Professional values education for undergraduate nursing students: developing a framework based on the professional values growth theory

With the rapid advances in various fields such as technology, economy, and culture, healthcare from an international perspective has witnessed the inclusive coexistence of multiple cultures and a deepening trend of globalization. China's nursing workforce has grown in numbers and qualifications since 2016. In 2020, China's National Nursing Career Development Plan (2021–2025) emphasises the need to fully mobilise the nursing workforce and improve the quality of nursing services [1]. The cultivation of nursing professionals has always been an essential mission of higher education institutions, in which the cultivation of nursing professional values has become an important element in the training of undergraduate nursing students [2]. In the context of global multiculturalism, the formation of good nursing professional values can not only enhance the professional satisfaction of undergraduate nursing students [3] and improve ethical decision-making ability [4], but also shape the profession's social image. Based on previous theoretical research, this study develops a framework for cultivating professional values among undergraduate nursing students and provides educational strategies and methods for the growth and internalisation of professional values among undergraduate nursing students.

Values are the deeper meanings and perspectives on something that are developed by one's needs and experiences; they are ideologies of social life that are formed and maintained over time by individuals through their life experiences, and are not affected by changes in the organisation's social environmen [5]. Values influence individuals' behaviour in everyday life and guide their evaluation of themselves and others, choices, and actions [6]. Professional values are a specific choice of values based on the connotations and characteristics of a profession and are used as an element in shaping the identity of a professional group [7]. Although there is no unified definition of professional values to date, more scholars have stipulated and explained them [8, 9]. It is also clear that professional values are a product of the inevitable formation of the socialisation process [10].

In nursing, values become a breakthrough in establishing a unified and accepted model of behaviour within the profession [11]. In 2016, Bonnie J. Schmidt et al. conceptualised nursing professional values through Walker and Avant's concept analysis, which identified nursing professional values as Human dignity, Integrity, Altruism and Justice, which are crucial professional nursing principles and frameworks for clinical practice and assessment [12]. Nursing professional values are closely related to three themes, namely patients, the profession and society, and are agreed upon in a global perspective based on ethical guidelines [13]. Meanwhile, Derek Sellman identified rigid value propositions among administrators and policymakers at all levels of health care, contributing to the marginalisation of nursing discourse, as well as the subordination of nursing to the health care system, which has marginalised and homogenised its values [14]. A study by Cho S.H et al. also found that in the social–historical process, the deep-rooted stereotypes formed about the image of nurses have influenced students' perceptions and formation of professional values in choosing whether to pursue a nursing profession [15]. Therefore, when the socialisation process of nursing students is fraught with a professional identity crisis, transforming their perceptions of nursing from a widespread perception of the profession to an understanding of the professional profession can be challenging and obstructive.

In China, nursing students are demanding about the geographical location of their employment, the salary package, and the number of night shifts, and hospitals and local governments need to adopt more material incentives to be able to attract more nurses to work in rural areas [16]. Yi qi feng et al.'s study also found that nursing students generally have employment anxiety [17], and that professional identity is a key factor influencing the employment intention and career planning of nursing students [18]. This highlights the importance of nursing education in fostering good professional values and socialisation to prepare students for the demands of the nursing profession and bridge the gap between theory and practise. Students' beliefs that 'I am doing this to serve the health of others' and 'I deserve to be paid well for my work' often coexist, requiring education to guide, assist, and adequately support them in this process. Kaya et al. investigated the changes in undergraduate nursing students' professional and personal values over four years of study [19]. They found that the differences in the measures of professional values between the four years of undergraduate nursing education were statistically significant, showing that education has been identified as a crucial prerequisite for forming and internalising professional values.

Instructors often focus more on the external norms reflected in professional values and less on their complex internal nature [20], making teaching values easier. However, this strategy fails to provide nursing students with emotional education and prevents them from forming and internalising professional values. The existing institutional system and the content of lessons focus on developing students' knowledge, skills, and behaviours. Still, the development of professionalism and values has yielded insignificant results, thus creating more of a professional identity crisis [21]. Students can gain satisfaction from technical mastery, but working in nursing solely for money and status is not nursing. It may even lead to questioning the fairness of external benefits [14], creating a dilemma for nursing staff. Therefore, on top of the emphasis on technical competency in professional education, there is a greater need for professional values to be involved in professional socialisation in the form of internal rewards. Furthermore, personal experience influences individual values and behavioural choices. It argues that all values are not simply given from the outside but spontaneously formed in their growth and development and all socialisation experiences.

At present, research on nursing professional values has focused on the current situation and influencing factors of professional values among nurses and nursing students, as well as the study of their correlation with several factors such as work environment, job satisfaction, self-esteem, and nursing organisational climate [21, 22]. In-depth research has yet to be been conducted on the relevant development programmes and frameworks for nursing professional values of nursing students at the undergraduate level. Our research group has developed nursing professional values growth theory based on grounded theory research in previous studies [23]. Therefore, the purpose of this study is to explore the current problems in professional values education in nursing undergraduates, and a theory specific to the growth of professional values in undergraduate students based on pre-theory is developed to guide the construction of an educational framework and address the challenges that may arise in future healthcare professionals' development.

This study aims to develop a framework for the cultivation of professional values in nursing based on theories of professional values growth for undergraduate nursing students.

The education framework is grounded in the theory of professional values growth for undergraduate nursing students and constructivist learning theory. The four stages, which comprise the key aspect of the theory, articulate the core development events and structure them in professional values education, fully demonstrating how the structured education framework is a process to achieve the growth and internalisation of professional values. Recent studies also argue that the current nursing education should clarify at which stage of development learning styles and professional values are developed [22]. The education framework under development integrates professional education and professional values cultivation throughout the undergraduate nursing program in an organic and seamless manner.. The four components of the education framework are permeably integrated with the existing education model for undergraduate nursing students. The content takes complete account of student-centred teaching and learning activities, uses available resources to mobilise students' independent participation, it also embeds cumulative, reflective, and collaborative learning among peers in the education framework to develop professional values. Therefore, based on the characteristics of the professional values growth theory for undergraduate nursing students, this study integrates professional values cultivation with undergraduate nursing education in an embedded way and adopts multiple perspectives to evaluate the cultivation effects comprehensively.

The nursing professional values growth theory for undergraduate nursing students is the basis for the formation of this education framework, which centres on key aspects and consists of four phases. In the initial stage, professional values growth is to develop attitudes and beliefs that honour life and are influenced by the subtle influence of family virtue education. Ingrid Snellman et al. [28] suggest that nursing's values are grounded in the principle of human worth and the power to experience a meaningful life, which emphasises the equality of human worth and respect for human rights, which is a reflection of the nursing professional values that identify with the equal right to life. In the consciousness stage, the formation of a sense of professional community is critical to the growth of professional values in nursing. For the power of role models, Bandura's [29] social learning theory points out that individuals need to learn through observation and imitate the exemplary behaviours and activities of role models to complete the process of individual social learning. The growth of professional values itself is the process of professional socialisation, which cannot be separated from social learning, and following role models and imitating them becomes the way to grow their professional values [30]. In addition, a study by Aimei Mao et al. [31] pointed out that nurses' professional identity is influenced by personal and professional values. In the core stage, in the process of growing professional values, people will actively or passively find out that there are contradictions in their understanding of the profession and find out how they can act by their professional values amid the contradictions, gradually clarifying their understanding of personal and professional values and clarifying what attitudes and behaviours are right and wrong in their professional values, what can be imitated, and what can be resolutely resisted, to achieve the internalisation of their professional values during their clarification process [32]. In the last action stage, the individual's professional values have the basic formation conditions; combined with other research on professional values [33], it can be found that the individual's interpretation of professional values ultimately needs to be embodied in the professional action. The formation of professional values needs to come from personal reflection and the support of the external environment. In the education process, students need to be aware of their personal and professional values and focus on their expressions of relevant behaviours, such as empathy and fraternity. Students engage in active or instructor-led reflection during ongoing values infusion education, identify the gap between themselves and practitioners in terms of professional values, and gradually grow and narrow the gap through continuous learning to develop mature professional values. A study suggests that the process of growing one's professional values is a journey of self-discovery and argues that what is "learned" does not influence what students "become" and "be" in the future [34]. At the same time, education also needs to provide space and opportunities for reflection, providing a supportive environment for instructors and peers to exchange and discuss. There are numerous strategic approaches to providing reflective teaching and learning, and a research demonstrates that film teaching can better help learners to enter professional contexts and also provide interventions and methods for their reflection [35].

In the current healthcare environment, the nursing profession often exists in a marginal or subordinate role, and active engagement in healthcare and demonstrating professional values are often weak [36]. It is more important for students to strengthen the development of professional values during education to deal with the threat of neglected professional values and the dilemma of ethical practice [37]. The development of professional values in the current research has usually been based on an unstructured hidden curriculum as a teaching model, but the hidden curriculum is defined as an informal course with no clear objectives and faces the problem that it is difficult to evaluate and give feedback on the effectiveness of the teaching in its unstructured framework. Therefore, a formal emotional education framework should be established to develop professional values and integrate them into the undergraduate nursing curriculum in an embedded manner [38]. In-class needs to be combined with the characteristics of the various types of nursing courses to develop professional values in a focused manner. Out-of-class is combined with the implicit curriculum and is not restricted by the materials. It is based on carrying out various types of thematic activities, with the students being the centre and participating actively, giving full play to their subjective initiative. In this study, the education framework is closely integrated with the professional nursing curriculum and the teaching design based on the objectives of the professional curriculum is combined with the professional values development objectives so that the professional values development will have a significant effect on the formation and internalisation of students' professional values.

This study was a structured and systematic education framework for cultivating professional values among undergraduate nursing students based on preliminary systematic theoretical research. The education framework formed in this study has a solid academic foundation, and the content design takes account of student-centred teaching activities and makes use of available resources to mobilise students' independent participation, and adopts a multi-faceted perspective to comprehensively evaluate the development effects, ultimately forming a professional values education framework for undergraduate nursing students with structural and practical significance, providing educational strategies and methods for internalisation of professional values for nursing students, and enriching the values development strategies in undergraduate nursing education. However, the study has not yet been validated, and our research group will explore the feasibility and practicality of this educational framework through experimental studies in the future.