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- v.18(1); Jan-Feb 2013
- PMC3748548
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Iran J Nurs Midwifery Res. 2013 Jan-Feb; 18(1): 1–8.
PMCID: PMC3748548
PMID: 23983720
Mohsen Shahriari, Eesa Mohammadi,1 Abbas Abbaszadeh,2 and Masoud Bahrami3
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Abstract
Background:
Ethical values offer a framework for behavior assessment, and nursing values influence nurses’ goals, strategies, and actions. A literature review was adopted in order to determine and define ethical values for nurses.
Materials and Methods:
This literature review was conducted based on the Centre for Reviews and Dissemination guidelines. The key words used to search relevant sources were nursing, ethics, ethical values, and nursing values. The search of articles in English was carried out in Medline, CINAHL, PubMed, Scopus, Ovid, and Proquest databases. The search of articles in Persian was conducted in databases of Magiran, SID, and Irandoc publications. After assessing and analyzing the obtained data, 17 articles which had a distinct definition of ethical values were chosen and subjected to a thorough study.
Results:
The search yielded 10 nursing ethical values: Human dignity, privacy, justice, autonomy in decision making, precision and accuracy in caring, commitment, human relationship, sympathy, honesty, and individual and professional competency.
Conclusions:
This study showed that common ethical values are generally shared within the global community. However, in several areas, influences of social, cultural, and economical status and religious beliefs on values result in a different definition of these values. This study revealed that based on humanistic nature of nursing, common values in nursing protect human dignity and respect to the patients. Recognizing and definition of ethical values can help to improve nursing practice and develop codes of ethics.
Keywords: Ethics, literature review, nursing, professional values, values
INTRODUCTION
Nurses as one of the health service providers and members in health system who are responsible for giving care to the clients and patients based on ethical issues.[1] They need ethical knowledge to conduct their appropriate function to manage situations and to give safe and proper legal and ethical care in today's changing world.[2] With regard to practical care, they always try to answer the question of “What can I do?,” whereas they should try to answer what is essential to be done for the patients in the context of ethical principles.[3] Ethics seek the best way of taking care of the patients as well as the best nursing function.[4]
Nurses are responsible for their clinical function, and their main responsibility is to take care of the clients and patients who deserve appropriate and safe care.[5] They act based on the values they have selected. These values form a framework to evaluate their activities influencing their goals, strategies, and function.[6] These values can also be counted as a resource for nurses’ conduct toward clinical ethical competency and their confrontation with contemporary ethical concerns. Values conduct human life priorities and form the world we live in. They act as one of the most basic parts of human life. Ethical values are inseparable components of the society and, as a result, nursing profession.[7,8]
Discovery of basic values and reaching an agreement on clinical ethical values are essential with regard to constant changes in nurses’ social class and role.[9] Nurses’ awareness of their values and the effect of these values on their behavior is a core part of humanistic nursing care.[10] They need to tailor their function to the value system and cultural beliefs of their service recipients.[11] Values originate from cultural environment, social groups, religion, lived experiences, and the past. Social, cultural, religious, political, and economic considerations influence individuals and their value system,[6] and ultimately, health, education, social strategies, and patients’ care. Numerous documents have been prepared in nursing texts and literature concerning these values and clarification of their traits.[7,9,12,13,14,15,16]
Recognition and definition of nursing ethical values in various communities can help nurses have mutual understanding in international level. It can also bring nurses closer to reach a common meaning of care in patients with different cultures. However, there is a paucity of research particularly in the Iranian context to deeply explore nursing ethical values. Therefore, in the first step, the main aim of the study was to identify and explore nursing ethical values reflected in nursing texts. This search was then used to prepare code of ethics and clinical guidelines for Iranian nurses, along with other documents and evidences. Results of other aspects of the study have been reported in other articles from the researchers.
MATERIALS AND METHODS
This study is a part of a bigger study conducted in the Isfahan University of Medical Sciences. A literature review was carried out in 2010 to determine ethical values and related definitions in nursing systems of various countries.
In this literature review, the York University four-step approach was applied. These steps are as follows: Forming questions and determining search strategies, extracting synthesis, providing quality assessments and applying study evaluation tools, and suggesting methods to analyze and data synthesis.[17]
Search strategy
The study tried to answer the following questions:
What nursing ethical values are determined and offered in this study?
What is the definition of each value?
In this literature review, all published articles in English language from 1995 to 2010, as well as articles in Persian from 1996 to 2010 were searched by separated keywords and then keywords in combination, respectively. AND/OR was used combination and collection of various key words together. A manual search was also adopted and the references of the articles were studied as well. The search yielded about 82 articles whose titles and abstracts were studied. The articles not meeting the inclusion criteria were left out. Inclusion criteria were: Articles published in English or Persian and those articles on nursing ethical values in patients’ care. At this stage, 37 articles were excluded and 45 were selected and comprehensively reviewed. In the next stage, the articles were completely studied with regard to inclusion criteria and their answers to the questions of the present study.
Finally, 17 related articles were selected and considered for the study. Data were extracted through firstly writing down the detected values and their definitions in the related articles. Then, the research team compared the findings and recorded them in a table, and selected the best definition of each value among the suggested definitions. Finally, after comparison of the names and words, a unique definition for each value was achieved based on the trait of definition.
Research team checked all selected articles concerning assessment of quality based on criteria of study quality evaluation tool. This tool was designed by the research team with regard to the study goal. Two questions were considered with respect to the various research methods employed in the selected articles. The questions were as follows:
Does the article express nursing ethical values?
Does the article contain a clear and specific definition for the expressed ethical values?
In order to increase study credibility, the abstracts were studied by researchers individually and the obscure points were discussed by the research team. In case of a disagreement to include an article in the study, a third member of the research team conducted further investigations, the obscure points were discussed in the group, and a final decision was made.
In the stage of data combination, all textual obtained data from the selected articles were classified and completely described. After textual data had been extracted and studied critically, the traits were separated and finalized based on the obtained definition for each value or ethical concept and finally a unique definition was obtained. Each obtained defined value has been explained in the section “Discussion.” These defined values suggested appropriate answers to literature review questions.
Articles methodological traits
The articles were from 12 countries: Four from US, two from Canada, five from European countries (Belgium, England, Finland), and six from Asian countries (Iran, Japan, China, Thailand, and Taiwan).
Reviewed articles included two quantitative studies, eight qualitative studies, three literature reviews, two philosophical inquiries, and two action research philosophical methods. Various sampling methods had been precisely employed in these studies. 1360 subjects comprised the recruited subjects in these 17 articles. In two quantitative descriptive studies, 922 clinical nurses and nursing students had been randomly selected through census sampling. In qualitative researches, the participants comprised 438, randomly selected through purposive sampling. The number of participants ranged between 20 and 300 individuals. In most of these qualitative studies, the participants included clinical nurses accompanied by nurse educators.[9,18,19,20] In one study, the participants were just clinical nurses, and in another,[21] they were just nursing students.[22]
The data were mostly collected through individual interviews which were, in some cases, the only source of data and in some other cases accompanied by other methods. The data had been collected by different methods: One by individual interviews and group discussion,[20] one by individual interview and observation,[18] one by narration and individual interview,[19] one by group discussion and narration,[22] and finally, in only one by group discussion.[9] In two studies, data had been collected through literature content analysis;[10,13] in two, by applying intervention;[16,23] in two other, through literature review;[7,24] and finally, in two studies, the data had been collected through philosophical inquiries.[6,25]
In two quantitative studies adopted to collect data, standard tools had been employed. In the study of Weis (2000), Nurses’ Professional Values Scale (NPVS) with confirmed reliability and validity had been utilized.[26] Rassin (2008) used nursing code of ethics related to International Nursing Association to evaluate nurses’ professional values as well as the Rokeach Values Survey with confirmed reliability and content validity to assess nurses’ personal values.[15]
Quality appraisal
The selected articles were reviewed concerning their quality. Application of a systematic literature scientific method in the present literature review study let the research review the articles based on research questions, research project, data collection method, data analysis method, data credibility, ethical considerations, and the results.
In quantitative studies reviewed, standard questionnaires had been adopted for data collection, data analysis method had been clearly defined, and the necessary permissions had been obtained from university and other needed institutes to respect ethical considerations. The results were also in the direction of research questions.
In qualitative studies, research methodology and data analysis had been clearly stated, and participants’ consents had been obtained to respect ethical considerations. Various methods had been employed for credibility: Data collection from various methods,[19,20,22] precise transcription, and data recheck and conformability with participants and colleagues.[18,19,20]
Data analysis methods of the studies, conducted based on philosophical research methodology and action research, had not been clearly mentioned, but their results were related.
General traits of reviewed studies
General traits of reviewed studies in the context of nursing ethical values have been presented in Table 1. The reviewed articles had investigated nurses’ ethical values from different aspects.
Table 1
Outline of studies included in the review
Open in a separate window
RESULTS
In various studies, the values had been differently introduced and defined. Most of the reviewed articles had focused on common nursing ethical values.[22] In some, several values and in some other, only one value had been introduced and defined. Konishi (2009) had only studied the value of harmony in nursing and had suggested that as one of the most fundamental values in Japan.[13] Verpeet (2003) had defined values as nurses’ responsibility against their patients, profession, other health team members, and society.[10] Naden (2004) in his study to define components of human dignity indicated braveness, responsibility, respect, commitment, and ethical desires.[18] Wros (2004) reported a significant difference in ethical value of decision making among the nurses in two countries.[19] Trailer (2004) claims that respect to the patients has the highest priority among codes of ethics and acts as a basic value to design the nursing ethical codes which include three main elements of respect, reliability, and mutuality.[25]
Shih (2009) reported that 75% of the participants had indicated taking care of the patients and their related individuals and altruism as the most common nursing values. Other values in his study were provision of holistic professional and appropriate care, promotion of personal and professional competency, disease prevention, health promotion, promotion of interpersonal communication skills, and receiving fair reward.[9]
Weis (2000), through factor analysis, introduced eight factors for professional values of which the most important one was nurses’ role in care and dimension of commitment.[26] Pang (2009) stated nursing professional values in seven themes of altruism, care, respecting the dignity, trust, accountability, independency, and justice.[20] Mahmoodi (2008) indicated responsibility, having mental and emotional communication, value, and ethics criteria such as honesty in work, mutual respect, religious margins and confidentiality, justice and fairness.[21] Shaw (2008) and Fahrenwald (2005) in our studies, in a different way, investigated application of five nursing professional values in nursing education, including altruism, independency, respect to dignity, nursing interventions’ integrity, and social justice.[16,23] Horton (2007) stated that personal and organizational values have effects on nursing and introduced values such as responsibility, honesty, patients’ participation, integrity and humanity protection, patients’ independency, deep humanistic relationship, dignity, hope, passion, teamwork, differentiation, versatility, altruism, nurturing, integrity and support, reciprocal trust, sound knowledge, clinical competence, communications, unity, hom*ogeneity, coordination, self-sacrifice and devotion, self-protection, privacy preservation, creativity, aesthetics, management, economizing, braveness, commitment, ethical attitude, personal orientation, judgment, freedom, individualism, acknowledgment, and personal success.[7] Two studies had stated detection of ethical values as the basis for collection of codes of ethics.[24,27]
DISCUSSION
In all of the articles studied in the present literature review, patients’ dignity and respect had been stated as the most frequent value indicated in 12 articles, equality and justice in 8 articles, and altruism and precise care and making appropriate relationships were indicated in 6 articles, respectively.
Comparison and finalization of the obtained data concerning nursing ethical values in patients’ care yielded 10 values mostly indicated in the articles: Human dignity, altruism, social justice, autonomy in decision making, precision and accuracy in caring, responsibility, human relationship, individual and professional competency, sympathy, and trust. The 10 obtained values in this literature review and their definitional traits are presented subsequently.
Human dignity
Respecting human dignity was the most common value indicated in the reviewed articles. Respect to individuals including the persons, their families, and the society has been mentioned as an important nursing ethical value. Dignity respect has been defined with definitional traits as consideration of human innate values, respecting patient's beliefs and preservation of their dignity and privacy during clinical procedures, and communication with the patients, and contains understanding the patients and devoting to fulfill clients’ needs.[15,16,18,20,22,23,24,27] Pang (2009) argues that nurses should accept that people deserve respect and dignity in action. They should practically cover patients’ body parts if exposed and keep patients’ secrets confidential.[20]
This value has been suggested in most of the articles possibly as a result of humanistic nature of nursing profession in helping others. This value had been emphasized in all articles of Asian countries, reflecting cultural similarities in these countries. This value has also been indicated in most of the codes of ethics in various countries all over the world.
Social justice
Justice is an ethical value suggested in nursing literatures. Social justice has been defined by the traits which, in addition to consideration of individuals’ dignity and respect, focus on equal access to health services and the right of being fairly treated and cared free of economic, social, and cultural status.[9,10,15,16,20,21,23] Social justice had been the indication in most of the countries and had been defined as fair distribution of resources and provision of individuals’ equal treatment and care.
Verpeet (2003) stated that equality means access of all individuals to health services. She claims every individual in Belgium is supposed to have equal right of receiving equal nursing care.[10]
Altruism
Altruism is a common nursing value in various countries. It has been defined with traits of consideration of human as the axis of attention and focus in nursing, helping others and provision of the utmost health and welfare for the clients, their families, and the society, selflessness, and self-devotion.[6,9,13,15,16,18,22,23,27] Therefore, altruism is defined as focusing on clients as a human and struggling to preserve their health and well-being. Pang (2009) debated that based on the principle of altruism, nurses should have spirit of selflessness and helpfulness toward others.[20]
Autonomy in decision making
Independency in decision making is a value suggested in some studies as a nursing ethical value. Nurses have defined its traits as having right of independency in decision making, right to accept or reject suggested treatments, interventions, or care. In addition, autonomy in decision making necessitates giving appropriate and adequate information to the clients and, if necessary, to their families.[13,15,23] So, autonomy in decision making occurs when nurses let patients be informed, free, and independent to decide on the diagnosis, treatment, and prevention through giving them appropriate information.
Konishi (2009) debates that conscious adult patients should themselves decide. With regard to nursing profession, nurses should provide the patients with information, explain suggested interventions, and let them free to either accept or reject oncoming procedures so that they and their families can make a decision about their condition.[13]
Precision and accuracy in caring
Precise and accurate care has been indicated as a nursing ethical value. Based on this definition, this sort of care is a precise, safe, appropriate, multidimensional, and kind care given to the patients by nurses. This is also thoughtful, based on adequate clinical skills and nursing knowledge to fulfill clients’ needs, promote their health, and relieve their pain and suffering. It is also based on standards and results in patients’ safety and satisfaction.[6,9,15,23,24,27] In this regard, Shih (2009) states that holistic and appropriate professional care is to prevent diseases, promote health, and make the feeling of comfort and safety for the patients.[9]
Responsibility
Responsibility has been defined as a nursing ethical value. It is defined with traits of commitment, feeling responsible for the duties toward patients, and respecting the patients’ rights for decision making.[15,18,19,21,24,26,28] Based on this definition, nurses are responsible for giving evidence-based care, best clinical function, and applicable and valid research, and are accountable for their actions and duties. Verpeet (2005) argues that nurses are responsible for promotion of patients’ well-being, having a holistic approach toward them and completing their duties.[28]
Human relationship
Human relationship has been indicated as a nursing ethical value with traits of mutual respect, trust, and reliance which are accompanied by patients’ confidentiality and privacy. It can be verbal or non-verbal and defined through having honesty in words and practice, sympathy and mutual understanding, courtesy, and friendliness.[9,15,19,21,25]
In this regard, giving care is possible only through making humanistic, efficient, and effective relationship, a relationship based on mutual respect and understanding.
Individual and professional competency
Individual and professional competency as a nursing ethical value has been defined with traits of struggling to make nursing as a profession, feeling the need to acquire personal and professional competency so that nurses can grow and develop in the direction of advances and new technology. Personal competency and development of the nurses result in acquiring up-to-date knowledge and promotion of clinical skills and practical abilities, and the ability to give more holistic and comprehensive care. Promotion of personal and professional competency comes true when nurses make a background for the best patients’ care by trying to give evidence-based care, and their empowerment for participation in activities in relation with other health team members and interpersonal and inter-professional skills development.[7,9,15,20,24] Pang (2009) debates that participation in continuing professional development suggests that individuals should preserve their competency in their activities and participate in professional continuing education programs throughout their occupational life.[20]
Sympathy
Sympathy has been indicated as a nursing ethical value with traits of understanding patients’ and their families’ needs and giving care based on making a fair communication.[6,19] In some cultures, such as Japanese, nurses share patients’ physical and mental pains and sufferings.[19]
Trust
Trust has been indicated as a nursing ethical value and is defined by traits of honesty in words and practice. Nurses should gain patients’, their families,’ and society's trust through understanding patients’ situation and status and appropriate conformation with them.[15,20,23,24] Based on this definition, gaining clients’ trust and reliance comes true when nurses are honest in their words and practice, and gain individuals’ trust and reliance by doing their duties appropriately.
CONCLUSION
This study showed that nursing ethical values in patients’ and clients’ care are similar in many cases due to a common core in humanistic and spiritual approach of nursing profession, which is taking care of a human. Values such as human dignity, kindness and sympathy, altruism, responsibility and commitment, justice and honesty, and personal and professional competency were similar in most of the cultures.
Despite the similarities in ethical and professional values among various countries, it is essential to detect and highlight these values in each country, for example, in Iran, with regard to the prevalent social, cultural, economic, and religious conditions. Detection and declaration of nursing ethical values in each country can be a valuable, scientific, valid, and essential document to design nursing codes of ethics. This search was used to prepare proposed code of ethics and clinical guidelines for Iranian nurses. Findings of this study search must be considered within its limitation. An attempt was made to conduct a search as vast as possible. However, it might be possible that we could not access to all articles available in the period of the search.
ACKNOWLEDGMENT
The authors would also like to acknowledge the Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, for supporting this work.
Footnotes
Source of Support: Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences
Conflict of Interest: None
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