Professional values and ethical sensitivities of student nurses during the COVID-19 pandemic.

BACKGROUND: Professional values in nursing are the foundation of ethical practice affecting patient care quality. AIM: The purpose of the present study was to evaluate the development of professional values and ethical sensitivities among new nurses during the COVID-19 pandemic.
METHODS: A prospective observational study with a pre-test and post-test design was used. The sample constituted students (n = 302). The Nurses Professional Values Scale-Revised and Modified Moral Sensitivity Questionnaire for Student Nurses were used for collecting data.
RESULTS: Professional values post-test mean scores of participants were significantly higher than the pre-test scores (p < 0.001). No significant difference was determined between the pre-test and post-test mean scores of ethical sensitivity (p > 0.05).
CONCLUSION: The current study concluded that the professional values of newly graduated nurses developed during the COVID-19 pandemic, but there was no change in ethical sensitivities. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study provides one of the first pieces of evidence for nursing educators and managers to assess the professional values and ethical sensitivities of newly qualified nurses who may have been affected both during and after the outbreak. Newly qualified nurses should are valued members of the health care institutions, and orientation programmes should be implemented to improve their perceptions of the profession.

INTRODUCTION

Values are conceptual and common principles of behaviour that maintain a primary standard in judging actions and goals. Professional values are explained by ethical codes of the profession (Poorchangizi et al., 2019; Shafakhah et al., 2018). Professional values provide an opportunity to define a common nursing ideology and mission, give meaning to professional practices and unite nursing students and nurses in a common culture (Ferrillo, 2020; Shayestehfard et al., 2020).

Values of a profession can be useful in gaining a professional identity (Nelwati & Chong, 2019). Because professional values are among the basic characteristics of the nursing profession, they become an important focus of nursing education programmes (Ferrillo, 2020; Poorchangizi et al., 2019). Professional values need to be developed with experience during nursing education (Arries, 2020; Ferrillo, 2020). The understanding of professional values by nursing students develops throughout the nursing education (Ayaz‐Alkaya et al., 2018).

Professional values in nursing are the foundation of ethical practice affecting the quality of care (Ferrilo, 2020). These values also contribute significantly to ethical decision‐making, providing safe and quality nursing care, positive development of professional identity and increasing job satisfaction (Nelwati & Chong, 2019; Poorchangizi et al., 2019; Schmidt & McArthur, 2018; Shafakhah et al., 2018). With the expansion of nursing roles in healthcare system, it is essential to develop ethical sensitivity among student nurses towards ethical problems that are increasingly experienced (Ferrilo, 2020; Poorchangizi et al., 2019; Shayestehfard et al., 2020). The ability to make ethical decisions in the nursing profession depends on the ability to think ethically and incorporate a sense of ethical sensitivity (Arries, 2020).

Ethical sensitivity is the recognition of the ethical nature of every practical action and the ability to distinguish ethical problems from other issues (Milliken, 2018). Ethical sensitivity includes recognizing an ethical problem, showing a safe, ethical, contextual and instinctive understanding of the unsafe condition in which the patient is in, and having a perception of the ethical consequences of decisions made on behalf of a person (Arries, 2020; Nelwati & Chong, 2019; Shayestehfard et al., 2020).

Professional values and ethical sensitivity are basic concepts taught in nursing undergraduate programmes (Arries, 2020). Professional values and ethical sensitivity can develop in times that cause stress in the healthcare system, such as the COVID‐19 pandemic. However, changes in the health and education systems of countries due to the pandemic may have affected professional values and ethical sensitivity. In many countries, face‐to‐face education and clinical placement of the students were restricted (Agu et al., 2021), and online learning was implemented. During the pandemic, it was reported that nursing students have a sense of participating in care, acquisition of new information and moving to a challenge that can be both individually satisfactory and professionally valuable (Swift al. et al., 2020). Santos (2020) reported that the pandemic improved students' feeling of professional belonging and decision‐making skills in terms of their desire to help patients and society.

Newly qualified nurses are also important members of the health workforce needed in the COVID‐19 pandemic as they can work in clinical practice areas (Gómez‐Ibáñez et al., 2020; Hayter & Jackson, 2020). Senior nursing students have been included in the care process to strengthen healthcare services in many countries during the pandemic (Gómez‐Ibáñez et al., 2020; Hayter & Jackson, 2020; Swift el al., 2020). Collado‐Boira et al. (2020) reported that 85% of senior nursing students voluntarily participated in providing healthcare during the pandemic because of ethical and moral reasons such as the request for help given the present event, spiritual obligations. Cervera‐Gasch and colleagues (2020) found that the majority of medical and nursing students (74.2%) were willing to help with healthcare services and (64.4%) felt a moral responsibility for caring for infected patients.

Several studies have been conducted before the pandemic regarding professional values (Ayaz‐Alkaya et al., 2018; Aydin Ayla et al., 2018; Bleda et al., 2020; Paşalak et al., 2021; Poorchangizi et al., 2019) and ethical sensitivities (Bayrak Aykan et al., 2019; Hançerlioğlu, et al., 2020; Hoseini et al., 2020; Kilic Akca et al., 2017) of nursing students. However, there is a gap in the literature about how the professional values and ethical sensitivity of newly qualified nurses are affected during the COVID‐19 pandemic. It is thought that many educational alterations, such as a transition to online learning, staying away from the hospital environment and patients, interruption of nursing care practices, discussion of clinical care practices with virtual cases in distance education may have changed students' professional values and ethical sensitivities.

The current research was performed to investigate the development of the professional values and ethical sensitivities of newly qualified nurses during the pandemic. The research questions were as follows:

Is there any change in the professional values of nursing students during the COVID‐19 pandemic?

Is there any change in the ethical sensitivities of nursing students during the COVID‐19 pandemic?

METHOD

The study design and participants

A prospective observational study was conducted. The population consisted of undergraduate nursing students who were near completion of their programme in two Turkish universities (N = 344). All final year nursing students were invited to the study. Of these participants, 11 were absent in the pre‐test data collection process, and 31 did not fill the post‐tests. In total, 302 senior nursing students were included in the sample. The response rate was 87.5%.

Inclusion criteria of the study were (1) being over the age of 18, (2) being a final‐year student and (3) being at the undergraduate graduation level. Exclusion criteria were (1) being the first‐, second‐ and third‐year student.

Setting

The research was conducted in two state universities located in the capital city of Turkey. In the nursing curriculum of both the universities, students learn about professional values, ethics and professional codes in nursing ethics, fundamentals of nursing and other courses.

Instruments

Data for the study was conducted using, a personal information forms, the Nurses Professional Values Scale‐Revised (NPVS‐R) and Modified Moral Sensitivity Questionnaire for Student Nurses (MMSQSN). The personal information form asked questions about the age, gender, willingness to work as a nurse after graduation, and career plan for the future.

The Nurses Professional Values Scale‐Revised, prepared by Weis and Schank (2009), assesses nurses and nursing students' professional values. Acaroğlu (2014) performed the Turkish validity and reliability and determined the Cronbach alpha as 0.96. For the present study the Cronbach alpha coefficient as 0.95 for the pre‐test and 0.96 for the post‐test. The five‐point Likert scale contains 26 items and the total score can be between 26 and 130. High scores indicate strong compliance with professional values. The Turkish version validity and reliability of the scale showed a unidimensional and multifactorial structure similar to the original scale. While the original scale contained five factors (Caring, Activism, Professionalism, Trust, and Justice) (Weis & Schank, 2009), the Turkish study only contained three factors (Caring, Professionalism and Trust) (Acaroğlu, 2014).

MMSQSN developed by Lutzen in Stockholm/Sweden in 1994 to measure the ethical sensitivities of nurses in ethical decision‐making processes was improved by Comrie (2012). Yilmaz‐Sahin et al. (2015) adpated it for Turkish context with Cronbach alpha value of 0.73. For the present study, the Cronbach alpha coefficient was 0.87 for pre‐test and 0.90 for post‐test. The scale has 30 items and 6 sub‐dimensions. The subgroups of the scale are interpersonal orientation, modified autonomy, beneficence, creating ethical meaning, experiencing the ethical dilemma and getting an expert opinion. Three items (items 3, 23 and 26) were not included under any dimension. It is a 7 point Likert score where ‘1 point’ indicates a high sensitivity to disagree at all, and ‘7 points’ indicates a low sensitivity to fully agree. The lowest and highest scores of the scale are 30 and 210, respectively. A high score mean high ethical sensitivity and a low score is considered low ethical sensitivity (Yilmaz‐Sahin et al., 2015).

Data collection

The research was conducted between February and July 2020. Before collecting data, the researchers informed the participants who agreed to participate and obtained their informed consent. Also, they explained to students that involvement or non‐involvement would not impact their situation in the relevant nursing programmes. The pre‐tests were administered in the first week of the classes face to face in February. Because of the increase in COVID‐19 cases in Turkey, online learning started instead of face‐to‐face classes at the end of March 2020. After this date, nursing education was conducted through online learning. Therefore, the post‐tests were administered two weeks after the online learning was completed in July. Instruments for the post‐test were created with Google Forms, in accordance with electronic participation, and a link was shared with the participants through email and WhatsApp groups. After they approved their participation on the button ‘I accept/do not accept participation to study’, they completed the questionnaire. Permission to use the instruments was obtained from authors.

Ethical consideration

Ethical approval for the study was obtained from the Ethics Committee of Ankara Yıldırım Beyazıt University (42/2020) and written permission from the relevant faculties were obtained. The research was carried out within the framework of the Helsinki Declaration. Before the questionnaire was administered, informed consent was obtained. Participation in the study was voluntary.

Data analysis

The data were evaluated by the IBM SPSS (Statistical Package for Social Sciences) for Windows version 25 (IBM Corp., Armonk, NY). Descriptive statistics such as mean, standard deviation, number and percentage were used to describe the data. The Kolmogorov–Smirnov test was used (K‐S = 0.047, p = 0.200) to evaluate normality distribution. A paired sample t test was used to compare the pre‐test and post‐test mean scores. The significance level was considered as p < 0.05.

RESULTS

The participants’ mean age was 21.96 (SD = 1.40), 87% were female, 85% stated that they would work as a nurse after graduation, and 41% planned to be a clinician nurse after graduation (Table 1).

TABLE 1

Descriptive characteristics of newly graduated nurses (n = 302)

Descriptive characteristics
Age (mean, SD)	21.96 ± 1.40
Frequencies (n, %)
Gender
Female	263	87.1
Male	39	12.9
Willingness to be a nurse after graduation
Yes	257	85.1
No	45	14.9
After graduation career plan (n = 257)
Nurse Manager	65	25.3
Nurse Clinician	106	41.2
Nurse Academic	74	28.8
Nurse Specialist	12	4.7

SD: standard deviation.

The NPVS‐R pre‐test score was 104.91 (SD = 15.00) and the post‐test mean score was 108.34 (SD = 15.42), and the mean scores on the post‐test increased significantly compared to the pre‐test (t = 4.000, p < 0.001). The post‐test mean scores of the factors regarding Caring (63.67 ± 9.15), Professionalism (32.33 ± 5.40) and Trust (12.33 ± 1.81) of the NPVS‐R of the students were significantly higher than those of the pre‐test mean scores (62.06 ± 9.00, 30.90 ± 5.19, 11.94 ± 1.90, respectively) (Table 2).

TABLE 2

The pre‐test and post‐test mean scores of the Nurses Professional Values Scale‐Revised and MMSQSN (n = 302)

	Pre‐test	Post‐test
Scales	Mean (SD)	Mean (SD)	t, p
Nurses Professional Values Scale‐Revised and subgroups
NPVS‐R	104.91 (15.00)	108.34 (15.42)	t = 4.000 p < 0.001
Caring	62.06 (9.00)	63.67 (9.15)	t = 3.000 p = 0.003
Professionalism	30.90 (5.19)	32.33 (5.40)	t = 4.810 p < 0.001
Trust	11.94 (1.90)	12.33 (1.81)	t = 3.358 p = 0.001
Modified Moral Sensitivity Questionnaire and subgroups
MMSQSN	146.43 (15.03)	147.16 (17.18)	t = 0.688 p = 0.492
Interpersonal orientation	22.44 (2.75)	22.41 (3.01)	t = 0.125 p = 0.901
Modified autonomy	23.55 (4.13)	23.99 (4.15)	t = 1.487 p = 0.138
Beneficence	37.20 (6.19)	37.42 (6.65)	t = 0.511 p = 0.610
Creating ethical meaning	30.32 (3.54)	30.38 (3.61)	t = 0.266 p = 0.790
Experiencing the ethical dilemma	11.43 (3.52)	11.24 (3.65)	t = 0.791 p = 0.430
Getting expert opinion	15.15 (2.42)	15.19 (2.37)	t = 0.258 p = 0.796

SD: standard deviation, t: paired sample t test.

There was no significant difference between the pre‐test (146.43 ± 15.03) and post‐test (147.16 ± 17.18) mean scores of the students in terms of MMSQSN (t = 0.688, p = 0.492). The difference between the pre‐test and post‐test mean scores of the students in terms of subgroups of MMSQSN was not found statistically significant (p > 0.05) (Table 2).

DISCUSSION

The professional values that constitute the basis of nursing practices are acquired during education are shaped by educational strategies (Schmidt & McArthur, 2018). For the development of professional values during the pandemic, participants were given case scenarios related to various topics including medical or surgical conditions, chronic diseases, COVID‐19, paediatrics, elderly health, mental health and community health. They were asked to prepare a nursing care plan, and discuss their care plans in online groups. In the current study, mean scores of professional values before the COVID‐19 pandemic increased significantly during the pandemic. It is thought that online courses did not negatively influence the formation of professional values, and that new nurses integrated their personal values with professional values while adapting to their professional roles in the COVID‐19 pandemic. In addition, the increase in the professional values of students during the pandemic can be explained by the fact that the ability of nurses to adapt to the intense and difficult working conditions due to an increased number of cases and deaths during the outbreak positively affected the students' perspectives on the profession and professional values.

In the literature, there are several cross‐sectional (Aydin Ayla et al., 2018; Poorchangizi et al., 2019) or descriptive–comparative (Ayaz‐Alkaya et al., 2018; Paşalak et al., 2021) studies that have examined the professional values of nursing students before the pandemic. However, no study was found that investigated the professional values of newly qualified nurses who are at the undergraduate level during the pandemic. Therefore, it is important to examine nurses' compliance with their professional values in crises such as pandemics.

Improving the level of ethical sensitivity of nurses during their education is important in terms of making the proper decisions for ethical dilemmas they will experience in their professional lives (Hançerlioğlu et al., 2020; Paslı Gürdoğan et al., 2018). In the present study, the ethical sensitivity of the participants during the pandemic was also examined, and no significant change was found. Before the pandemic, studies examining the ethical sensitivity of nursing students in the literature revealed that the ethical sensitivity of the students is at a medium‐high level (Bayrak Aykan et al., 2019; Hançerlioğlu et al., 2020; Hoseini et al., 2020; Kilic Akca et al., 2017) supporting this study. Nurses often have ethical problems in practice. Overall, ethical sensitivity is extremely important for health care and treatment as it shapes nurses ability of ethical decision‐making. Therefore, student nurses should develop ethical sensitivity during their academic education (Hançerlioğlu et al., 2020; Hoseini et al., 2020). For nursing students to become nurses with a developed sense of ethics after graduation, they must first be aware of their own emotions, thoughts and values, and also undergo an education programme that provides the capacity to deal with the ethical dilemmas brought by the patient care (Hançerlioğlu et al., 2020). It is thought that although senior nursing students did not perform clinical practice during the COVID‐19 pandemic, they were aware of the moral and professional obligations of nurses in providing care to patients even in difficult conditions and in the face of some risks for themselves.

This is one of the first pieces of evidence that investigate the professional values and ethical sensitivity of newly qualified nurses during the COVID‐19 pandemic. There are several limitations. Since the participants of two public universities participated in the research, it cannot be generalized to all new nurses at the undergraduate level in the country. Since the answers of the instruments are based on the statements of the individuals, there may be a possibility of bias in the answers.

CONCLUSIONS

The present study revealed that the professional values of student nurses increased during the COVID‐19 pandemic; however, their ethical sensitivities did not change. It is recommended to evaluate the professional values and ethical sensitivity levels of newly qualified nurses both in ordinary and extraordinary situations. This will help develop strategies to improve their ethical sensitivity if necessary.

Implications for nursing and health policy

Around the world, there may be exceptional situations such as the COVID‐19 pandemic affecting the health of people. Disasters such as pandemics may affect the professional values and ethical sensitivities of healthcare professionals including newly qualified nurses. The findings of this study can support nursing educators and managers to figure out the similarities and differences in the professional values and ethical sensitivities that nurses developed before and during the COVID‐19 pandemic. Academic and health institutions could support newly qualified nurses and student nurses through quality higher education that reinforces professional values and ethical sensitivity, thus improving patient care quality. Orientation and mentoring programmes could be planned for the newly qualified nurses to further develop their professional values and ethical sensitivities. A nursing manager or leader may be more competent in assisting novice nurses to integrate their professional nursing values and acquire their career potential in the nursing profession and improve ethical sensitivities. In the future, nursing educators and managers could plan prospective studies to determine how the professional values and ethical sensitivities of both newly qualified and experienced nurses are affected in extraordinary situations.

AUTHOR CONTRIBUTIONS

Study design: SAA, AA; data collection: AA; data analysis: SAA; study supervision: SAA; manuscript writing: SAA, AA; critical revisions for important intellectual content: SAA, AA.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.