- Nermin Ersoy, Ph.D. , Insaf Altun, MSN.
Kocaeli University Medical School , Dept Medical Ethics & Medical History, 41900 Derince, Kocaeli ,TURKEY
Eubios Journal of Asian and International Bioethics 8 (1998), 72-75.
Those values which must play critical roles in the professionalization of nursing and in practical nursing, also have strategic impact in their acceptance or rejection by the professional community.
Nurses are with individuals during birth and death, illness and healing. So if they are without knowledge of their own and their patients' values, it seem impossible for them to provide expected nursing services. Here, especially, such questions as "what should I do?" as so often asked by the bedside nurse with responsibilities for patient care, can only find adequate answers when framed within patients' values as well as their own. The definition of the nurse-patient relationship as forming values can contribute to the ethical dimension of nursing practices, and, thus, should result in qualified nursing care (1-5).
Until the beginning of the twentieth century, the prevailing values in nursing were, for example, benevolence, self-sacrifice, obedience, serious-mindedness, faithfulness, compassion, patriotism as well as love of humanity. Now in our day, the essential values identified by the American Association of Colleges of Nursing (1985) are commonly accepted. They might be listed as; aesthetics - in terms of , events and personal characteristics which generate a sense of deep satisfaction, altruism - active effort for others' benefit, equality - possession of the same rights, privileges or position, freedom - the capacity to decide, human dignity - belief in an individual's uniqueness and values, justice - respecting to the moral and legal principles, truth - adherence to the fact or reality. The essential values may be explained by some personal qualities and attitudes.
These qualities and attitudes can be described in the following manner. Aesthetics includes personal qualities such as sensitivity, creativity, imagination and it can be reflected in adapting the environment so that it is pleasing the patient. Altruism includes personal qualities such as caring, compassion, generosity and it can be reflected in expressing concern about social trends and issues that have implications for health care. Equality includes personal qualities such as fairness, tolerance, self-esteem, and it can be explained as the nurses' interactions with other providers in a nondiscriminatory manner. Freedom includes personal qualities such as confidence, hope, independence, openness, and it can be explained as to honor the individual's right to refuse treatment. Human dignity includes personal qualities such as consideration, empathy, humaneness, kindness, respectfulness, trust, and it can be reflected in safeguarding the individual's right of privacy, and in treating others with respect, regardless of background. Justice includes personal qualities such as courage, integrity, objectivity, and it can be reflected in acting as a health-care advocate, and in allocating resources fairly. Truth includes personal qualities such as honesty, rationality, accountability, authenticity, and it can be explained as to document nursing care accurately and honestly (6). These new professional values are leading to an inescapable reevaluation of the patient-nurse relationship model as well as of our understanding of what nursing is. The modern nursing model has resulted in a preference for a contemporary relationship which presents mutual responsibility in place of a one-way patient-nurse relationship and patient centered nursing in place of physician-centered (6-12).
The purpose of this study, was to determine the personal and
professional values of nurses in Turkey. The current study has
been proposed to determine what values are accepted by nurses
and which are not and also to see how the contemporary nursing
model is understood in the minds and actions of nurses. We believe
that in view of the obtained results, suggestions concerning teaching
ethics and values in present day nursing education shall be proposed.
Subjects and Methods
The improved questionnaire included three parts. The first part consisted of descriptive data about nurses including age, levels of education, marital and family status, duration of occupation, place of work and reason for nursing choice. The second part consisted of the questions revealing the priority of the nurses' personal and professional values in their own lives and the other questions to determine some attitudes related to their daily patient care practices . The third part included the questions about the definitions relating to an ideal person, an ideal patient, an ideal nurse and an ideal physician in the minds of nurses.
The questionnaire was presented to nurses working as bedside
care givers at four hospitals in Kocaeli district (an industrial
region near Istanbul) between February and July 1996. Almost
ninety percent of nurses (N=282) working in these four hospitals
responded to the questionnaire. After being enlightened about
the study, the nurses were left alone to fill in the questionnaire.
For statistical analysis Chi-square and Fisher's tests were used
by using the SPSS statistical package. The characteristics of
the nurses were used as independent variables.
Table 1: The Characteristics of Nurses
|AGE (N= 282)||%|
|19 - 29 yr.||66.0|
|30 - 39||30.5|
|40 - 49||3.5|
|TYPE OF HOSPITAL|
|zmit Public Hospital||44.3|
|zmit Social Security Hospital||32.6|
|Kocaeli Social Security Hospital||11.7|
|Kocaeli University Hospital||11.3|
|REASON FOR NURSING|
|Love of humanity||29.6|
|Ease of employment||18.6|
|Having no idea||23.5|
The characteristics of participating nurses: A greater percentage of nurses were aged between 19-29 years, half were practical nurses, more than half were married and more than half had no child. Most nurses were working at the public hospital, and the same percentage of nurses were working at social security hospitals. 42% of nurses had professional experience between one and five years. The reasons for the choice of nursing among the participants were found to be (in decreasing order) human love, ease of employment, to gain status, family satisfaction, having no alternatives. 24% did not state a reason for their choosing nursing (Table 1).
We asked the participating nurses which the most important values for their lives were. According to their classification; the personal values were found as honesty, trust, respect, independence, professional competence, humanism, equality, justice, benevolence, rationality, altruism, etc. (Table 2).
We asked other questions which would give us information about some actions of the participating nurses (five nurses did not participate) in daily practices. According to the obtained findings, 42% of nurses stated that they provided a favorable physical environment for their patients. 63% of nurses stated that they provided a qualified nursing care for their patients. More than half (62%) stated that they discussed with physicians for their patients. Less than half (44%) stated that they discussed with their patients for a good decision related to their treatment. Most nurses (76%) stated that they did not inform their patient in case of a very high blood pressure. Almost, most nurses (79%) stated that they did not inform their patients in case of a bad prognosis, even if the patient requested. Almost half nurses stated that they tried to hold the medical records of the patients, particularly, when the patient had a bad prognosis.
These results seem to be associated with the most important values
for nurses, and their actions in daily practices. In the view
of this, the professional values of the participating nurses were
found to be first, human dignity, then, truth, freedom, justice,
aesthetics, altruism, and least, equality (Table 3).
Table 2: The Personal Values of Nurses (N=282)
|5. Professional competency||6.4|
|12 Economical power||3.3|
Table 3: The Professional Values according to Personal
and Professional Values and Attitudes of Nurses
Although, age, experience period in profession, reason of nursing choice, marital status were not statistically significant when associated to professional values; educational level showed a high statistical significance (P<0.0001). 22% of practical nurses and 23% of registered nurses stated "human dignity" as the first value. Almost the same percentage of practical nurses stated "altruism" as the first value, whereas almost all research and academic nurses stated "freedom", and the least research and academic nurses stated "altruism" as the first professional values. This significance seems to be related to the values of human dignity and altruism. In spite of the fact that the reasons for choosing nursing were not affected to a statistically significant degree, nurses who wanted to be a nurse by reason of human love, gave priority to altruism, nurses who wanted to be a nurse by reason of ease of employment gave priority to truth and freedom.
We wanted to know much about the bedside nurses particularly
with respect to the considerations in their minds, about an ideal
person, an ideal patient, an ideal physician and an ideal nurse.
The findings about their considerations are shown in Table 4.
According to their replies, it seems that they want an ideal nurse
to be more altruistic in their professional sense (Table 5).
Some results of this present study resemble those of other studies carried out in Turkey on the topic of professional selection. The studies by ÷zcan, Bahar and Kuzulu also show that love of humanity has been the main reason for selecting nursing as a career. Also the second reason was the relative ease of finding employment and, the desire to satisfy their families (Table I) (13-15).
Although in the current study, the first five personal values appeared respectively as: honesty, trust-worthiness, respect, independence and professional competence, in the research of BahÁecik and Pek (stanbul,1995), the basic values which nurses desired to obtain were defined as self-respect, equality, freedom, world-peace and self-happiness (16). In G¸ven's study (stanbul, 1990), the nurses' most important values and attitudes appeared to be equality, respect to rules, success, knowledge and ambitiousness (17). In the nursing school study among first-term students, carried out by Kuzulu and et.al. (Ankara,1993), the values were found to be family security, world-peace, self-peace, self-respect, and true friendship (15). These differences in value priority between our study and those of others may be due to changes in education, status and time. Significant differences between the education levels of the subject nurses and the preferred personal values have been observed in our study. Most research and academic nurses (19%) stated the first five personal values as trust, independence, knowledge, rationality and correctness.
The value of independence, being in the fourth position in the results of the present study (Table 2) was also observed to be in important ranking position in the cited studies. It would appear that the nurses in Turkey have accepted the profession as an independent one and have become well aware of their independent roles. Professional competence, also being one of the first five values, is likely to be another indicator of growing awareness of the independent practices of the professional as one of the requirements of contemporary nursing.
One of the most important professional values selected by the nurses participating in our study turned out to be human dignity (Table 3) which is shown to be appropriate to their attitudes and personal characteristics (Table 2). Here it could be emphasized that the nurses give importance to the respect to human dignity, the value which is thought to be reflected by the personal characteristics such as thoughtfulness, empathic approach, humanism, respectfulness and trustworthiness (6). These observations are in accordance with the results of the reasons for selecting nursing (Table 1) and their attitudes in daily practice. In conclusion, the nurses have accepted the supreme values named as respect to human dignity, individual uniqueness, and love of humanity, and also they have adapted to the contemporary nursing understanding.
According to the results of the current study, altruism stands as the first ranking in the definition of ideal nursing concept (Table 5). Nonetheless, for their own selves, the value of altruism seems to have less importance (Table 3). It is likely that, although altruism should be a desired value in minds of the professionals, especially for the practical and registered nurses, there appears to be a considerable disagreement in the nurses' profession understanding.
It has been found that the nurses appreciate the truth and freedom values as equally important for both a good nurse and for themselves (Table 3, 5). It seems obvious that the value of truth, including attitudes and characteristics such as responsibility, trustworthiness, honesty, rationality, and sensitivity; and the value of freedom, including those such as confidentiality, independence, open-mindedness, and competence (training own self) are likely to be carefully kept by the Turkish nurses. These results give rise to the fact that most nurses in our country seem to accept contemporary nursing model and also to have ethical sensitivity.
Most of the participating nurses gave priority to compassion in their definition of being an ideal nurse (Table 4). This dichotomy leads to a conclusion that compassion (18) as the very core of nursing, in daily patient caring practice, seems to be accepted as an important value in terms of ideal nursing; on the other hand the nurses do not accept it as important for their own professional lives.
The nurses propose that good patients should be respectful, polite, obedient, brave and with sense of understanding others (Table 4); thus, it appears that they still prefer the one-way relation in patient-nurse relationship. Our results raised a suspicion of the nurses' tendency to maternalistic attitudes, since they preferred traditional patient-nurse relationship instead of mutual responsibility (19), because most nurses did not tell the truth when the patient had bad vital symptoms and a bad prognosis. Less than half nurses stated that they discussed with their patient, when the patient made a decision for his treatment and if this decision was not good for the patient according to the nurse.
According to Rokeach's point of view in studying a person's value
system, it is not enough to study the individual. The cultural
setting must also be considered. This statement has encouraged
us to suggest that in our country, the expected or supreme values
are honesty, rationalism, respect, justice, trustworthiness, benevolence,
and sensitivity, in which the nurses believe as important for
being a good person. In addition, Turkish nurses included in this
study, believe that some of these values should also resemble
those ( honesty, respect, justice, trustworthiness, sensitivity,
intelligence, etc.) of a good physician (Table 4).
Table 4: The Identifications of Ideal person, Ideal patient,
Ideal nurse and Ideal physician by Nurses
|Ideal person||%||Ideal patient||Ideal nurse||Ideal physician|
The knowledge we have obtained by this study shows to which extent the nurses in Turkey include the values accepted as essential for qualified nursing care. By this knowledge we also get the opportunity to achieve the clues about the opinions of those nurses in the sense and aim of nursing.
When we evaluate the personal and professional values of nurses with respect to important ranking; we can say that; even though Turkish nurses consider the values of contemporary nursing, such as human dignity, truth, freedom, and justice, they also try to balance these new values with traditional nursing values, such as benevolence, serious-mindedness, obedience, and compassion. We believe in the fact that the nurses appreciate the sense, aim and the values of contemporary nursing by combining the ideal nursing concept with love of humanity, compassion and altruism. This point seems very important, because almost only one nurse is obligated for the nursing care of fifteen to twenty patients in Turkey. In such a condition, one may easily think that the bedside nurses are likely to lose their ethical sensitivity.
Both the present study and those of others lead us to a conclusion that nurses accept nursing as an independent profession. However, their belief in a good patient being respectful, understanding and obedient raise a suspicion about their one-way relation preference in patient-nurse relationship, This finding suggests that the traditional patient-nurse relationship is still carefully kept in the meantime. The attitudes related to their professional practices show us that they try to keep their some traditional roles, such as; to hold bad news related to the patient and to change the decision of the patient or to make a decision for the patient. Thus, the nurses seem to have a tendency to maternalistic attitudes. In view of this fact, our suspicion is that they will be a decision maker behalf on their competent patients. In addition, such attitudes might threaten the realization of the patients' values. On the other hand, a tendency to the maternalistic attitudes of the nurses shows that compassion and benevolence can be considered as important qualities for nursing care in Turkey.
Whereas, in our previous study, less than half nurses (45.8%)
stated that they believed in the patients' right to refuse treatment
, even if it would hasten his death. Even a greater percentage
of nurses (84.5%) stated that patients have the right to participate
in all decisions related to their treatment. Also most nurses
(63.9%) stated that they believed in patients' right to know the
truth (20). These findings show the existence of some conflicts
between their beliefs and their practices. This dilemma can be
prevented by ethics and values training in nursing; so that the
nurse will become more competent in identifying both her own values
and her patient's values. To achieve this aim, we must seriously
emphasize the fact that nursing ethics should not only be based
on the western nursing professional values (aesthetics, altruism,
equality, freedom, human dignity, justice and truth) around the
world, but also be a cross-cultural discipline.