Strengthening Professional Values of Doctoral-Level Nursing Students.

Introduction: Multiple recent critical societal/world events have impacted nurses' beliefs and emphasized the importance of the standards of behavior that frame nurses' professional values.
Objectives: This study focused on the professional values of students in a Doctor of Nursing program (DNP), including the relationship between professional values, time in program, and intentions to participate in professionalism-focused activities.
Methods: From fall 2019 through Spring 2021, 227 participants were invited to participate in this study through the completion of an online survey at several points in time. The survey contained various demographic variables, items from the Nurses Professional Values Scale-3 representing the dimensions of caring, activism, and professionalism, and Likert scale items that measured intentions to participate in professionalism-focused activities.
Results: The overall mean NPVS-3 score was 118.30 (out of a possible range of 28-140). The highest mean score among the three dimensions was for caring (45.38), followed by activism (40.20) and then professionalism (32.71). Students indicated high intentions to participate in activities focused on professionalism (5.77 on a scale of 1 to 7). A moderate correlation between intentions and professionalism (r = .44, p < .0001) was noted. The association of intentions to caring and activism was weaker but significant (r = 0.26; p = .012) and (r = 0.37; p = .0003), respectively.
Conclusion: DNP curricular efforts can strengthen nurses' professional values by focusing on the development of critically important professional attributes. Nurses, especially those who have a doctoral-level education, need to have strong professional values and understand the importance of their voice and impact as a leader in the profession.

Introduction/Background

Values are personal preferences learned over time as we grow and develop, and are influenced by culture, our environment, education, and past experience (Dellafiore et al., 2020; Kantek et al., 2017; Sibandze & Scafide, 2018). The uncertainty, complexity, and ambiguity that exists in today's world (Yoder-Wise, 2021) due to various critical societal/world events, including the COVID-19 pandemic, has impacted nurses’ values and illustrated the importance of focusing on professionalism in graduate education. Values elucidate what we believe is right or wrong, help direct our behavior and guide our moral decisions (Elliott, 2017; İlaslan et al., 2020; Schmidt & McArthur, 2018). Values change as students are socialized into the nursing profession and develop professional values (Elliott, 2017; Kantek et al., 2017). Through the socialization process, students internalize behavioral norms and standards to form an identity as a nurse (Dinmohammadi et al., 2013). Giardino and Hickey (2020) note that the professional identity process continues as nurses progress through master’s and doctoral programs and move into advanced practice specialty roles.

The shaping of one's professional values occurs along a continuum as nurses acquire and internalize standards important for nursing (Weis & Schank, 2009). Along with professional values, nurses also form work values that may influence or become part of their professional values (Hampton & Welsh, 2019). Professional values may be associated with improved organizational and patient outcomes (Dellafiore et al., 2020). The COVID pandemic caused nurses to rethink their professional values as they coped with unprecedented changes, constant disruption, and volatile situations. Other critical situations such as increasing mass violence, racial and ethnic inequities, and violence against nurses and other healthcare workers have brought increasing attention to the environmental uncertainty and ambiguity that exists in the healthcare world. Finally, the recent trial and conviction of a nurse who made a medical error (ANA, 2022) has brought attention to the system and workforce challenges faced by nurses and caused nurses to rethink the importance of values.

During times of uncertainty and ambiguity, individuals face unknowns since no precedent exists for coping (Bennett & Lemoine, 2014). Over the last two years nurses, including those who are in graduate education programs, have been called upon to work longer hours than they ever have before while being fearful about their own health and the health of family and significant others. Challenges have seemed never-ending as students have balanced their home life, work, and school. Refocusing on professional values can help students find meaning in a world of chaos, feel a greater sense of direction, and envision a better time (Ghabour, 2020).

Review of Literature

Various factors influence nurse professional values. Professional values are strengthened by participation in academic programs and through socialization to specific nursing roles (Gallegos & Sortedahl, 2015). Schmidt and McArthur (2018) define professional values as “important professional nursing principles of human dignity, integrity, altruism, and justice that serve as a framework for standards, professional practice, and evaluation” (p. 72). Development of professional values begins when students start their nursing education, continues as they progress through the professional socialization process, and is further modified when students move into nursing practice roles (Liddell et al., 2014; Poorchangizi et al., 2019). Professional values can be advanced or enhanced by continuing one's education (Gallegos & Sortedahl, 2015; İlaslan et al., 2020) as indicated by data demonstrating that nurses with a baccalaureate degree scored lowered on the Nurses Professional Values Scale (NPVS) than nurses with a graduate degree (Gallegos & Sortedahl, 2015). Asiandi et al. (2021), in a study with 600 nurse participants, found that nursing education, expertise, and working experience significantly impacted professional values as measured by the NPVS-3. Five of seven studies analyzed during a systematic review demonstrated a significant difference in either recognition of the importance of professional values or prioritization of specific values based on level of nursing education (Sibandze & Scafide, 2018).

Values may change over time as nurses acquire more experience (Asiandi et al., 2021; Poorchangizi et al., 2019). Professional values scores of nursing students were significantly higher than those of practicing nurses in a study done by Poorchangizi et al. (2019). The highest mean professional values score in the Poorchangizi et al. study (2019) was caring (M = 3.85 and 3.99 for nurses and students, respectively) and the lowest average scores were for professionalism and activism; they used Weis and Schank’s (2017) NPVS-Revised, which included five components: trust, justice, professionalism, activism, and caring. Overall professional values scores may decline after nurses move from a student to a novice nurse role, but the literature shows that values scores tend to increase as nurses obtain more experience. Monroe (2019) found that nurses with 10 years or more of experience had higher professional values scores than those with less experience. The highest scoring professional value in the study done by Monroe (2019) was focused on maintaining practice competency, followed by accepting responsibility and accountability for one's own practice. In a pilot study done to compare professional values between Doctor of Nursing program (DNP) students and nurse practitioners, professional values did not differ significantly between graduate students and advanced practice providers (Hampton et al., 2021).

A study focused on the perceptions of post-master's DNP students (N = 47) regarding their professional development during the DNP education experience identified several themes. Students indicated that graduate education helped them redefine their role as an advanced practice nurse. Results also illustrated that students felt a stronger professional identity upon program completion, which helped them become more competent, responsible, and accountable (Giardino & Hickey, 2020).

The new American Association of Colleges of Nursing Essentials (2021) outlines 10 domains of professional nursing practice and the competencies expected of nurses within each domain. The Essentials address two levels of sub-competencies, undergraduate education (needed for entry into practice) and graduate education (which prepares nurses for advanced practice nursing specialty roles). Intertwined in the Essentials is an emphasis on professional values, which need to be the focus of nursing education. Professionalism includes three aspects, character, conduct, and quality (Benson & Hummer, 2018), and requires the application of professional expertise or competencies to ensure effective performance in one's role; the new AACN Essentials emphasizes all three aspects of professionalism.

The DNP degree was created to advance nurses' professional values and practice competencies and prepare nurses for leadership in clinical practice (McCauley et al., 2020). DNP programs are focused on “the scholarship of application, integration and clinical practice” to prepare graduates to implement data-driven quality and outcome improvement strategies (Giardino & Hickey, 2020). Dobrowolska et al.’s (2021a, 2021b) scoping reviews highlighted the importance of DNP education as a step forward in the advancement of clinical nursing practice and addressed the value doctoral-educated nurses bring to the clinical setting. DNP education prepares nurses to be effective leaders in complex healthcare environments by being able to work with interdisciplinary teams to put initiatives into action to improve outcomes (Bowie et al., 2019). DNP-prepared nurses have been shown to have strong assessment skills, to be effective collaborators, and to be able to better address system-level quality and finance challenges than non-DNP-prepared nurses (Beeber et al., 2019). Their unique combination of clinical expertise and change management skills makes DNPs of value to employers (Giardino & Hickey, 2020; McCauley et al., 2020). Although much has been learned about the value of DNP education, more information is needed to quantify the value of DNP education (Labardee et al., 2020) and assess the impact of graduate education on one's professional values.

Whether graduate education leads to different or higher professional values scores is a question that is critical for consideration as the new Essentials are implemented in colleges of nursing across the nation (AACN, 2021). The purpose of this study was to evaluate the professional values of students who were enrolled in a DNP, including the identification of which aspects of professional values were most important to participants. A secondary purpose was to determine whether there were associations among professional values dimensions, intentions to participate in activities focused on professionalism, and length of time in the DNP.

Methods

Design

A descriptive, longitudinal design was employed for data collection in this study. This study provided students in the DNP multiple opportunities to participate by completing an anonymous survey (which was unaltered over time). Students were invited to complete the survey near the beginning of the fall semester and near the end of fall and spring terms during a two-year time period.

Sample

Participants included Bachelor's to DNP and Masters to DNP graduate nursing students and nurse practitioner certificate students in a United States land-grant university College of Nursing, with approximately 160 enrolled DNP students at any given time. Over the two-year period, 227 students were invited to participate in the study.

Inclusion/Exclusion Criteria

Inclusion criteria included students who already were enrolled in the DNP as of the beginning of the fall semester, 2019 and those who were admitted to start in the fall semester of 2020. No DNP or nurse practitioner certificate students were excluded from participation in the study.

Institutional Review Board Approval and Informed Consent

This study was approved by the University Institutional Review Board in 2019 prior to the initiation of the study, as an expedited project. Participants were provided a cover letter that included information about the study. Completion of the survey was considered to be implied consent to participate in the study since participants were not required to sign an informed consent form.

Procedures

The participants received an invitation to complete the survey through the Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, Tennessee) at up to five different time points, including initially at the start of the Fall 2019 academic year and approximately every five months (or at the end of each semester) thereafter. The first group of invited participants consisted of all students enrolled in the program as of Fall, 2019 including those who had been admitted to the program that semester. These students received an invitation to complete the survey at the beginning of the fall semester, at the end of the fall semester, and at the end of the spring semester. At the beginning of the Fall, 2020 semester, all new students in the program were invited to participate in the study by completing the survey; they along with students who had participated in the prior academic year were invited to complete surveys at the end of Fall 2020 and Spring 2021 semesters.

Students were also invited to attend a series of optional education sessions focused on professional development that were given by the Dean of the College of Nursing once each semester, near the end of the semester. These sessions were focused on leadership and career planning, creating an impactful curriculum vitae, how to make an impact through verbal and nonverbal communication, and stewardship of time and resources. The end-of-semester surveys were sent out following these educational sessions, but study participants may or may not have attended the educational session in that attendance was not required for participation in this study. More than half of the 91 participants had not attended any of the educational sessions at the time they completed their first survey (n = 51, 56.0%).

Measures

The survey contained various demographic variables including age, gender, race, years of experience as an RN, the year when the student enrolled in the program, program of study, and specialty. The survey also included items focused on professional values and intentions to participate in professionalism-focused activities.

Professional values

Professional values were measured by NPVS-3, a 28-item scale that was based on the 2015 American Nurses Association (ANA) Code of Ethics for Nurses with Interpretative Statements (Weis & Schank, 2017). The scale consists of three dimensions: caring, activism, and professionalism (Asiandi et al., 2021; Dellafiore et al., 2020; Weis & Schank, 2017). The ANA Code of Ethics for Nurses provides information about the ethical obligations and behaviors expected of professional nurses (ANA, 2015). The NPVS-3 is a revision of the NPVS-Revised scale developed in 2009 (Weis & Schank, 2009).

Each item in the NPVS-3 reflects a specific code and its interpretation and is written in a Likert scale format ranging from 1 (not important), 2 (somewhat important), 3 (important), 4 (very important), to 5 (most important). Scores are summed, with higher scores reflective of stronger professional values (Weis & Schank, 2017). Validity and reliability of the initial scale were obtained through a study by Weis and Schank that involved 1,139 participants who included undergraduate baccalaureate students and graduate students, as well as nurses in practice settings. Validity and reliability also have been confirmed by other researchers (Alabdulaziz et al., 2021; Asiandi et al., 2021; Dellafiore et al., 2020). Internal consistency reliability was initially established by Weis and Schank (2017) with Cronbach's alpha for the total scale equal to 0.944 and 0.885, 0.912, and 0.799 for the dimensions of caring, activism, and professionalism, respectively.

The Cronbach's alpha scores for the NPVS-3 for this study were 0.963 for the total scale, and 0.937 for caring, 0.937 for activism, and 0.883 for professionalism. Caring represents nurses’ commitment to quality care that prioritizes the needs of the patient (sample item: “Protect moral and legal rights of patients”); activism involves advocating for the greater good and sustainment of professional integrity (e.g., “Establish collaborative partnerships to reduce healthcare disparities”); and professionalism focuses on duty, loyalty, and work environment responsibilities (e.g., “Initiate actions to improve environments of practice”) (Alabdulaziz et al., 2021; Subih et al., 2021; Weis & Schank, 2017). Permission was obtained from Weis and Schank to use the NPVS-3 in this study.

Intentions

Through two survey items, students were also asked about their intentions to participate in activities focused on professionalism (“Your intentions to increase your professional identity and values”) using a Likert scale item of 1 (“no intentions”) to 7 (“very high intentions”). Examples of activities included being an active professional voice for nursing and engaging in activities focused on the profession.

Statistical Analysis

Descriptive statistics were used to analyze demographic variables and the outcomes of the professional values scores and intention scores, including means and standard deviations or frequency distributions, as appropriate. Cronbach's alpha evaluated the internal consistency of the professional values dimensions. Pearson's product–moment correlation assessed bivariate associations among outcome variables, and between the outcomes and the demographic variables of time in the DNP program and years as an RN. Data analysis was conducted using SAS version 9.4 (SAS Institute Inc, Cary, North Carolina), with an alpha level of .05.

Responses at different points in time from the same student were able to be matched to identify the number of unique individuals who participated. In all, there were 91 individual students who completed the survey at least once, which represented a 40% response. There were 17 who completed the survey twice (18.6%), 14 who completed three surveys (15.4%), and 5 who completed it four times (5.5%). Given the scarcity of longitudinal data available and the lack of significant changes in outcomes over subsequent responses to the survey, the results presented here are based only on the last survey completed by each of the participating students (N = 91; 40% response rate). The decision to use only the last survey completed by the participant in the analysis was made because, for those who completed more than one survey over time, no significant differences were seen in the study measures.

Results

Sample Characteristics

The average age of participants was 35.5 (SD = 9.1), with a range of 23 to 59 years old (see Table 1). Most participants were female (87%) and White, non-Hispanic (91%). The average time post RN degree was 9.2 years (SD = 7.9), with a range from 0.5 to 35 years. Nearly three-quarters of participants were from the three most recent incoming classes of students (72%), but students who completed surveys were from more than six distinct cohorts. Participants included BSN to DNP students (72.5%), MSN to DNP students (16.5%), and Post Masters Certificate students (11%). The majority of participants (75%) were in nurse practitioner programs and 25% were in executive or clinical leadership programs.

Table 1.

Descriptive Summary of Demographic Characteristics (N = 91).

Variable	Mean (SD); range or n (%)
Age	35.5 (9.1); 23–59
Gender
Male	12 (13.3%)
Female	78 (86.7%)
Race
White	83 (91.2%)
Asian	3 (3.3%)
Black	1 (1.1%)
Other/prefer not to answer	4 (4.4%)
Years as an RN	9.2 (7.9); 0.5–35
Year started in the program
<F2016	6 (6.8%)
F2016	9 (10.2%)
F2017	10 (11.4%)
F2018	16 (18.2%)
F2019	26 (29.5%)
F2020	21 (23.9%)
Program
BSN to DNP	66 (72.5%)
MSN to DNP	15 (16.5%)
Post masters certificate	10 (11.0%)
Program specialty
Family nurse practitioner	21 (23.3%)
AGACNP	27 (30.0%)
Pediatrics (acute or primary)	10 (11.1%)
Psychiatric/mental health	10 (11.1%)
Executive or clinical leadership	22 (24.5%)

Note. Mean, standard deviation, and range data are presented in regular print; number and percentage data presented in italics.

Findings

As shown in Table 2, the overall mean NPVS-3 score was 118.30 (out of a possible range of 28–140), with a per-item mean score of 4.23. The highest mean score among the three dimensions was for caring (45.38 overall; 4.54 per item), followed by activism (40.20 overall; 4.02 per item) and then professionalism (32.71 overall; 4.09 per item). Students indicated high intentions to participate in activities focused on professionalism (5.77 on a scale of 1 to 7; SD = 1.2).

Table 2.

Nurses Professional Values Scale-3, Scores by Dimension and by Item (N = 91).

NPVS total, dimension scores, item scores	Mean	Std Dev	Range
Nursing professional values total score (sum of 28 items)	118.30	14.00	82–140
Caring dimension score (sum of 10 items)	45.38	4.81	30–50
Activism dimension score (sum of 10 items)	40.20	6.41	22–50
Professionalism dimension score (sum of 8 items)	32.71	4.16	21–40
Act as a patient advocate. (C)	4.68	0.58	3–5
Protect the moral and legal rights of patients. (C)	4.62	0.61	3–5
Provide care without bias or prejudice to patients and populations. (C)	4.62	0.55	3–5
Respect the inherent dignity, values, and human rights of all individuals. (C)	4.60	0.53	3–5
Protect the health and safety of the patient/public. (C)	4.59	0.54	3–5
Safeguard patients' right to confidentiality and privacy. (C)	4.55	0.60	3–5
Accept responsibility and accountability for own practice. (C)	4.54	0.64	3–5
Practice guided by principles of fidelity and respect for a person. (C)	4.51	0.60	3–5
Protect the rights of participants in research. (C)	4.41	0.71	2–5
Actively promote the health of populations. (A)	4.30	0.67	3–5
Seek additional education to update knowledge and skills to maintain competency. (P)	4.29	0.65	3–5
Confront practitioners with questionable or inappropriate practices. (C)	4.27	0.67	3–5
Recognize professional boundaries. (P)	4.27	0.63	3–5
Assume responsibility for personal well-being. (P)	4.26	0.65	2–5
Engage in consultation/collaboration to provide optimal care. (A)	4.23	0.78	2–5
Assume responsibility for meeting the health needs of diverse populations. (A)	4.12	0.76	2–5
Initiate actions to improve environments of practice. (P)	4.11	0.71	2–5
Promote mutual peer support and collegial interactions to ensure quality care and professional satisfaction. (A)	4.10	0.73	2–5
Engage in ongoing self-evaluation. (P)	4.09	0.63	2–5
Promote and maintain standards where planned learning activities for students take place. (P)	4.08	0.76	2–5
Establish collaborative partnerships to reduce healthcare disparities. (A)	4.07	0.80	2–5
Advance the profession through active involvement in health-related activities. (A)	4.03	0.84	2–5
Participate in professional efforts and collegial interactions to ensure quality care and professional satisfaction. (A)	4.03	0.78	2–5
Establish standards as a guide for practice. (P)	4.02	0.70	2–5
Recognize the role of professional nursing associations in shaping health policy. (A)	3.81	0.94	2–5
Participate in nursing research and/or implement research findings appropriate to practice. (A)	3.81	0.86	2–5
Take action to influence legislators and other policy makers to improve health care. (A)	3.69	0.87	2–5
Participate in peer review. (P)	3.59	0.86	1–5

Note. (C) = caring; (A) = activism; (P) = professionalism

Average ratings on individual professional values items ranged from a high score of 4.68 for an item in the caring dimension to a low score of 3.59 for one of the professionalism items; see Table 2 for a descriptive summary of the items, including which dimension each belongs to. Participants as a group rated the following professional values items, all part of the caring dimension, as the four most important: “Act as a patient advocate” (M = 4.68), “Protect moral and legal rights of patients” (M = 4.62), “Provide care without bias or prejudice” (M = 4.62), and “Respect the dignity, values, and human rights of all individuals” (M = 4.60). The four items rated least important were a mix of activism and professionalism items. These include: “Participate in peer review” (P item; M = 3.59); “Take action to influence legislators and other policy makers to improve health care” (A item; M = 3.69); “Participate in nursing research and/or implement research findings appropriate to practice” (A item; M = 3.81); and “Recognize the role of professional nursing associations in shaping health policy” (A item; M = 3.81). All other items were rated above 4, representing the opinion that on average these items were rated between “very important” and “most important.”

Intention to increase professional identity/values was positively correlated with the dimensions of caring (r = .26; p = .012), activism (r = .37; p = .0003), and professionalism (r = .44; p < .0001) as noted in Table 3. As expected, the three dimensions of the NPVS-3 instrument were positively correlated with each other (p < .0001 for each correlation). The correlations between each of these four variables (caring, activism, professionalism, and intentions) and the demographic characteristics of the year of entry into the program and the number of years as an RN were not significant (p > .05 for each test of association).

Table 3.

Pearson Correlations among Professional Values Dimensions and Intentions to Participate in Activities Focused on Professionalism in the Future (N = 91).

Variable	Caring	Activism	Professionalism
Intentions to participate in activities focused on professionalism	r = .26; p = .012	r = .37; p = .0003	r = .44; p < .0001
Caring		r = .68; p < .0001	r = .68; p < .0001
Activism			r = .85; p < .0001

Discussion

This study was focused on the assessment of professional values of students who were enrolled in varied DNP specialty programs/courses. This study provided the opportunity to obtain information about the impact of DNP programs of study on professional values during a challenging time for the nursing profession. A focus on professional values is important since lack of professionalism along with multiple pathways for education in nursing have been identified as factors that impact the image of the nursing profession (Godsey et al., 2020). Additionally, attention to the importance of values can help students cope during tumultuous times. Recognizing that the overall professional values score was 118.30 during such challenging times (maximum score if all items had been rated “very important” would have been 112; maximum score if all items rated “most important” would have been 140) was a positive finding. This illustrates that as a group, students rated most aspects of the professional values dimensions to be quite important. In particular, students rated caring-focused items, on average, between “very important” (average score of 4) to “most important” (average score of 5). Scores focused on activism and professionalism-related items tended to hover closer to 4 on average, or “very important.”

Similar to what was found in this study, caring has been rated as the most important professional value across studies. A study done to measure NPVS-3 scores in a participant group of 324 baccalaureate nursing students in Jordan revealed a professional values overall score of 98.2, with a mean score of 3.9 for caring, 3.3 for activism, and 3.3 for professionalism (Subih et al., 2021). The overall professional values score in this study was 118, with a per-item mean score of 4.5 for caring, 4.0 for activism, and 4.1 for professionalism, all higher than demonstrated in the Subih et al. study. In the NPVS-3 instrument validation study done by Weis and Schank (2017), the factor that accounted for the greatest variance in professional values was caring (39.9%). They noted that caring deals with nursing's commitment to the patient, social group, or population, including the concepts of respect for persons, responsibility, and accountability. In Weis and Schank's study (2017) activism accounted for the second largest percentage of variance (7.8%) followed by professionalism (3.9%). In the study done by Asiandi et al. (2021) caring also accounted for the greatest variance in nurses’ professional values, followed by activism and professionalism. In the study described in this article, the items focused on activism, or nursing's role in shaping public policy, advancing the public's health, addressing social determinants of health, involvement in nursing organizations, and contributing to knowledge through scholarly endeavors were not considered as important as the aspects of caring, consistent with the Weis and Schank findings. Additionally, items in this study focused on professionalism, including authority, accountability, responsibility, promotion of health and well-being including for self, ethics, safety, and quality-focused care activities, were considered less important than those included in the caring dimension; this is also consistent with the findings in Weis and Schank's study.

Various factors can have an impact on professional values. The scores for the dimensions of caring, activism, and professionalism in this DNP-focused study were higher on average than they were in a study by Poorchangizi et al. (2019), who focused on the professional values of undergraduate nursing students at a School of Nursing in Iran and nurses employed in four teaching and referral hospitals. This could be due to the focus on professional values that occurs in our DNP or to the fact that participants in our study had more experience (an average of slightly over nine years of nursing experience across participants). Monroe (2019) found that nurses with 10 years or more of experience had higher professional values scores.

The literature supports the fact that advanced education can impact professional values, although this study did not demonstrate that students who had been in the DNP program longer rated professional values overall more important. Nursing education or academic level has a potentiating impact on the importance one places on professional values development (Alabdulaziz et al., 2021; Kantek et al., 2017). A significant difference in the means for caring, activism, and professionalism based on nurse education level was noted by Asiandi et al. (2021). Giardino and Hickey (2020) found that themes from their study focused on students’ perceptions of the impact of their DNP educational experience reflected student professional development from their journey through the program. Students who had completed the DNP reported a stronger professional identity with their profession, which led to increased competence and a higher level of responsibility and accountability. Students in Giardino and Hickey's study described their DNP education experience as transformational and enlightening, and “stated that the DNP program was the catalyst that helped them grow and change their professional identity” (p. 602).

Strengths and Limitations

Participants were initially invited to participate in this study at the beginning of the academic years starting Fall 2019 and Fall 2020, but the first invitation was sent to both students who were newly enrolled as well as those who had attended in previous years. Thus, the professional values of some participants who were admitted prior to Fall 2019 may have already been affected by the experience of being in the DNP, prior to the start of the study. An additional weakness was lower participation for subsequent invites to complete the survey. Ninety-one participants completed their first survey sometime during the two years, but for more than half of them, this was their only participation. Future studies in this area will benefit from greater student participation over the trajectory of their degree program, which would allow a more powerful assessment of changes in these outcomes over time.

In spite of these limitations, this cross-sectional, at specific points in time examination of student assessments of professional values and intentions to participate in activities to develop professionalism represents a diverse group of students enrolled in the program during a two-year period. Participants included students just joining the program and those who had been in the program longer, students with a wide range of years of experience as an RN, and those who had and had not attended the educational sessions. Though the study was not specifically planned to capture this, the inclusion of students across the range of preparation for the DNP degree represents a strength of the study due to a wider representation of the underlying population of all students in the program.

Implications for Practice

As nursing programs do course crosswalks to determine what changes need to be made in programs/courses to ensure that students have the knowledge and competencies expected as per the new AACN Essentials, one focus needs to be on professional expectations. Curriculum and courses need to address domains that support professional values development. As noted by Poorchangizi et al. (2019), “purposeful integration of professional values in nursing education is essential to guaranteeing the future of nursing” since having strong values increases the student's capacity for making autonomous ethical decisions. Given that intentions to participate in activities focused on professionalism in the future are significantly correlated with professional values, educators should focus on ensuring that nurses understand the value of participation in activities to promote the health of the public, in advocacy, and in policy development.

The new AACN Essentials (2021) address multiple professional values aspects. Nurses at advanced nursing education levels will be expected to have the skills required to engage in personal and collaborative scholarship endeavors, as outlined in Domain 4, “Scholarship for the Nursing Discipline.” “Domain 9: Professionalism” addresses the “cultivation of a sustainable professional identity, including accountability, perspective, collaborative disposition, and comportment, that reflects nursing's characteristics and values” (p. 54). This Domain, along with “Domain 3, Population Health,” indicates that nurses at an advanced education level will be expected to have competencies focused on designing advocacy strategies, engaging in policy development, and assessing and evaluating the impact of policies. Nurses with advanced education need to support and advocate for policies focused on culturally appropriate care, social justice, health equity, and civility. It also will be key that nurses, especially those prepared at the DNP level, can articulate the value of nursing and be active advocates for the profession through participation in leadership development activities and membership in professional organizations.

Several of the individual values items (e.g., the role of professional nursing associations in shaping health policy, taking action to influence legislators and other policy makers, etc.) ranked as less important for nurses in this study, which indicates that we have work to do to ensure that DNP prepared nurses to understand the importance of being a voice for nursing. A positive finding from this study was that DNP students already rate several professional values focused on activism and professionalism as very important. Recognizing that professional identity formation can evolve through career maturity and progression through academic programing may help students more effectively respond to challenges and build strength to flourish and thrive.

Conclusions

The toll of the COVID-19 pandemic and other critical healthcare situations/events has helped elucidate the workforce challenges experienced by nurses. The world will be looking to nurses to continue making a difference in caring for and improving the health of others, providing leadership to transform communities and inspiring hope for those that need it most. It is important that nurses, especially those who have a doctoral-level education, have strong professional values and understand the importance of their voice and impact as a leader in the profession. Understanding one's own strengths and opportunities for making a difference, clarifying personal values, and having the agility to pivot and adjust goals for professional advancement during challenging times are critical for the next generation of educators, researchers, practitioners, and leaders.