Countries’ cultures and professional nursing values: Cross-cultural evidence from Spanish and Colombian nursing students

Journal Pre-proof COUNTRIES’ CULTURES AND PROFESSIONAL NURSING VALUES: CROSSCULTURAL EVIDENCE FROM SPANISH AND COLOMBIAN NURSING STUDENTS María de los Ángeles Rodríguez-Gázquez, Salomé Basurto Hoyuelos, José Rafael González-López PII: S1471-5953(20)31039-8 DOI: https://doi.org/10.1016/j.nepr.2020.102953 Reference: YNEPR 102953 To appear in: Nurse Education in Practice Received Date: 6 June 2020 Revised Date: 20 October 2020 Accepted Date: 12 December 2020 Please cite this article as: Rodríguez-Gázquez, M.d.l.Á., Hoyuelos, S.B., González-López, J.R., COUNTRIES’ CULTURES AND PROFESSIONAL NURSING VALUES: CROSS-CULTURAL EVIDENCE FROM SPANISH AND COLOMBIAN NURSING STUDENTS, Nurse Education in Practice, https://doi.org/10.1016/j.nepr.2020.102953. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd. María de los Ángeles Rodríguez-Gázquez: Conceptualization, Methodology, Formal analysis, Writing - Original Draft. Salomé Basurto Hoyuelos: Methodology, Writing - Original Draft. José Rafael González-López: Conceptualization, Methodology, Validation, Formal analysis, Writing - Original Draft, Writing - Review & Editing. Journal Pre-proof COUNTRIES’ CULTURES AND PROFESSIONAL NURSING VALUES: CROSSCULTURAL EVIDENCE FROM SPANISH AND COLOMBIAN NURSING STUDENTS María de los Ángeles Rodríguez-Gázquez a , Salomé Basurto Hoyuelos b , José Rafael González- López c a Ph.D, Full Professor, Facultad de Enfermería, Universidad de Antioquia, Colombia. C/70 No. 52-21, Medellín, Colombia. Email: [email protected] b Ph.D, Associate Professor, School of Nursing of Vitoria/Gasteiz, Spain. C/ Jose Atxotegi, s/n. 01009 Vitoria- Gasteiz, Álava. Spain. Email: [email protected] c Ph.D, Associate Professor, Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, Spain. C/ Avenzoar, n° 6, 41009, Seville, Spain. Email: [email protected] Corresponding Author: José Rafael González-López. Associate Professor, Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, Spain. C/ Avenzoar, n° 6, 41009, Seville, Spain. Phone number: 0034 954556362. Email: [email protected] Blinding codes in the manuscript: University A: University of Antioquia. University B: University of Seville. Journal Pre-proof ABSTRACT This study aimed to identify countries’ cultural values associated with the importance given to certain professional nursing values by nursing students from Spain and Colombia. Weis and Schank’s Nurses Professional Values Scale-Revised (NPVS-R) in its Spanish version and the Hofstede cultural classification were used for this purpose. The sample was composed of 880 nursing students. Nursing students from both countries showed a greater importance for professional nursing values compared to evidence from other countries. Significant differences were also found in the total score, dimensions, and items, always being higher for Colombian students. Based on regression results, the impact that the academic year had on the importance given to NPVS-R is non-linear (U-inverted). Both groups of students gave the highest importance to the same group of items. Those showing the largest difference in the rankings were associated with country culture differences based on the scores identified by Hofstede. Colombian and Spanish societies present similarities in Power Distance and Uncertainty Avoidance, as well as differences in the other cultural dimensions. Keywords: Cross-Sectional Studies; Nursing Ethics; Professional Practice; Students. Declarations of interest: none Journal Pre-proof 1 Countries’ cultures and professional nursing values: cross-cultural evidence from Spanish 1 and Colombian nursing students 2 ABSTRACT 3 This study aimed to identify countries’ cultural values associated with the importance given to 4 certain professional nursing values by nursing students from Spain and Colombia. Weis and 5 Schank’s Nurses Professional Values Scale-Revised (NPVS-R) in its Spanish version and the 6 Hofstede cultural classification were used for this purpose. The sample was composed of 880 7 nursing students. Nursing students from both countries showed a greater importance for 8 professional nursing values compared to evidence from other countries. Significant differences 9 were also found in the total score, dimensions, and items, always being higher for Colombian 10 students. Based on regression results, the impact that the academic year had on the importance 11 given to NPVS-R is non-linear (U-inverted). Both groups of students gave the highest importance 12 to the same group of items. Those showing the largest difference in the rankings were associated 13 with country culture differences based on the scores identified by Hofstede. Colombian and 14 Spanish societies present similarities in Power Distance and Uncertainty Avoidance, as well as 15 differences in the other cultural dimensions. 16 Keywords: Cross-Sectional Studies; Nursing Ethics; Professional Practice; Students. 17 18 Journal Pre-proof 2 INTRODUCTION 19 Ethics has been linked to nursing care since the origins of the profession (Kangasniemi et al., 20 2015). Nursing practice implies dealing with ethical dilemmas (Iacobucci et al., 2013), and nurses 21 need to have the tools that guide their behaviours. Professional nursing values are defined by 22 Schmidt and McArthur (2018, p. 72) as ‘important professional nursing principles of human 23 dignity, integrity, altruism, and justice that serve as a framework for standards, professional 24 practice, and evaluation’. To internalise professional nursing values is key to developing a 25 professional identity (Weis and Schank, 2009). 26 Professional nursing values are influenced by the level of education (Fisher, 2014; Cetinkaya- 27 Uslusoy et al., 2015; Gallegos and Sortedahl, 2015), experience (Riklikiene et al., 2018; 28 Fernández-Feito et al., 2019; Poorchangizi et al., 2019a), and also by personal values (Iacobucci 29 et al., 2013; Sibandze and Scafide, 2018). 30 Although the culture of the country in which the professional is developing their practice on 31 professional nursing values has been discussed in theoretical terms (Horton et al., 2007; Rassin, 32 2008; Parandeh et al., 2014), the empirical evidence is scarce (Alfred et al., 2013; Lin et al., 33 2016). Presently, there is a call for further research to better comprehend the role of national 34 culture on professional nursing values (Poorchangizi et al., 2019a). 35 Consequently, this study aimed to identify the cultural values associated with specific 36 professional nursing values through the comparison of nursing students’ values from two 37 countries with different cultures (Spain and Colombia), and to analyse if this importance varies 38 according to certain factors. 39 The findings will be helpful to provide a better understanding about how countries’ cultures 40 influence professional nursing values. Specifically, countries’ cultural characteristics associated 41 with certain professional nursing values will be identified. 42 Journal Pre-proof 3 BACKGROUND 43 Professional nursing values are an issue of growing relevance in academic literature (Elliot, 44 2017). Nurses’ codes of ethics articulate the values, specific behaviours and ethical obligations of 45 nurses (Schmidt and McArthur, 2018). Each country has developed its own code of ethics, 46 although there is a common set of professional nursing values (Erkus and Dinc, 2018). Human 47 dignity, altruism, social justice, autonomy in decision making, precision and accuracy in caring, 48 responsibility, human relationships, individual and professional competency, sympathy, and trust 49 were identified as professional nursing values by Elliot (2017) who carried out an integrative 50 review of the literature. 51 Values ought to be the core of care (Parandeh et al., 2014), and they should guide nurses’ 52 behaviours in professional practice (Shahriari et al., 2013). There is an agreement about the 53 important effect that professional nursing values have on the practice, and the high 54 interdependence between personal and professional values (Kaya et al., 2017; Poorchangizi et al., 55 2017). In the exercise of their profession, nurses must make many decisions that will be 56 significantly affected by their personal and professional values (Weis and Schank, 2000; Özsoy 57 and Donmez, 2015). As nurses build a professional identity through their training, these personal 58 and professional values change, and their behaviour also changes as a consequence (Fagermoen, 59 1997; Schmidt and McArthur, 2018). 60 Although this training is an ongoing process that continues throughout their professional practice 61 (López-Pereira and Arango-Bayer, 2017; Posluszny and Hawley, 2017), many researchers have 62 pointed out the appropriateness of training in professional nursing values during the training for 63 their degree (Leners et al., 2006; Bang et al., 2011). 64 In this regard, Johnstone (2015) found that pre-graduate training is the ideal moment for future 65 nurses to learn the obligations, responsibilities, and challenges involved in the profession. The 66 Journal Pre-proof 4 cognitive and affective components of this training in nursing values (Taylor, 2014) may change 67 the student’s attitudes once they start their university studies (Ranjbar et al., 2017). The process 68 of becoming a nurse implies the adaptation of one’s attitudes to professional nursing values 69 (Halperin and Mashiach-Eizenberg, 2014). 70 Furthermore, as a consequence of the training progress, the importance of professional nursing 71 values should increase (Fisher, 2014; Dever et al., 2015; Kantek et al., 2017; Posluszny and 72 Hawley, 2017), even though this is not always supported by statistical data (Lin et al., 2010; 73 Donmez and Özsoy, 2016). 74 At this point, some authors (Shahriari et al., 2013; Poorchangizi et al., 2017; Kantek et al., 2017) 75 claim that nursing programmes need to give greater priority to values training since it will be 76 helpful in building a professional identity and generating progress towards excellence (Adeniran 77 et al., 2012; Graan et al., 2016). 78 In addition, Schmidt and McArthur (2018) observed that the literature on the subject has 79 suggested that there are some common professional nursing values across the world, although 80 cultural differences in the priorities of values exist. Based on the Value Theory (Rokeach, 1973), 81 the relative importance given by each nurse to professional values differs due to his/her personal 82 background, which includes his/her country´s culture. In this sense, Pang et al. (2003) argued that 83 comparative analysis helps to understand the substantial role that cultural values play in the 84 determination of the healthcare professional moral experience. The comparison in how nurses are 85 trained is relevant considering the globalisation of healthcare and the sharing of professional 86 resources across continental borders (Kraft et al., 2017). 87 Considering this argument, previous research (Alfred et al., 2013; Lin et al., 2016) confirms the 88 appropriateness of the comparison of values commitment between different countries since the 89 priorities vary depending on the cultural context. In order to better understand how countries’ 90 Journal Pre-proof 5 cultures influence the importance of professional nursing values, it is necessary to conduct 91 analyses in other different settings that will allow to evidence-based conclusions to be reached. 92 According to Horton et al. (2007), whether a culture was more individualistic or more 93 collectivistic has an impact on professional nursing values. Most previous studies have focused 94 on Asian countries (Poorchangizi et al., 2019a; Bijani et al., 2019; Lee et al., 2020) and the 95 United States (Weis and Schank, 2009; Iacobucci et al., 2013), but there has been a lack of 96 evidence from Europe and Latin America. 97 In particular, this research is focused on Spain and Colombia. Nursing competencies in both 98 countries are defined by their Codes of Ethics (Spanish: Consejo General de Colegios Oficiales 99 de Diplomados en Enfermería, 1989; Colombia: República de Colombia, 2004). According to a 100 study by García (2015), both codes are focused on achieving a patient’s wellness. However, the 101 Spanish nursing code of ethics emphasises how professionals should act while the Colombian 102 code is focused on what professionals ought to avoid to not incur a sanction (García, 2015). 103 Previous comparative research has been focused on highlighting the difference in the importance 104 of professional nursing values (Alfred et al., 2013; Lin et al., 2016; Alkaya et al., 2018), but our 105 research goes further since the aim of our study was to identify specifically which cultural values 106 from countries are linked with certain professional nursing values. 107 STUDY AIM 108 The main objective of this research was to compare the perception of the importance of 109 professional nursing values between nursing students from Colombia and Spain, identifying if the 110 similarities and differences found are associated with their countries’ cultural characteristics. 111 Hypothesis 112 Journal Pre-proof 12 nursing values with the US (Alfred et al., 2013), Taiwan (Alfred et al., 2013), China (Lin et al., 254 2016), South Korea (Moon et al., 2014) and Indonesia (Nelwati et al., 2019), particularly, in 255 ‘Participate in public policy decisions affecting distribution of resources’, ‘Participate in peer 256 review’ (Professional Commitment dimension), while Iranian nursing students give the lowest 257 importance to some values included in the Professional Mastery dimension (Poorchangizi et al., 258 2019b). 259 At this point, it is necessary to highlight that Taiwan and South Korea present similarities with 260 Colombia and Spain regarding Power Distance (high-medium) and Uncertainty Avoidance (a 261 high level, although the Taiwan score is slightly lower). 262 The highest differences among the subsamples analysed in this research are showed by items 263 which belong to the Professional Mastery dimension. The relevance reported by item 9 (“Seek 264 additional education to update of knowledge and skills”) in the Colombian sample is similar to 265 that reported in the US (Alfred et al., 2013), while previous research pointed out a higher 266 importance in China (Lin et al., 2016), Taiwan (Alfred et al., 2013) and Iran (Poorchangizi et al., 267 2019b). In this regard, the relative importance given by Spanish nursing students (ranked 15 th ) is 268 similar to that reported in Indonesia and South Korea. Based on Hofstede et al. (2010), Colombia 269 and the US are close in Masculinity (high-medium) as well as Spain and Indonesia (medium), 270 while Spain reported similar scores to South Korea in Power Distance (high-medium) and 271 Uncertainty Avoidance (high) 272 Moreover, item 15 (“Maintain competency in area of practice”) presents a medium relative 273 importance in the Colombian subsample as is reported by nursing students in Taiwan (Alfred et 274 al., 2013). According to Hofstede et al. (2010), these two countries have similarities in Power 275 Distance (high-medium), Individualism (low), and Uncertainty Avoidance (high). Spanish 276 nursing students give more relevance to this item but they do not have the first positions in the 277 Journal Pre-proof 13 ranking like in the US (Alfred et al., 2013), China (Lin et al., 2016), Indonesia (Nelwati et al., 278 2019) and South Korea (Moon et al., 2014). 279 Based on the regression results, nursing students enrolled in the last academic year generally gave 280 less importance to professional nursing values than those from second and third courses. These 281 findings differ from most previous evidence that had reported a continuous increase in the 282 importance given to professional nursing values throughout the degree programme (Lin et al., 283 2010; Özsoy and Donmez, 2015; Kantek et al., 2017; Posluszny and Hawley, 2017; Lee et al., 284 2020), and these differences were sometimes statistically significant. However, fourth year 285 nursing students in Iran also reported giving lower importance to professional nursing values than 286 students from the previous years (Poorchangizi et al., 2019b), but the differences were not 287 supported statistically. Nursing students in both countries involved in the study start their 288 practical training in the second course, which means they were immersed in the profession and 289 realized the importance of professional nursing values. During the third course, they acquired 290 new abilities and faced new situations, so that they gave more importance to professional nursing 291 values. Finally, a decrease of the importance of professional nursing values came in the fourth 292 course. As previously stated, nurses gave less importance to professional nursing values than 293 students (Riklikiene et al., 2018; Poorchangizi et al., 2019a; Fernández-Feito et al., 2019), so this 294 decrease could be explained by fourth-year nursing students feeling themselves as “nurses” more 295 than nursing students since training is intensive and has similarities with their future jobs. 296 This study has the limitation that data were self-reported, that is, there is a potential desirability 297 bias in the responses. At this point, it was mitigated by anonymity since it favoured sincerity 298 when the questions in the scale were answered. In addition, it did not measure how students 299 learned professional values nor were personal values considered. 300 Journal Pre-proof 14 Future research should be conducted with cohort studies with the aim of documenting the 301 changes in the perception of the importance of professional values of the nursing students from 302 the beginning of their training experience until their graduation. With view to improve 303 knowledge of the importance which professional values have for students and that there are 304 values that have more weight during their training process as future nurses, it is also suggested to 305 carry out meta-analysis studies with the data obtained from research conducted in other countries 306 that have used the NPVS-R. 307 CONCLUSION 308 Colombian and Spanish nursing students gave greater importance to professional nursing values 309 than any other setting analysed in previous literature. However, the results showed differences by 310 dimensions and items among the countries. The sample was large enough and provided evidence 311 from two different cultural settings that have not been previously compared. Both countries, 312 characterised by a medium-high Power Distance and high Uncertainty Avoidance, gave the 313 highest importance to values which belong to the Ethics dimension, while the lowest relevance 314 was given to values of the Professional Commitment dimension. In addition, the results were 315 compared to those obtained by previous research in other countries and discussed considering the 316 country cultural differences based on Hofstede et al.’s (2010) cultural classification. One of the 317 main strengths of this research lies in the consideration of multiple countries culture 318 characteristics since previous research only focused on the Individualism/Collectivism 319 dimension. 320 As discussed previously and considering our results, nursing schools should continue teaching 321 professional values since it is key to the development of a nursing identity. 322 323 324 Journal Pre-proof 15 REFERENCES 325 Abdollahimohammad, A., Jaafar, R., Rahim, A.F.A., 2014. Similarities and differences in 326 cultural values between Iranian and Malaysian nursing students. Iran. J. Nurs. Midwifery 327 Res. 19, 542–544. 328 Adeniran, R.K., Bhattacharya, A., Adeniran, A.A., 2012. Professional excellence and career 329 advancement in nursing: a conceptual framework for clinical leadership development. Nurs. 330 Adm. Q. 36, 41–51. https://doi.org/10.1097/NAQ.0b013e31823b0fec 331 Alfred, D., Yarbrough, S., Martin, P., Mink, J., Lin, Y.-H., Wang, L.S., 2013. 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(2010). PD (Power Distance): the degree to which the less powerful members of a society accept and expect that power is distributed unequally. I (Individualism): the degree of interdependence a society maintains among its members. M (Masculinity): a reference in society for achievement, heroism, assertiveness, and material rewards for success. UA (Uncertainty Avoidance): the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity. LTO (Long Term Orientation): how every society has to maintain some links with its own past while dealing with the challenges of the present and future. IVR (Indulgence): the extent to which people try to control their desires and impulses. 67 13 64 80 13 83 57 51 42 86 48 44 0 10 20 30 40 50 60 70 80 90 100 PD I M UA LTO IVR Spain Colombia Journal Pre-proof Highlights • Countries’ cultures influence professional nursing values of students. • The importance given to the professional nursing values was high in both settings. • In both countries, the most important items belong to the Ethics dimension. • Academic year also has an impact on the importance given to professional values. Journal Pre-proof CONFLICT OF INTEREST None declared. FUNDING SOURCE This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ETHICAL APPROVAL DETAIL Ethical approval for this research was sought from both Faculties involved in the research. ACKNOWLEDGMENTS The authors wish to thank all the nursing students who voluntarily participated in this study. Journal Pre-proof