specific including items such as considering patients’ feelings, having nursing knowledge and skills, and advocating for patients. Although some insight is offered into the values nurses consider important in the clinical relationship, these categories have not been reduced to deeper Western concepts such as altruism or paternalism. Appropriate (and equivalent) Japanese concepts were applied to the findings. Martin, Yarborough, and Alfred (2003) explored nursing values across ethnic groups using a validated Nurses’ Professional Values Scale based on codes of professional conduct. No attempt was made to group these results into wider conceptual value categories although very similar concepts to those reported by Gregg and Magilvy were inherent in the work.

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Haigh and Johnson: Attitudes and Values of Nurse Educators



To explore value longevity, Fagermoen (1997) carried out a value analysis of qualified nurses of varying degrees of experience. She identified 4 specific values with which her sample (n=731) was in almost total agreement: upholding humanness, attending to needs for help, intellectual stimulation, and personal stimulation.

A clear theme from these studies is that some key nursing values are applicable across philosophies, ethnicity, and experiences. Although the nomenclature varies, it can be argued that these values all belong to the wider value categories of altruism, intellectualism, and honesty.

Nursing Teachers’ Influence on Students’ Values

It is also clear from the literature that values held by nursing students change and develop over the course of their education, and that nurse teachers have been acknowledged as playing a key role in their socialisation. .The longer a student spends in the academic environment (in contrast to the clinical area), the closer their values and professional identity mirror those of their teachers (Lewis, 1998). The relationship between the nursing student and the educator is of necessity a close one, although this closeness may fluctuate as the student develops into a qualified practitioner. For example, the responsibility for the transmission of fundamental nursing skills is a dynamic one, with senior students often perceiving practitioners as more credible sources of clinical information than educators (Ramage, 2004).

However more philosophical and moral challenges that are attendant upon modern health care tend to remain the province of the academics throughout nurse training (Milligan, 1997; Paterson & Crawford, 1994). Gullberg (1996) noted that amongst the underlying dimensions of professionalism or professional identity are empathy and discernment. Building on this work, Öhlén and Kerstin (1998) suggested that the practical elements of the nursing role are more easily observed than the professional identity elements, which are often sited in the deeper level of an individual’s self-image and self-esteem. Öhlén and Kerstin argued that education plays an important role in the development of professional image and self-esteem, a stance supported by Lewis (1998). Thus it can be seen that the conceptual understanding, the philosophical beliefs, and the underpinning values of nurse educators form the core of the contribution that educationalists make to nursing students.

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International Journal of Nursing Education Scholarship, Vol. 4 [2007], Iss. 1, Art. 14

DOI: 10.2202/1548-923X.1374



One of the difficulties associated with this educational contribution to the development of a student’s value framework is the identification and the embedding of the ‘appropriate’ values in the nursing curriculum. Melnick (2002) found that educators were unanimous in acknowledging the importance that values education played in the development of health care practitioners, but they were less clear about how values education should be managed .Teaching of core values occurred in an informal manner and was described as having been integrated into the entire curriculum (Melnick), and aesthetics was not taught on any level. This informal approach to values education had also been described a decade earlier by Elfrink and Lutz (1991), who reported few teachers incorporating values discussion into formal lesson plans, preferring to deal randomly with values-related issues as needed. It was interesting to note that values teaching tended to be accorded greater importance in religious affiliated institutions. This may have implications in more secular countries or for institutions that do not traditionally have such affiliations. For example, in the United Kingdom (UK), nurse education is lodged within universities that are government-funded rather than supported by religious organisations.

There is widespread recognition that nurse educators have an important and fundamental role to play in the transmission and inculcation of nursing values, even though such transmission occurs on an ad-hoc basis. However there is little understanding of the fundamental values, be they professional, moral or nonmoral, which nurse educators hold, and it is this knowledge gap that this study addresses.

THE STUDY

Research Aim, Design, and Questions

The aim of the study was to provide some insight into the values and attitudes of contemporary nurse educators from a number of different countries. To address this goal, a quantitative survey study was designed to answer the following research questions;

1. What are the attitudes and values of contemporary nurse educators to nursing behaviours?

2. Do these attitudes differ among countries?

Data-Collection Instrument

The questionnaire consisted of 57 items in a five-point Likert scale format. The first 37 questions were drawn from a general attitudes and values questionnaire (Scott, 1959), with response options ranging from Always Admire to Always

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Dislike, a format that assumes that ‘liking’ the behaviour in others reflects one’s personal values. In this paper items which are labelled as ‘Scott’ items are drawn from this section of the questionnaire. These elements have been subjected to validation in the past and were reported as having good internal consistency with a Cronbach’s alpha coefficient of .64. In the current study, the Cronbach’s alpha coefficient was .92.

The remaining 20 questions were directly related to nursing and were designed for the original 1983 research by one of the team (MJ). The response range was from Strongly Agree to Strongly Disagree. Items labelled as ‘Johnson’ items are drawn from this section of the questionnaire. Cronbach’s alpha coefficient of .96 was obtained on these 20 items, exceeding the value of.7 for tests of ability) and .8 for cognitive tests, suggested by Kline (1999) The final items requested demographic data including country of origin.

Sample and Participants

The questionnaire was distributed to nurse educators from 19 different countries who were delegates at the Elsevier First International Nurse Education Conference in Vancouver in 2006. Four hundred questionnaires were included in conference packs.

Ethical Considerations

This study was subjected to ethical review and given approval by the ethics committee of the University of Salford. Permission to include the questionnaire in delegate packs was obtained from conference organisers.

Data Analysis

The questions within the study instrument were grouped into 9 broad conceptual categories: Honesty, Religiousness, Intellectualism, Self control,Academic achievement, Independence, Altruism, Paternalism, and Authority. In this paper, the results for Honesty, Altruism, and Intellectualism/Academic achievement are reported. The choice of these categories was informed by literature which suggests that these three broad value concepts underpin a large majority of nursing ideals. The themes of Intellectualism and Academic achievement are conflated to reflect the importance highlighted within the literature that nurses put upon knowledge, skills and education.

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DOI: 10.2202/1548-923X.1374



Analysis was conducted using the software Statistics Package for Social Sciences V13 (SPSS). Descriptive statistics were used with non-parametric correlation analysis to explore the relationship between specific variables. Furthermore, the relevant items in each of the conceptual categories were transformed using the SPSS programme into a ‘set’ which allowed for the percentage frequencies for all of the responses for each of the category elements to be calculated.

RESULTS

Demographics

The 74 completed questionnaires constituted a response rate of 18.5%. A total of 9 countries of a possible 19 were represented (47%). Table 1 shows the number of respondents by country. The countries with the largest responses was Canada (n=28, 33%), closely followed by the UK (n=23, 27%), and the United States (US) (n=14, 17%). After Australia (n=3, 4%) respondents were single representatives from 5 other countries.

Most respondents were in the 50-59 age range (n=35, 41.7%). The mean age was 48.5 years (range 26-69.07). Fifty-five (85.6%) respondents had an advanced degree at the Masters level and 19 (25.6%) were educated at the Doctoral level. There was a strong gender bias in the sample with 67 (90.5%) of the sample being women and 6 men (8.1%). One person did not respond to this item.

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Table 1 Responses by Country

Nurse Educators’ Values

The results for each relevant category are presented here. Scott items refer to general, i.e. non nursing specific, attitudes whilst Johnson items place the concept in a nursing context. Additionally, a correlation matrix for each category was produced using the non-parametric test for categorical data, Spearman’s Rank Order Correlation (Spearman’s rho - rs). All variables that made up each of the concepts were compared with level of education, exemplified by whether the respondent had a higher (doctoral) degree and country of origin (although given the Canada/UK/US skew of the sample, any country-of-origin correlations should be viewed with caution).

Honesty. The respondents showed high levels of respect for honesty. The Scott items showed some uncertainty about the situations described. For example, while 13.6% (n=10) responded that they would be reluctant to tell a lie even if it

Myanmer (Burma)

Switzerland

Australia

Canada

US

302520151050

28

1

1

1

1 1

3

14

23

Malaysia

Ireland

Scotland

UK

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DOI: 10.2202/1548-923X.1374



would make the situation more comfortable, 32.4% (n=24) stated that it would depend on the circumstances. For the Scott items, the overall mean score was 3.50 (2.91-3.88). In contrast, however, the items relating to nursing honesty were far more polarised; for example, 86.5% (n=64) believed that patients should always be told anything they want to know about their condition and 85.1% (n=63) disagreed that nurses ought to keep quiet about minor mistakes that cause no real harm. For these items the overall mean score was 3.85 (3.42-4.27)

When the frequencies for the identified set honest were analysed, 666 responses were possible. This number represents the product of the sample number (74) multiplied by the number of questions (9). Missing data were excluded from the analysis, leaving a total of 586 viable responses. Overall 66.5% (378) of responses showed a disapproval of dishonest practice.

Two statistically significant relationships were identified by the correlation analysis. In the general Scott items category there was a weak, statistically significant negative correlation between the variable, Never cheating, or having to do with cheating situations, even for a friend, and possession of a higher degree (rs = -.242; p = .05.) In relation to professional honesty, there was a weak, statistically significant positive correlation (rs = .252; p = .05) between the variable, Assuming that disciplinary action is often very severe; nurses ought to keep quiet about minor mistakes, and possession of a higher degree.

Altruism. The importance that respondents attached to the concept of kindness both generally and professionally was clearly demonstrated. Most (63.5%, n=47) disagreed that being calm and efficient was more important than being kind when busy and 81.1% (n=60) agreed that there ought never to be any excuse for being unkind to a patient. In the ‘general’ non-nursing specific section of the questionnaire 93.2% (n=69) felt that one should be kind to people even if they do things contrary to one’s beliefs’.

The overall mean score for the Scott items was 4.05 (3.54-4.34) and the overall mean score was 3.14 (1.91-4.11) for the Johnson items. The frequencies for the identified set altruism had a potential 666 responses, and when missing data were excluded from the analysis, there were a total of 639 viable responses. Overall, 71.3% (454) of responses demonstrated an appreciation of altruistic behaviour. There were no statistically significant correlations found between possession of a doctoral degree and general altruistic behaviour. There was a weak, statistically significant positive correlation (rs = .286; p = .05).between the variable Refusing aid to people who don’t deserve it and country of origin. There were no statistically significant relationships between higher levels of education

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and altruism. A weak, statistically significant positive correlation (rs = .239; p= .05) between the variable Being calm and efficient is more important than being kind … and country of origin.

Intellectualism/academic achievement. The importance that nurse educators attach to awareness of international affairs and intellectual pursuits was demonstrated. Most (n=67, 90.5%) approved of developing an interest in national and international affairs and 97.3% (n=72) admired a strong intellectual curiosity. For the ‘Scott’ items the overall mean score was 4.01 (range 2.93 – 4.68). For the ‘Johnson’ items the overall mean score was 3.82 (range 3.18 – 4.18).

When the frequencies for the identified set Intellectualism/academic achievement were calculated, 1101 potential responses were possible. Missing data were excluded, leaving a total of 1065 viable responses. Overall, 80.3% (955) of responses reflected an appreciation of Intellectualism/academic achievement. There were no statistically significant correlations between possession of a doctoral degree and intellectualism/academic achievement at either a general or a professional level.

DISCUSSION

There is evidence from the current literature that the attitudes and values that student nurses develop and take with them into the clinical area are fostered and nurtured by the nurse educators to whom they are exposed throughout their education. Of course, a wide previous literature has focused on the importance of professional socialisation, notably under the influence of role models in the clinical or practice setting rather than in the academy. For example, in the USA, Kramer (1974) drew attention to the role and value strain that newly qualified nurses endured when faced with bureaucratic values of the hospital after being taught ‘professional’ values in the school. In Scotland, Melia (1987) elicited the separation or segmentation of values that students seemed to endure between the ‘pragmatic’ care environment and the ‘theoretical’ School of Nursing. In these studies the influence of nursing teachers is evident, but arguably superseded in practice by the values learned in the field. Now, with longer periods of nurse training spent in school and final qualifications higher than in the past, it seems time to re-appraise the influence of both the mediums of student nurse education and the relative importance of each. This study begins such a process.

Although the definition of value is fluid, there are broad areas of consistency with the categories of Honesty, Altruism, andIntellectualism/academic achievement being inherent in many studies of nursing

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values. These consistencies informed the elements of the overall questionnaire used in this investigation. This reflects the work of Fagermoen (1997) about the longevity of values.

Generally, the educationalists in this study had a strong regard for honesty at all levels, although there was an indication that professional honesty was of greater importance to them than honesty in general. Although Öhlén and Kerstin (1998) suggested that the practical elements of a nurse role are more easily observed than the professional identity elements, in the study sample the practical nursing elements are subsumed into the academic environment, thus allowing for the professional identity elements to be more easily observed. It may also be a reflection of the maturity and life experiences of the respondent since Öhlén and Kerstin also suggest that such professional identity elements are associated with self-image and self-esteem.

In comparison, the mean score for general altruism was higher than that for professional altruism. This may imply that educators have a strong sense of altruism towards people in general, but a more jaundiced view of the role that altruism can play in modern health care. However, the importance that respondents placed upon the sub-category of kindness illustrates both the underpinning philosophy and the non-judgemental approach that nurse educators and practitioners aspire to, and lends cross-cultural support to the findings of Gregg and Magilvy (2004).

Unsurprisingly, the respondents had strong positive opinions about the importance of the intellectual life and academic achievement. The ‘set’ analysis of each of the concepts showed a greater percentage approval for the concept of intellectualism and academic achievement than any other. This finding resonates with the work of Melnick (2002).

The values strongly represented in nurse educators in this study are not often formally taught (Elfrink & Lutz, 1991; Melnick, 2002). Although students gain these ‘deeper’ attitudes from their exposure to academics (Lewis, 1998), it can be argued that nurse education has ignored the formal transmission of these values for too long. The prime implication for nurse education found in this study is that nurse educators have the values and attitudes appropriate to nursing in the 21st century and so should be encouraged to communicate them in a more structured way than the ad hoc methods of the past

The main study limitation is the poor response rate, and therefore, results and insights must be treated with caution. Although the generalisability is limited,

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it must be emphasised that this work provides new knowledge which will contribute to a previously under-researched area of education. Chalmers (2006) noted that “study findings should be communicated, regardless of outcome for the benefit of the community at large” (p. 2).

CONCLUSION

In conclusion, this study has provided some insights into the strength of values and attitudes of nurse educators. The values of honesty, altruism, and Intellectualism/academic achievement that underpin nursing care are strongly represented in nurse educators. Since these are, arguably the values that educators hope to inculcate into their students, this is encouraging. Previous work has demonstrated that student gain these ‘deeper’ attitudes from their exposure to academics (Lewis, 1998), and nurse education now need to examine ways in which these values can be transmitted in formal rather than haphazard ways. Thus, although this study has limitations in the size and countries of origin of the sample, it does provide an analysis of the values that educators are transferring to their students and, as such, suggests future avenues of useful enquiry.

REFERENCES

Chalmers, I. (2006). Biased under reporting of research. RSS News, 34(2) 1-3.

Elfrink, V., & Lutz, E. M. (1991). American Association of College of Nursing essential values: National study of faculty perception, practices and plans. Journal of Professional Nursing, 7, 239-245.

Fagermoen, M. S. (1997). Professional identity: values embedded in meaningful nursing practice. Journal of Advanced Nursing, 25, 434-441.

Fawcett, J., Watson, J., Neuman, B., Hinton Walker, P., & Fitzpatrick, J. (2001). On nursing theories and evidence. Journal of Nursing Scholarship, 33, 115-119.

Gregg, M. F., & Magilvy, J. K. (2004). Values in clinical nursing practice and caring. Japan Journal of Nursing Science, 1, 11-18.

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Gullberg, M. (1996). Health care professionals’ self description. Linköping University Medical Dissertations No. 479 (Thesis abstract). Retrieved June 14, 2006 from

http://www.bibl.liu.se/liupubl/disp/disp96/med479s.htmKline, P. (1999). The handbook of psychological testing. London: Routledge.

Kramer, M. (1974) Reality shock: Why nurses leave nursing. St Louis: Mosby.

Lewis, M. A. (1998). An examination of the role of the learning environments in the construction of nursing identity. Nurse Education Today, 18, 221-225.

Martin, P., Yarborough, S., & Alfred, D. (2003). Professional values held by baccalaureate and associate degree nursing students. Journal of Nursing

Scholarship, 35, 291-296.

Melia, K. (1987). Learning and working. The occupational socialisation of student nurses. London: Tavistock.

Melnick, E. (2002). Values based education in baccalaureate education in the tri- state area. PhD Thesis. Columbia University Teachers College. Retrieved

June 14, 2006 from http://wwwlib.umi.com/dissertations/preview_all/

Milligan, F. (1997.) In defence of Andragogy. Part 2 an educational process consistent with modern nursing’s aims. Nurse Education Today, 17, 487-493.

Öhlén, J., & Kerstin, K (1998). The professional identity of the nurse: Concept analysis and development. Journal of Advanced Nursing, 28, 720-727.

Paterson, B., & Crawford, M. (1994). Caring in nursing education: An analysis. Journal of Advanced Nursing, 19, 164-173.

Ramage, C. (2004). Negotiating multiple roles: Link teachers in clinical nursing practice. Journal of Advanced Nursing, 45, 287-296.

Scott, W. (1959). Empirical assessment of values and ideologies. American Sociological Review, 24, 299-310.

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Attitudes and Values of Nurse Educators: An International Survey