Abstract
Background and aim
Nursing students form a professional identity from their core values, role models, and past experiences, and these factors contribute to the development of their professional identity. The hidden curriculum, a set of ethics and values learned within a clinical setting, may be part of developing a professional identity. Nursing students will develop a professional identity throughout school; however, their identity might be challenged as they attempt to balance their core values with behaviors learned through the hidden curriculum. The purpose of this project was to educate students on the hidden curriculum in the development of their professional identity.
Materials and methods
A sample of 112 senior nursing students was recruited from a northeastern university in the United States for this study. Pre–post survey design was used, and an educational session was administered prior to the post-survey. Descriptive statistics and a valid percentage were used to describe the data within the surveys.
Ethical consideration
Study was approved by the author’s University Institutional Review Board.
Findings
A significant finding was for advocacy as students would speak up if witnessing inappropriate behavior toward patients or families with a mean score increase from 2.50 (pre-survey) to 1.45 (post-survey). Also, over 95% (n = 106) found the educational session beneficial as they learned they had the ability to advocate and speak up for their patients.
Conclusion
Students were able to use their core values and advocate for their patients and families which allows for safer patient care.
Introduction
Nursing is considered one of the most trustworthy professions with high moral standards. 1 Nursing students typically begin their educational program with preconceived ideas of the nursing profession. The literature suggests that there might be some disparity on student expectations of the nursing profession and what is witnessed once they begin their program of study. 2 Browne et al. 3 consider this a pre-professional identity based on their connection to becoming a nurse. As students progress through their nursing education, they will develop their professional identity based on core values instilled at a young age, the witnessing of role model behavior, and the formation of ethical principles based on cultural and social norms. 4 Within the classroom, they are taught how core values and role models can influence and help them develop professionally. Ethical theories may be introduced and become part of the nursing student’s decision-making process. While the formal curriculum is designed and taught with intent, it may be the hidden curriculum that influences how nursing students form their professional identity. 5 As students enter the clinical setting, a hidden curriculum, defined as indirect learning of behaviors and attitudes usually seen in clinical settings, may affect how their professional identity is formed. Students enter the program with core values but may adopt new values as the formal and the hidden curriculums play a role in their professional development. 6
The hidden curriculum exists in many areas of healthcare education and may play a role in how students are socialized into their professional practice. 7 Intended learning or formal curriculum happens in the classroom as students are taught using lecture material and assigned readings. 7 The hidden curriculum may be clinical experiences in which students witness behaviors or attitudes not discussed within the formal curriculum. 5 It is the complex interaction of the formal and hidden curriculums within the clinical, classroom, and lab settings that may influence what the nursing student is learning. 5
The hidden curriculum may be beneficial as it may lead to opportunities for discussion and reflection; however, several studies have documented that changes, which are often negative in student development, are due to the various attitudes and values that are modeled within the clinical setting. 8 Nursing students have their own set of core values, ethics, and role model influences derived from family and previous experiences; however, it will be the blend of these factors and the looming hidden curriculum that affects how they form their professional identity.
For this project, an educational session was used to teach nursing students about the hidden curriculum and the influence core values, ethics, and role models have on the formation of their professional identity. This study reports on an examination of the outcomes of this education on students’ understanding to identify the hidden curriculum and how their values impact their professional identity.
Background
Professional identity is a complex process in which the professional role is learned by virtue of core values and ethical behaviors that are integral to the profession. 9 Nursing students’ professional identity will come from a blend of their core values along with the caring and compassion they have toward their patients. 9 As they enter clinical practice, nursing students are exposed to many experiences that play a significant role how they view themselves as professionals. A study conducted with Iranian nursing students found that having a professional identity led to higher satisfaction with their commitment to and satisfaction with nursing as a profession. 10 Similarly, Langendyk et al. 11 found that in healthcare professions, providers with well-developed professional identities had more workplace satisfaction and less attrition in their chosen field.
Clinical practice and role model behaviors can contribute to how students develop their professional identity. 4 Professional identity formation may be altered as students adopt or modify core values that are expressed into behaviors seen on the clinical units. 12 For example, the nursing student’s clinical experiences play a pivotal role as core values and ethical principles are questioned.
It is usually clinical faculty and clinical nurse educators who are the first nursing role models for students. However, as students gain more experience in clinical settings, they are exposed to diverse providers, some with value systems and decision-making different from their own. 13 Within a formal curriculum, the hidden curriculum might be exposed from classroom interactions. The interaction may be as simple as the instructor using feminine terms to describe the nurse role. 7 As the student enters the clinical setting, this blend of formal and hidden curriculums may affect how they develop in their role. The feminine terms used in the classroom during lecture could affect attitudes of nursing as a predominantly female profession in the clinical setting. 7
Expectations within a clinical setting can dampen students’ professional identity as they witness unethical behaviors and their core values are challenged. Students will need to balance their core values with decisions made by other healthcare professionals in the clinical setting, particularly when these decisions are in conflict with what students believe is best for the patient. A study of nursing students after a 6-month internship revealed that students with well-developed professional identities had higher quality clinical performances that led to improved patient outcomes. 14 Professional identity may also lead to better caring abilities among students and less stress when faced with making ethical decisions. 15 As students develop their clinical competence, they will need to stay true to their own core values and the values of the nursing profession. 16
Core values are learned behaviors that are significant to a person’s professional development. The ability of students to articulate their core values, which are learned early in life, will help them as they form their own professional identity. 11 Studies have revealed that new nurses with a defined professional identity are able to recognize the importance of delivering quality care to their patients. 17 There is supporting evidence that education can cultivate compassion and empathy; however, some question the challenges of cultivating and sustaining this in nursing. 18 Schmidt and McArthur 12 discuss a lack of research related to understanding the impact of core values of pre-licensure nursing students. A study on the core values of compassion and empathy in relation to cancer patients resulted in better outcomes; however, some studies have limitations and do not clearly identify the components of core values in nursing. 19 It is imperative to have clarity of these core values as they are a vital component to the nurse–patient relationship and may have a direct impact on patient outcomes. 20
However, even with a core value system, the ability for the student to develop and transition into a practicing nurse may not be easy. This transition can be multidimensional and interlaced with the values, culture, and practices from nursing institutions and clinical settings in which students have gained their experiences. 21 Core values can guide ethical decision-making. However, a new nurse’s ability to make sound ethical decision may affect their problem-solving skills and, in turn, affect the delivery of patient care. 22 The American Nurses Association Code of Ethics with Interpretive statements supports that nurses must create a culture of excellence and maintain practice settings that support nurses and others in their fulfillment of ethical obligations. 23 Ethical principles are not only used to guide decisions but also integrated into the development of a professional identity. 24 Nursing students need to have opportunities to discuss and debrief on situations that challenge their ethical principles based on their core values and role model experiences. Students witnessing unprofessional behavior in a clinical setting need to be allowed a time of discussion and reflection. There are various debriefing methods to help educators guide students to reflect upon situations that may happen in the clinical setting. One model used by nurse educators is Debriefing with Good Judgment. 25 This method allows students to feel psychologically safe to share witnessed accounts of behavioral dilemmas and discuss them in a safe learning environment. 25
Professional identity formation happens as students observe others in the healthcare setting and role model their behaviors. Role modeling is an unintentional act of not only observing the behaviors of others but also interacting with other healthcare professionals. 26 Nursing students are influenced and motivated by positive role models. 27 Role modeling can enhance students’ ability to use their core values to make sound ethical decisions in the care of their patients. It is also important that students have strong relationships with faculty who can serve as role models and for nursing students to have the same opportunity to reflect upon role modeling seen in the clinical setting. The need has never been greater for role models to help new graduates make sound ethical decisions and guide them to develop strategies as they establish their professional identities. 13,22,28
The hidden curriculum
Professional identity may be impacted by a form of education known as the hidden curriculum. The hidden curriculum is not teaching by lecture; it is the moral, ethical, and value-based teaching that is taught in a non-explicit manner. 5 What students are learning in the classroom about values and ethical behavior may be different from practices they observe in the clinical setting. 24 In addition, the behaviors of nurse educators may be observed as incongruent with what is formally being taught by them.
The hidden curriculum was first identified in medicine and observed during internships and residencies as a curriculum created from behaviors witnessed in the hospitals’ hallways, elevators, or cafeteria. 24 These messages are received and conveyed through a hidden curriculum which may be different than what is taught in the classroom. 29 It consists of behaviors and actions of nurses in practice settings—how they interact with patients, families, and other providers. The behaviors and actions may be lessons that are not intended to be learned in a clinical setting as opposed to the classroom. As nursing students spend a significant portion of their education in the clinical setting, it is important for them to recognize a hidden curriculum. 30 Recognizing it and understanding why it happens can assist students in using their core values as they are challenged to make ethical decisions about their patients care.
Methods
Design and sample
This was a pre–post survey study offered to 112 senior pre-licensure nursing students enrolled in a transition to practice course in a baccalaureate nursing program located in the northeastern United States in spring 2019. The convenient sample of students (n = 112) completed the pre-survey with 110 students completing the post-survey. The reflective narrative resulted in completion from 98 students. There were eight male students in the group; students’ mean age was 22 (standard deviation (SD): 3.05) years. The study was approved by the author’s University Institutional Review Board.
Intervention
The hidden curriculum module, developed by Drexel University College of Medicine 31 was used for the educational session. This is one of 12 modules to educate healthcare professionals on interprofessional development and is available on the Professional Formation website. Final development of the professional formation website was completed in the first quarter of 2018. Studies of the modules using various survey methods were launched in the fourth quarter of 2018 as collaborative partners from the universities began to incorporate them within their curriculums.
The hidden curriculum module is designed to develop healthcare professionals’ understanding of behaviors that shape a professional identity. The module contains 20 short videos and educational materials to discuss and reflect on situations of acceptable and unacceptable behaviors that a healthcare provider might encounter and how to handle those situations. An example from one video depicts an attending physician and medical residents outside of a patient’s room inappropriately discussing the patient’s obesity. 31 Subsequent videos from that scenario depict the physician using different methods to educate students on the situation and how different methods are used to correct the inappropriate behavior. 31 One example of correction is the attending physician discussing the medical implications of obesity and having a student research more into this debilitating disease. 31 After viewing the videos, reflection and discussion focused on the behaviors and attitudes witnessed and how value systems and ethical behaviors can help students to advocate for their patients.
Data collection
The educational session was conducted during a scheduled 2-h class time in a large conference room. Students were required to participate in the educational session as part of their course requirements, but were not required to complete the surveys or the reflective narrative. Both surveys and the reflective narrative were independent of student identifiers and placed in sealed envelopes. The investigator received the sealed envelopes at the completion of the education. Students who did not want to participate placed blank surveys into the envelope.
Instruments
The study used paper and pencil pre- and post-surveys. Students completed a pre-survey on their core values, role models, and ethical behaviors, prior to beginning the education, and at its conclusion, completed a post-survey with an option to write a reflective narrative about a clinical experience, in which they believed they used their core values. The items were modified from the survey included with the Professional Formation modules. 31 The researcher modified the items so that they were specific to nursing student experiences in regard to their core values, ethics, and role modeling. The Cronbach’s alpha for pre-survey was 0.70, and the alpha for the post-survey was 0.72.
The pre-survey was administered 30 min before the start of the educational session and contained 15 items. The survey used a Likert-type scale with 12 items scored from 1 (Always) to 5 (Never) and included 1 multiple choice and 2 open-ended responses. The items focused on students’ core values and how those values affect their ethical decisions toward caring for their patients and families. The multiple choice item asked students to choose how they would handle a situation if a healthcare provider’s behavior toward a patient was inappropriate. Students were given two open response questions; one asked students to name a core value that was instilled in them and helped guide them in their nursing program, and the other question asked them to name a role model that guided in their development of a professional identity.
The post-survey was administered at the conclusion of the 1-h educational session. The survey used the same Likert-type scale as the pre-survey and contained nine items. Eight of the nine items including the multiple choice items were the same questions as asked on the pre-survey. An additional open-ended item asked students to recall a lesson from the educational session they found most beneficial as it related to their own professional identity. At the conclusion of the educational session, students were given the option to write a short reflective narrative about a clinical experience in which they believed they used their core values.
Data analysis
Data analysis was performed using SPSS Statistics 25 (Statistical Package for the Social Sciences, IBM 25 Chicago, IL, United States). Descriptive statistics was used to describe the data within the surveys allowing to view patterns of response. A valid percentage was used, and open-ended write in responses were viewed for patterns of responses. The data from the reflective narratives were assessed by the researcher for patterns of similarity in core values. Core values such as advocacy, empathy, compassion, and caring were the areas of focus and reported patterns.
Results
In all, 4 of the 12 Likert-type scale questions were only asked on the pre-survey. The highest mean score related to using core values that were learned in the nursing education program (mean: 1.48). Students also indicated that they frequently used their core values to empathize with patients (mean: 1.62) (Table 1).
Value and role modeling pre-survey questions.
SD: standard deviation.
a The survey used a Likert-type scale scored from 1 (always) to 5 (never).
The other seven items on the pre-survey and the post-survey examined how students would advocate for their patients and how professional behavior affects how disputes witnessed in the clinical area are handled. The pre-survey scores ranged from a mean of 1.75 on handling disputes to a low of 3.75 on student’s biases regarding a patient’s health circumstances. The post-survey scores ranged from a mean of 1.34 on how disputes may be handled in a professional manner to a low score of 4.00 regarding the biases about a patient’s health. While most of the scores on the post-survey did not change much after the educational session, there were some areas that had a noticeable changes.
One of the main areas in which students demonstrated improved understanding was when they would speak up if witnessing inappropriate behavior toward patients or families. Mean scores increased from 2.50 on the pre-survey to 1.45 on the post-survey. Another item that demonstrated improvement was that students would speak up if they witnessed inappropriate behavior toward a peer as these scores increased from 2.64 (pre-survey) to 1.56 (post-survey) (Table 2).
The results revealed that 70% (mean: 1.75) of the students after the educational program believed that disputes could be handled in a professional manner compared with 33% (mean: 1.34) on the pre-survey. This was the highest mean on the post-survey. Results also showed that after the education 56% (mean: 1.90) of the students understood the relationship of their personal and professional core values compared with 22% (mean: 1.46) on the pre-survey (see Table 2).
Values and behavior questions—pre- and post-survey comparison.
SD: standard deviation.
a The survey used a Likert-type scale scored from 1 (always) to 5 (never).
Open-ended responses pre- and post-survey
Students were given two open response questions on the pre-survey. When asked to name a core value that was instilled in them as part of their nursing program, approximately 75% (n = 84) of the students indicated their core value was honesty. Other values identified frequently were respect for others, nursing as hard work, telling the truth, and having empathy. When asked to name a role model who guided their development of a professional identity, over 95% (n = 106) of the students identified either both or one parent, grandparents, or other close family members.
In the post-survey, the open-ended question asked students to write in one key aspect they learned from the educational session. Over 95% (n = 106) of the students learned about advocacy and gained an understanding that they had to speak up for their patients.
Reflective narrative
At the end of the educational session, students had the opportunity to write a narrative in which they used their core values. More than half (n = 68) of the participants completed narratives with common themes of advocacy, empathy, caring, and compassion. On the theme of advocacy, a student shared about “advocating for a transgender patient that the nurses were making comments about at the nurse’s station” while another student shared about “unprofessional behavior among other nursing students.” Students described the need to educating the person exhibiting unprofessional behavior or report the incident to their instructor or the nurse in charge.
On the theme of empathy, students wrote about helping patients who were vulnerable and unable to speak for themselves. A particular narrative related to this theme was about how a student “helped her preceptor make a homeless man comfortable in the Emergency Department after discharge since he had nowhere to go.” Students shared stores of compassion and caring regarding how they were present with family as a loved one was dying or sitting with a patient who was all alone.
Discussion
Professional identity is formed while in nursing school from students’ own core values combined with the expectations learned in school such as attitudes, behaviors, work experiences, and role modeling from other nurses. 4,32 The development of a professional identity is critical in guiding nursing students to make sound ethical decisions about the care of their patients. Patient safety has been linked as a fundamental ethical concept in relation to professionalism. 33 The ability to provide safe and effective care is the cornerstone of nursing ethics. Nursing students may begin to develop an ethical morality that evolves during their education. 1 However, there continues to be limited research on sustainability of these ethical values. 1 Straughair et al. 18 suggest that there are challenges in sustaining values such as compassion due to the complexity of how nurses work and the limited number of role models.
Research supports that core values are linked to developing a professional identity and nurses who demonstrate confidence and self-assurance have higher retention rates and overall better job satisfaction. 4 As stated in the literature review, professional identity may also lead to better caring abilities among students and less stress when faced with making ethical decisions. 15 Following the educational intervention, students showed increased awareness of their future role as a nurse and how their core values might have played a role in how they handled certain situations. Students discussed how disputes could be handled professionally, which allowed for further discussion on their ability to advocate and care for their patients.
Students stated core values such as empathy and advocacy as important in caring for their patients. In a qualitative study of oncology nurses, it was found that nurses with strong core values were able to empathize and provide quality care to their patients. 20 Schmidt and McArthur 12 revealed from a qualitative study of nurses that the characteristics of empathy and caring were identified as core values used in association with patient advocacy. However, it is also important for nurses to have the self-assurance in their abilities as they advocate for their patients. Nursing students enter their programs with a strong desire to care for patients, and it is important for them to have the confidence as they begin to learn to advocate for patients. 11 The responses from students in the reflective narratives revealed that students had the confidence to advocate for better care for their patients.
It is important as they will soon begin their careers that they are able to have this strong ability to speak up when necessary. In this study, over 95% (n = 106) of the students responded that they learned about advocating for their patients and that they gained an understanding that they had a right to speak up for their patients. The results of this finding are significant as studies have shown that nurses would prefer to negotiate with a healthcare provider rather than advocate for patients. 34,35 The study supported that nurses would negotiate with a healthcare provider as “they know best” to the procedure or care as opposed to speaking up for the patient if the nurse deemed it inappropriate. 34,35 Rainer 34 discusses that personal and organizational factors may influence how well a nurse may be able to advocate for their patients. This is important as new nurses might be more willing to follow what is done and not question the “status quo.” It is important to prepare new nurses for these types of situations, and educators will need to find the balance and teach students how to use positive influences as they strive to advocate and administer quality care to their patients.
After the hidden curriculum educational session, the post-survey scores improved on how students demonstrated an understanding of when they would speak up if witnessing inappropriate behavior toward patients, families, or peers. Sayre et al. 35 conducted a quasi-experimental study using an educational intervention to demonstrate the value of advocating for patient safety to avoid harm. The educational intervention was successful as the results revealed that the intervention group had a significant difference from baseline to posttest scores. 35
The shared narratives from students support that they use their core values in clinical situations that engendered advocacy, empathy, and compassion. Students shared and reflected on stories from clinical experiences when witnessed behaviors were noticed. Cohen and Plack 36 conducted an educational intervention for students to write and reflect on professionalism and found that it is important to use this type of method to teach professionalism.
Many narratives from this study of professionalism shared by students were of situations of when the student was able to speak up and advocate for their patients. Students expressed other core values such as caring and compassion by sharing stories of clinical experiences while in nursing school. Raso et al. 37 discusses a qualitative study conducted of nursing students and found they reported discrepancies in what was being taught in the classroom compared to clinical about professionalism. It is important that students share and reflect their experiences about what is seen in the clinical setting to allow for rich discussion and learning opportunities. For this study, students were encouraged to discuss and reflect throughout the session and many were eager to share their clinical stories. While the other results from the survey showed little change from the pre-survey to post-survey, the educational session had the ability to increase awareness of the importance of advocating for and speaking up for patients.
Strengths and limitations
The strength of the educational session was the professional formation module on the hidden curriculum. The educational session allowed for rich discussion and sharing of stories about clinical experiences of advocacy not always shared in a classroom format. An unfortunate limitation was that not all question responses were included in the data analysis as the instructions were unclear for some of the students. The survey was conducted using a convenient sample of students, and their reflections and results are based on one class from one university. The survey was paper and pencil, and some items were created by the investigator. For future research, a review of the literature would be conducted to find valid and reliable instruments to survey student’s professional development. Assessing students at various levels of their nursing program might provide more insight to different behaviors as they are introduced into the clinical setting. Narrative reflections could be administered once students have completed an internship to assess if they have similar results of advocating for their patients as when they began their nursing program.
Conclusion
The hidden curriculum is part of the formal curriculum and needs to be addressed early within nursing programs. Students entering nursing should have an introduction to the hidden curriculum and its relevance within a professional education. The hidden curriculum needs to be addressed and discussed as students will have to identify what is the formal curriculum and what is part of the hidden curriculum. Identifying the curriculums may help students understand the roles and responsibilities of the nursing profession and allow them to reflect on how different aspects of the hidden curriculum may play a role in how they form their own identity.
The ability to advocate for patients was an important finding from this study as the students will soon graduate and embark on their nursing careers. However, the sustainability might be questionable and needs to be studied further. Nurses who have developed their professional identity and use their core values of advocacy and empathy will be in a stronger position than those without these values to provide safe patient care. The professional formation organization module on the hidden curriculum is an educational session that will be able to be used as the foundation for future educational sessions to all levels within the nursing program. 31
A future study would use the hidden curriculum module as an educational session and compare responses of students from their freshman to senior level. Freshman students are not exposed to clinical practice until later in the program and their view of advocacy could be clouded from their idealization of the nursing profession. The module would be used as an educational session in their freshman introductory to nursing course. The same students would have the same module reintroduced the beginning of their senior year as many students may have had internships prior to their senior year of school. The study would use a guided reflective model to assess student’s personal growth throughout the nursing program. The model will move students from descriptive through examination of experiences in accordance with specific learning objectives. 38 Comparing students as freshman and then again as senior nursing students on the development of a professional identity would lend itself to how educators can implement curricular changes on how to use the hidden curriculum to teach professionalism throughout the nursing program.
Clinical faculty who teach in the program would also benefit from an educational session on the hidden curriculum. A focus group of clinical faculty could be used to role-play with nursing students in educating and highlighting aspects of the hidden curriculum. In turn, this could allow rich discussion and guided reflection on how to identify different attributes of the hidden curriculum.
The modules may be implemented into the on-line learning system to use with the graduate family nurse practitioners on how the hidden curriculum may affect their professional development. Future research on the methods of use will continue for this group of students.
Studies in how the hidden curriculum is embedded within a professional education are important to recognize and will continue to be a part of nursing education. It will be imperative that nurse educators identify and understand how it evolves and use it for discussion and reflection on how nursing students may recognize it and how it may form their professional identity.
Footnotes
Author’s note
The author was a participant in the 2019 NLN Scholarly Writing Retreat, sponsored by the NLN Chamberlain College of Nursing Center for the Advancement of the Science of Nursing Education.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
