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When defining a personal nursing philosophy, the individual nurse must not simply review his or her own schema of values and beliefs, but must also reassert their own personal confidence in their value system. By taking into consideration the frameworks of theorists, such as Kohlberg (1981) and Gilligan (1982), nurses will better understand their own personal values as well as the values of the profession (Burkhardt & Nathaniel, 2008). Theorists of the recent past must be viewed with a professional respect in order to ensure that a nurse coming into an increasingly difficult health care environment has a core sense of their own personal and professional values and is also flexible enough to respond to individual obstacles, which they may encounter over the course of their nursing career.
The purpose of this paper is to describe an event in which two or more personal values were demonstrated and describe how these values influenced the professional decisions that were made. It will further assess the level of development of these values. Personal values will be differentiated from those of the institution and in will be discussed where these values are compatible and where they result in conflict. Finally, it will describe how these values align with the specific tenets of the American Nurses Association Code of Ethics.
Nurses have one patient and one event that stay with them throughout their career. It is the patient that they never forget, the interaction that will influence all future interactions, and the event that leads to their self-awareness.
I encountered this very patient, the one who forced me to reconcile my values with those I pledged to care for, early in my career on the intermediate unit. His diagnosis was pulmonary fibrosis. My challenge was to maintain his oxygen saturation. His care consumed the majority of my time, as I had him on both a nasal cannula and nonrebreather mask to maintain adequate oxygenation. I assisted him in his all self-care activities in order to conserve his energy and monitored him to all his tests that shift. Throughout the day, I learned he was a widower, had two daughters, and was an avid ballroom dancer.
When I returned to the unit the next day, he was again assigned to me. As I was getting report, the ward secretary advised me his oxygen saturation had dropped to 70%. I went to check on him and found him very anxious, and struggling to breathe. I knew I had to establish his code status and began to ask him why he was so anxious. His response was his daughters would arrive from out of town in a few hours and he knew he did not have that long. At that time I began to discuss whether he wanted intubated and the implications of such a heroic effort, explaining that he would more than likely never survive extubation. He begged me to do what was necessary for his daughters to see him one more time.
I called his physician, received an order for Ativan, and was advised to have the house officer see the patient. The house officer arrived in the room and understanding his poor prognosis, advised me to just continue comfort measures. However, since I had discussed this at great length with the patient and was aware of his wishes, I felt compelled to act more aggressively. I again called his physician and explained to him the conversation I had with the patient. He gave me the order to call anesthesia and have the patient intubated and transferred to the Coronary Care Unit.
Once the patient was intubated, I accompanied him to the Coronary Care Unit and advised them his daughters would be arriving soon. Shortly after returning to the unit, I was paged to the phone. Coronary Care wanted to speak with me. The patient’s nurse advised me that he had expired minutes prior to his daughters reaching the hospital. They were requesting to speak to me, as I was the last person to talk to their father.
Throughout this experience, I maintained my personal values of family, compassion for others, integrity, and honesty. Although I knew as a nurse, intubating this patient was futile, I had to honor his wishes. However, I was also obligated to make certain he was well informed of his prognosis and the consequences of intubation.
Personal values are unique individual beliefs, attitudes, standards, and ideals that guide behavior, life experience, and decision making. These values are arranged in a hierarchy based on the level of importance the individual places on each value. Therefore it is imperative that nurses recognize that another’s personal value system mat differ from their own. Identifying one’s own value system through introspection and self-reflection is the first step in ethical decision making (Bandman & Bandman, 1995). The second step is understanding the value system of others, and acknowledging and respecting them as equally valid as one’s own system (Yeo & Morehouse, 1996).
In this situation, I knew intubating the patient was not effecting his prognosis, but his strong family values compelled me to advocate for the fulfillment of his wishes. Through our honest interaction, I was comfortable that the patient was well informed that this was a means to prolong the inevitable. I understood he was attempting to give his daughters closure. Of all the nursing actions over the two days I cared for this patient, the most meaningful to me was the time I spent talking with this patient. I was able to relate to his daughters and genuinely relay his last conversations, conveying how important family was to him. More importantly, I recognized his family values and why he was requesting intubation.
Psychologist Lawrence Kohlberg modified and expanded upon Jean Piaget’s (1963) work to form a theory that explained the development of moral reasoning. Kohlberg’s (1981) theory of moral development outlined six stages within three different levels. Kohlberg extended Piaget’s (1963) theory, proposing that moral development is a continual process that occurs throughout the lifespan. Through an understanding of Kohlberg’s (1981) theory, nurses better understand their values and how they relate to the ethical decisions they make (Burkhardt & Nathaniel, 2008).
The post-conventional level, also known as the principled level, consists of stages five and six of moral development (Kohlberg, 1981). There is a growing realization that individuals are separate entities from society, and that the individual’s own perspective may take precedence over society’s view; they may disobey rules inconsistent with their own principles. Post-conventional morality views rules as useful but changeable mechanisms-ideally rules can maintain the general social order and protect human rights (Kohlberg, 1981).
In Stage Five (social contract driven), the world is viewed as holding different opinions, rights and values. Such perspectives should be mutually respected as unique to each person or community. Rules that do not promote the general welfare should be changed when necessary to meet “the greatest good for the greatest number of people” (Kohlberg, 1981). This is achieved through compromise. My level of value development falls into this level, as I was able to respect the values of my patient and base my care on his values.
Several congruencies exist between my personal values and the institution’s values. The words in the mission statement that are emphasized are patient-centered healing, quality care, and balanced priorities related to patient care, community commitment, financial health and physician and employee well-being. My personal values include a strong sense of compassion for people and a passion for excellence.
However, incongruencies exist when individual commitment is not enough to keep patients safe and their care effective. There is a direct correlation between staff collaboration and patient outcomes. Responsibility for fostering an environment of teamwork rests on the shoulders of leadership, which is currently falling short of including the best interest of the patients and all members of the healthcare team in their decision making. This is a time for change within the organization, as we have recently been bought by a for-profit organization. I foresee these incongruencies as temporary.
My values are in alignment with the ANA Code of Ethics (2001) tenet 1.4, which states that the nurse respects the patient’s right to self-determination or autonomy (Burkhardt & Nathaniel, 2008). It further states that the nurse is obligated to provide accurate, complete and appropriate information that will facilitate the patient in the decision-making process. I personally did not support my patient’s decision, but respected his rights and was comfortable that he had accurate information to make his decision.
According to Burkhardt and Nathaniel (2008), ethical relationships are grounded in a self-awareness of one’s own values and the confidence to share these values with others. We must be committed to the ever evolving process of value development and respect the values of others. These concepts are the foundation for ethical decision making and facilitate the nurse in conflict resolution when personal, professional and institutional values are not in alignment.
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