Offe Omobolanle Angel

Latest global trends/issues related to biethics

There are so many latest issues or trends going on around the world ranging from very majour and
professional/societal affecting to minor which affect individuals Nursing has been called the oldest of the art, and the
youngest of the profession. As such, it has gone through many stages and has been an integral part of social
movements. Nursing has been involved in the existing culture, shaped by it and yet being to develop it. The trend
analysis and future scenarios provide a basis for sound decision making through mapping of possible futures and
aiming to create preferred futures The future will see great advantages in prevention, diagnosis and treatment of
illness and diseases with increasing demand for health care and health information. As large hospital are replaced by
high tech and small hospitals, health care will be provided in homes and out reach facilities and the focus will be on
provider skill, out comes and user preference and satisfaction.Nurses will be the preferred care providers and entry
points for diverse services.On the other hand there will be challenges related to ethics, rising costs, access to care
and quality of care. Nurses will have an essential public health role and patients will become more demanding.
Healthier life styles, continuum of care, health environments and evidence based practice will be emphasized and in
the forefront of nursing agenda. Globalization will enhance free movement, standardization, and wider opportunities
and challenges. The changing work environment will be driven by cost effectiveness and quality of care for which
nursing is well positioned.The multifaceted components in this unfolding will be; the revolutionary advances that we
continue to witness in modern medical practice as a result of technological advances from the fields of physics,
electronics, instrumentation, chemical and material sciences. The advent of molecular medicine, with work at the
frontiers of modern biology particularly on the human genome, and its relevance to the generic basis of disease; the
importance of recent advances relating to the human brain the wide range of opportunities becoming available through
advances in information technology; the great importance of community and social medicine, of hygiene and
epidemiological studies in understanding and preventing disease.Philosophy of life, elements of human nature,
Religious factors, political ideologies,socioeconomic factors, cultural factors and expiration of knowledge are the
factors determining educational aims Vocation, knowledge, complete living, Harmonious development, mental and
emotional development, physical development, moral development, character development, self realization, cultural
development, ideal citizenship and education for leisure are the general aims of education.
but no matter how majour or minor this issues are one can not but say it puts the health care practitioner in some
dilemma when it comes to decision making and maintaining professional ethics. Some of the issues around the world
are listed below and the names of the autors of each articles and years of publication, of which few will be expanciated
on

Ethics: Beyond Patient Care: Practicing Empathy in the Workplace

Christine Sorrell Dinkins, PhD (May 10, 2011)
Ethics: Patients Rights and the Code of Nursing Ethics in Iran
Tahmine Salehi, Msc, BSc in Nursing; Dehghan Nayeri, PhD, Msc, BSc; Reza Negarandeh, PhD, Msc, BSc (July 14,
2010)
Ethics: Ethics in Healthcare Organizations: Struggling with New Questions
Jeanne Merkle Sorrell, PhD, RN, FAAN (August 20, 2008)
Ethics: The Expanding Circle of Environmental Ethics
Christine Sorrell Dinkins, PhD; Jeanne Merkle Sorrell, PhD, RN, FAAN (November 30, 2007)
Ethics: The Power of One
Francine Mancuso Parker, RN, MSN, EdD (November 26, 2007)

Ethics: What Would You Do? Ethics and Infection Control

Ruth Ludwick, PhD, RN.C, CNS; Mary Cipriano Silva, PhD, RN, FAAN (November 6, 2006)
Ethics: Is the Doctor of Nursing Practice Ethical?
Ruth Ludwick, PhD, RN.C, CNS (March 20, 2006)
Ethics: Relationship of the ANA Code of Ethics to Nurses Collaborative Efforts
Joan Garity, EdD, RN (July 26, 2005)
Ethics: Ethics and Collective Bargaining: Calls to Action
Kathleen O. Williams, PhD, RN (July 23, 2004)
Ethics: Ethical Challenges in the Care of Elderly Persons
Ruth Ludwick, PhD, RN,C; Mary Cipriano Silva, PhD, RN, FAAN (December 19, 2003)
Ethics: The Ethics of Diversity: A Call for Intimate Listening in Thin Places
Jeanne Sorrell, PhD, RN (August 25, 2003)
Ethics: Errors, the Nursing Shortage and Ethics: Survey Results
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN,C (August 15, 2003)
Ethics: Ethics and Terrorism: September 11, 2001 and Its Aftermath
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN, C (January 31, 2003)
Ethics: Ethics and the Brave New World of e-health
Peggy Jo Maddox RN, MSN, EdD (November 21, 2002)
Ethics: Ethical Grounding for Entry into Practice: Respect, Collaboration, and Accountability
Mary Cipriano Silva, PhD, RN, FAAN, Ruth Ludwick, PhD, RN, C (August 30, 2002)
Ethics: Domestic Violence, Nurses, and Ethics: What are the Links?
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN, C (May 14, 2002)
Ethics: Ethical Issues in Complementary/Alternative Therapies
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN, C (November 10, 2001)
Ethics: The Nursing Shortage and Ethics: Up Front and Personal
Mary Cipriano Silva; Ruth Ludwick (August 13, 2001)
Ethics: Ethical Implications of Genetic Information
Jean Jenkins PhD, RN, FAAN (February 9, 2001)
Ethics: Nursing Around the World: Cultural Values and Ethical Conflicts
Ruth Ludwick, PhD, RN, C; Mary Cipriano Silva, PhD, RN, FAAN (August 14, 2000)
Ethics: Ethics of Electronic Publishing
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN,C (May 5, 2000)
Ethics: Ethical Thoughtfulness and Nursing Competency
Ruth Ludwick, PhD, RN,C (December 10, 1999)
Ethics: Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century
Mary Cipriano Silva, PhD, RN, FAAN; Ruth Ludwick, PhD, RN,C (July 2, 1999)
General Letters to the Editor

Letter to the Editor by Deborah Santivaez to the Ethics column

Deborah Santivaez PhD (January 9, 2014)
Letter to the Editor by Tanya Ushakof to Ethics and Pain Management in Hospitalized Patients
Tanya Ushakof (June 28, 2013)
Reply by author Bernhofer to Ushakof to Ethics and Pain Management in Hospitalized Patients
Esther Bernhofer, BSN, RN-BC (June 28, 2013)
Letter to the Editor by Moore to "Ethics: The Value of Nursing Ethics: What about Nurse Jackie?
Caitlin Moore (May 21, 2010)
Reply by Author to Macke and Moore on "Ethics: The Value of Nursing Ethics: What about
Nurse Jackie?
Jeanne M. Sorrell (May 21, 2010)
Letter to the Editor by Macke to "Ethics: The Value of Nursing Ethics: What about Nurse Jackie?
Krissy R. Macke, RN, BSN, EMT-P (May 21, 2010)
Reply by Author to Macke and Moore on "Ethics: The Value of Nursing Ethics: What about
Nurse Jackie?
Jeanne M. Sorrell (May 21, 2010)
Letter to the Editor by Tanya M. Wilson on Ethics: The Value of Nursing Ethics. What about Nurse
Jackie?
Tanya M. Wilson, BSN, RN (January 11, 2010)
Reply by Author to Wilson on Ethics: The Value of Nursing Ethics: What about Nurse Jackie?
Jeanne Merkle Sorrell, PhD, RN, FAAN (January 11, 2010)

Letter to the Editor by Riedel, Sander and Miller-Wenning on Ethics: Is The Doctor of Nursing Practice
Ethical?
Lisa M. Riedel, Theresa M. Sander, and Kimberlee Miller-Wenning (December 8, 2009)
Reply by Authors to Riedel, Sander, and Miller-Wenning on Ethics: Is The Doctor of Nursing
Practice Ethical?
Mary Silva; Ruth Ludwick (December 8, 2009)
Letter to the Editor from Lohman on Ethics: Is the Doctor of Nursing Practice Ethical?
Theresa A. Lohman, MS, RN, CNM, FNP-BC (June 24, 2009)
Letter to the editor by Sophia M. Jones to What Would You Do? Ethics and Infection Control
Sophia M. Jones (August 9, 2007)
Reply by Authors to Sophia M. Jones on What Would You Do? Ethics and Infection Control
Ruth Ludwick, PhD, RN.C, CNS; Mary Cipriano Silva, PhD, RN, FAAN (October 2, 2007)
Letter to the Editor on Ethics: Is the Doctor of Nursing Practice Ethical?
Rob Detlefsen (October 27, 2006)

HEALTHY NURSES: PERSPECTIVES ON CARING FOR OURSELVES

APRN ROLES OPPORTUNITIES AND CHALLENGES
SOCIETAL VIOLENCE: WHAT IS OUR RESPONSE?
HEALTHCARE AND QUALITY: PERSPECTIVES FROM NURSING
DELIVERING NURSING CARE: CURRENT FACTORS TO CONSIDER
PATIENT AND VISITOR VIOLENCE
SOCIAL MEDIA AND COMMUNICATION TECHNOLOGY
EVOLVING AND EMERGING NURSING ROLES
NURSE ADVOCATES: PAST, PRESENT, AND FUTURE

And much more ..

Ethics and Pain Management in Hospitalized Patients

Optimal pain care for hospitalized patients continues to remain elusive. Results of the Hospital Consumer Assessment
of Healthcare Providers and Systems Survey (HCAHPS) show that only 63-74% of hospitalized patients nationwide
reported that their pain was well controlled (Summary of HCAHPS Survey Results, 2011). Although pain research has
resulted in a better understanding of pain modalities and the development of new treatments, patients report little
increase in satisfaction with the management of their pain while hospitalized (Department of Health and Human
Services, 2011). This column will examine how the deliberate use of ethical principles, when making pain
management decisions for hospitalized patients, may provide more optimal outcomes.
Assessment and treatment of pain is often complex. The standard definition of pain is whatever the experiencing
person says it is, existing whenever the experiencing person says it does (McCaffery, 1968, p.95). In practice,
however, practitioners personal biases about the patients pain may interfere with the realization of this definition
when doing a pain assessment. Regrettably, the intrinsic subjectivity of pain is often disregarded. Practitioners who
would likely not judge the character of a patient who needs increased amounts of medication to treat hypertension; yet
they may believe that a patient whose persistent pain does not respond to standard medications is drug-seeking, a
narcotic abuser, or has a current need to escape reality. The unemotional, transparent principles of ethics may be
useful in such cases to provide guidelines for better, more effective pain treatment. The ethical principles of autonomy,
beneficence, nonmaleficence, and justice should guide all health professionals when they make assessment and
treatment decisions.
Autonomy
Autonomy is the right of individuals to make decisions regarding their own healthcare regardless of what others think
of these decisions (Evans, 2000). It is the right of self-determination (American Nurses Association, 2001).
The Belmont Report clearly confers this right on all human beings as a respect for persons regardless of age,
capacity, or even imprisonment (National Institutes of Health, 1979). Individuals must be treated with respect for their
personal healthcare decisions regardless of whether the healthcare provider agrees with these decisions. The
principle of autonomy is violated when a practitioner dishonors patients rights to choose how they want their pain to
be treated.
Infringement on the right to autonomy or self-determination may also be seen in the withholding of information from
patients about how much and how often they can receive pain medication while in the hospital. Patients have the right

to know, consider, request, and refuse any treatments that they believe will help manage their pain. They also have
the right to have all medications, side effects, and other treatments clearly explained to them in order to make the right
decisions.
Interestingly, when patients are fully extended their right to autonomy, their pain is often better managed, and they
report better satisfaction with their care. When patients perceive that they are understood, and can make their own
decisions regarding pain control, they often do better. One example of this is the growing use of Patient Controlled
Analgesia (PCA) for the treatment of acute pain in the hospital setting. When analgesics are adequately ordered and
the pump is properly programmed for the individual, patients experience personal control over their pain and receive
effective analgesia (Hudcova, McNicol, Quah, Lau, & Carr, 2005).
Beneficence
Beneficence is defined as doing good for an individual (National Institutes of Health, 1979). Most nurses and other
clinicians easily ascribe to this tenet because they entered the healthcare profession, ostensibly, to do good for others
and provide comfort and pain relief. In the modern hospital setting, it is very rare that pain must be allowed for
diagnostic reasons; and it is even rarer that severe pain cannot be controlled in some fashion. Undertreated pain can
lead to respiratory, cardiac, and endocrine complications as well as delay healing and potentiate the onset of chronic
pain issues for an individual (Brennan, Carr, & Cousins, 2007). Although complete relief may not always be possible,
the means for bringing pain under control quickly is usually available and must be done to be considered good patient
care.
Making decisions regarding pain treatment and doing good, however, can take on a distinct complexity. Many
reasons are often given for not providing pain relief expeditiously. Excuses range from nurses being too busy, to
difficulties in getting medication orders from physicians and pharmacy departments. Patients sometime wait hours for
pain relief. If nurses do not make the management of pain a priority for their patients, and do not do all they can to
advocate to the physician for a patients need for increased dosages in medication so as to properly combat pain,
they are guilty of neglecting the principle of beneficence. Likewise, when adequate pain relief is withheld because the
patient has a history of substance abuse, the nurse has not given good care to the patient. The principle of
beneficence is upheld when the appropriate amount of medication or other treatment is administered to the patient in
a timely fashion resulting in the best pain control with acceptable side effects.
Nonmaleficence
The principle of nonmaleficence is defined as refraining from doing harm (National Institutes of Health, 1979). Herein
may lie the greatest obstacle to ethical adherence in deciding the appropriate treatment for pain in the acute care
setting.
Nonmaleficence is often the principle of ethics invoked by nurses and practitioners when having difficulty deciding on
pain treatments: they withhold medication citing safety. There certainly can be a reasonable fear on the part of the
practitioner of causing harm while treating pain since so many treatments for pain have potentially dangerous side
effects. It is imperative to understand, however, that pain itself may be more harmful to the patient than the side effects
of the drugs used to control it. As stated previously, untreated pain can have detrimental physical and emotional
effects on a patient. For example, an opioid may be the only effective treatment for an acute pain situation in a
hospitalized person, yet a nurse or physicians general fear of opioids (usually a fear of respiratory depression) can
result in inadequate pain treatment. This fear is often unsubstantiated in the hospital setting since the administration of
opioids and their effects are carefully monitored. Nurses must remember that expecting a patient to remain in
unacceptable pain can cause harm in many ways ranging from mild (anxiety) to severe (suicide).
Justice
The principal of justice states that all persons should be treated fairly according to their situation (National Institutes of
Health, 1979; Velasquez, Andre, Shanks, & Meyer, 1990). This principle is violated when treatments are withheld or
are not administered solely based on a persons sex, age, race, or religion, unless those factors have a distinct
bearing on treatment. For example, when choosing a pain medication for a person who is 80 years old, age must be
considered since certain medications have been shown to be more harmful in older people. However, all safe pain
treatments should be considered for a patient who is 80, just as they would be for a patient who is 40. When a
demanding and wealthy socialite receives more consideration in the management of her pain than the quiet,
unassuming, poor, single mother, the principle of justice is violated.
Disparities in treating pain continue. Persons in minority groups have been shown to receive less pain medication than
their white counterparts in emergency rooms, post-operatively, and in labor (Ezenwa, Ameringer, Ward, & Serlin,

2006). It is important for nurses to be aware that these discrepancies still exist in modern hospitals and to examine
their own biases when treatment decisions are made.
Ethical Pain Management
Due to the inherent subjectivity of pain, assessment and treatment decisions can easily be influenced by bias and
emotion. Evans (2000) makes the case that adhering to the principles of ethics (principlism) provides a very practical,
unemotional way of making right decisions. Decisions, such as those involving pain management, can be made with
thought, regard, and transparency for all involved (Evans, 2000). In making decisions about pain management, it may
be helpful for nurses to ask themselves questions similar to the following:

Are the patients preferences in pain treatment (autonomy) given the highest priority?
Does the patient benefit (experience good) from my pain treatment decisions?
What can I do to decrease harm (nonmaleficence) when deciding on a pain treatment regimen?
Did I do my best to protect the most vulnerable patient, treating his/her pain in the best possible way with
respect and without discrimination (justice)?

Conclusion
In order for ethical principlism to become a practical and integral way of making pain management decisions, the
nursing culture must embrace it as a matter of course. The conscious use of basic ethical principles can help nurses to
see their own biases clearly and make evidence-based decisions that provide optimal pain treatment for every patient.
Referring to ethical principles may also help the nurse advocate for the patients pain relief needs when talking to
physicians who may also have their own biases in pain treatment.
At first it seems difficult to understand why hospitalized patients pain is not well controlled. After all, nurses want to
relieve suffering to do good without causing harm and to treat each individual justly without moral judgment,
respecting each patients autonomy and ability to make his/her own decisions. But management of pain is complex
and influenced by the personal values and biases of practitioners. Although consciously following the principles of
ethics when deciding on pain treatment can be time consuming, applying the four basic principles to pain care in every
situation is imperative if pain is to be managed at optimal levels. Making unbiased, ethical decisions in the treatment of
pain for hospitalized patients instills confidence and trust in patients and may ultimately lead to greater patient
satisfaction with pain management.
Societal Violence: What is Our Response?
Sarah Kelly, PhD, RN
Citation: Kelly, S., (January 31, 2014) "Overview and Summary: Societal Violence: What is Our Response?" OJIN:
The Online Journal of Issues in Nursing Vol. 19, No. 1, Overview & Summary.
DOI: 10.3912/OJIN.Vol19No01ManOS
In recent years, we have focused an enormous amount of attention on societal violence, in particular violence that
affects the nations youth. Violent acts, such as the shootings at Columbine (1999), Virginia Tech (2007), Aurora
Movie Theater (2012), and more recently at the Sandy Hook Elementary school (2013) have had a profound effect on
todays youth and adults. These shootings are examples of societal violent acts; however, other forms of societal
violence occur every day throughout the United States.
So what is violence? What is societal violence? How does societal violence affect us? These seem like simple
questions that are easy to answer, but understanding violence is complicated. First, many researchers have differing
conceptualizations of what violence is, thus leading to a plethora of definitions. The World Health Organization (WHO,
2002) provides the most comprehensive definition of violence. WHO defines violence as:
The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a
group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation (pg. 5).
In addition to defining violence, WHO (2002) differentiates violence into three categories: self-directed violence (e.g.,
suicide), interpersonal violence (e.g., intimate partner violence or community violence), and collective violence (e.g.,
social or political violence). Although, WHO does not specifically define societal violence, I suggest that societal

violence is a blending of community and social violence. Societal violence can range from an interpersonal act of
violence between two people on the playground to a mass shooting by one person. These examples of violence can
have a profound effect on families, local communities, and society as a whole.
Violence in society can range from a simple assault to homicide (Bureau of Justice Statistics, 2013). According to the
Bureau of Justice Statistics (2013) from 1992 to 2011, there was a 49% decrease in homicides. In addition, from 1994
to 2011, there was a decrease in intimate partner violence (IPV) for females (72%) and for males (64%). Homicides
among youth declined by 22%; however, this age group still had the highest homicide rate. Despite the declination of
homicides, there was actually an increase in violent victimizations (rape, sexual assault, robbery, simple and
aggravated assault) for those 12 years and older from 2011-2012.
Researchers have explored the influence societal violence has on the victims. For example, Graham-Bermann and
Seng (2005) and Kelly (2010) found that exposure to this violence has an immediate direct negative impact on youths
physical and mental health. Further, there is evidence showing that the consequences of violence can continue to
have a lasting impact on their adult lives (Scarpa, 2001). The lasting effect of exposure to violence on youth in our
society warrants and deserves attention from healthcare professionals, such as nurses.
Nurses are in a distinct position to facilitate preventive methods geared toward decreasing societal violence. Nurses
practice in a variety of settings that enable them to interact with those who have experienced or are experiencing
some form of violence. In this OJIN topic, different forms of societal violence are presented, along with preventive
strategies that nurses may incorporate in to their practice. Please join me in exploring the various forms of societal
violence discussed and learn about how nurses can have a positive influence on those most at risk.
The introductory article, Healthy People 2020 Objectives for Violence Prevention and the Role of Nursing, by Simon
and Hurvitz, offers an overview of violence in todays society, a public health approach to preventing violence, and
discusses how nurses are an integral part of violence prevention. The authors describe objectives related to violence
prevention, one of the targeted goals for Healthy People 2020. Using the goals in Healthy People 2020 and a public
health approach to preventing violence, Simon and Hurvitz describe a four step method for violence prevention. They
provide nursing specific resources and recommendations for violence prevention. More importantly, through examples
of successful programs, such as the Cardiff Violence Prevention Program, the authors show the important contribution
that nurses make toward violence prevention.
Child Maltreatment (CM) is a major public health concern affecting children. One of the main problems with exploring
CM is the various ways the term is defined and operationalized. In the article Child Maltreatment: A Public Health
Overview and Prevention Considerations, Merrick and Latzman present a valid argument, that the inability to have a
consensus definition and method to capture the phenomenon leads to barriers in identifying the incidence and
prevalence of CM. This inconsistency can lead to obstacles in preventing and treating CM. Further, the sequelae of
CM can have a lasting impression on children, leading to problems in their adult lives. Certain factors that children are
exposed to can potentiate or moderate the effects of CM. Nurses are vital to identifying those children at risk for and
helping to prevent CM. Nurses assess and implement interventions aimed at protecting patients. The authors describe
three types of programs (universal, selected, and indicated) that nurses and other healthcare providers can use for
prevention and treatment of CM.
Gang violence is a serious public health issue that threatens society. Youth are at risk for gang membership. Engaging
in gangs and gang violence can result in the need for healthcare. McDaniel, Logan, and Schneidermans article,
Supporting Gang Violence Prevention Efforts: A Public Health Approach for Nurses, focuses on preventing gang
violence and providing nurses with information they need to decrease incidences of gang violence. In this article, the
authors lay out a public health approach nurses can use to understand and prevent gang violence. The four step
public health approach focuses on describing and monitoring the problem; identifying the risk and protective factors;
the development and evaluation of prevention programs; and the implementation and dissemination of these
programs. Prevention programs are geared toward universal education about gangs; educating those at risk for gang
involvement; and youth already involved in gang activity. There are opportunities for nurses to engage in each phase
of gang prevention and in each type of prevention program. Nurses should have an understanding of gangs and gang
violence. To help nurses facilitate their education about youth risk for gang activities and prevention initiatives, the
authors provide web resources to access information about gangs and gang violence.
Nurses also play an important part in decreasing and preventing school violence. The various forms of violence
affecting children in schools can influence their physical and mental health. In the article Violence in the School
Setting: A School Nurse Perspective, King discusses different forms of violence and the school nurse response. The
statistics on school violence presented in this article are staggering. King suggests that children use violence at school
to deal with problems; this is one method of problem solving. Real life experiences from school nurses show that
children have differing reactions to their exposure of violence at school. School nurses have the opportunity to develop

a trusting relationship with children. Children frequently confide in and share personal experiences with school nurses.
The information that the school nurses gather during interactions with children is valuable because it may be useful to
help deescalate or intervene in the violence. This article provides a wealth of information on school violence and how
nurses can provide a safe learning environment for all children.
The journal editors invite you to share your response to this OJIN topic addressing Societal Violence either by writing
a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been
initiated by these introductory articles.
Authors
Sarah Kelly, PhD, RN
Email: sarah.kelly@rutgers.edu
Nursing Around the World: Cultural Values and Ethical Conflicts
Ruth Ludwick, PhD, RN, C
Mary Cipriano Silva, PhD, RN, FAAN
Keywords: culture, cultural values, ethical conflicts
Related Issue: "Nursing Around the World"
In a recent article, Heller, Oros, and Durney-Crowley (2000) note 10 trends to watch regarding the future of nursing
education. The first trend listed relates to diversity and its impact on disease and illness and the subsequent challenge
to change education and practice to be congruent and respectful of differing values and beliefs. In a like manner other
authors (e.g., Bellack& ONeil, 2000; Gibson, 2000 ; Hegyvary, 2000; Outlaw, 1997) have called attention to the need
for closer scrutiny of our values and beliefs about diversity. Outlaw, for example, expressively requests "a call for
scholarly inquiry on human diversity" (p. 69).
Implicit or explicit in the works of these authors are the notions of culture and of values. Both words have many
interpretations but each word has a primary association with a discipline. Cultures primary homebase is
anthropology. Values primary homebase is philosophy, especially as it relates to ethics. One can identify subsets of
words associated with each. For culture, terms that immediately come to mind are ethnocentrism, cultural imposition,
cultural importation, and cultural exportation. (See definitions and assumptions) For values, terms that immediately
come to mind are belief systems and norms. The rubber meets the road when the two terms are joined: cultural
values. Therefore, our purpose in writing this article is threefold: a) to clarify the relationships among cultural values,
ethics, and ethical conflicts; b) to demonstrate with examples from the culture predominant in the United States how
cultural attitudes and values in nursing may lead to conflict as a result of increasing globalization, and c) to formulate
nursing strategies to decrease ethical conflicts related to cultural values.
Cultural Values, Ethics, and Ethical Conflicts
Cultural values refer to enduring ideals or belief systems to which a person or a society is committed. The values of
nursing in the States are, for example, embedded in the values of the U.S. American culture with its emphasis on selfreliance and individualism (Davis, 1999). Basic to the value placed on individualism are the beliefs that "individuals
have the ability to pull themselves up by their bootstraps" and that an individuals rights are more important than a
societys.
However, many cultures do not share the primacy of the value of individualism. Consider the factual data presented by
Davis that about 70% of all cultures are collectivistic (i.e., loyalties of a person to a group exceed the rights of the
individual) rather than individualistic (i.e., the rights of the individual supercede those of the group). "With
individualism, importance is placed on individual inputs, rights and rewards" (Andrews, 1999, p. 476). In many
cultures, health decisions are not made by an individual but by a group: family, community and/or society. Socialized
medicine or government sponsored health care for all residents is reflective of the value placed on collectivism.
Therefore, reflecting on the values that predominate in the culture you practice, attain an education, visit, or read
about is a requirement for ethical thoughtfulness. Ethics has many definitions but, typically, ethics is viewed as a
systematic way of examining the moral life to discern right and wrong; it also requires a decision or action based on
moral reasoning. Ethical conflicts occur when a person, group or society is uncertain about what to do when faced
with competing moral choices (Silva, 1990). Ethical conflicts and issues occur within or among cultures and are
usually precipitated by cultural/subcultural values in opposition.

Conflict and Globalization

Certainly members of any culture may hold varying degrees of commitment to the predominant values of the culture,
but being in opposition to those values sets the stage for conflict. Even countries where people were once relatively
isolated from other cultures or were homogenous (e.g., Asian cultures) are also becoming more culturally diverse.
Why? Through increased communication, travel, and trade, differing perspectives have been imposed upon the
cultural beliefs and ethical values of people because they are believed to be right or better (ethnocentrism at work).
For example, North Americans and others with Western ethical perspectives who live in their own homelands may,
unwittingly, export products abroad like textbooks, curriculums, and used equipment. These products, even though
well intentioned, may present a cultural imposition. In addition, the altered attitudes of international students who
return to their homeland after a westernized education in a capitalistic culture are a source of inculcating new but
perhaps unsettling ethical perspectives on a country or profession. Globalization, with its outcome of increased
cultural diversity, has not only given nurses pause for thought but also has contributed to ethical conflicts.
Davis (1999) recognizes how ethical conflicts and issues can arise, especially when nurses acknowledge the profound
influence that the values of nurses in the United States have had on other countries worldwide. The value on
individualism, for U.S. nurses, for example, can be examined in relation to the ethical principles of autonomy and
justice. The ethical principle of autonomy is related to self- determination, that is, the individuals right to make
decisions for him or herself. Consistent with this principle is respect for the autonomy of others. Therefore, the lack of
respect for the decision-making of culturally diverse people in nursing practice is unethical.
The other principle, justice, which deals with what is due or owed to an individual, group, or society, has numerous
definitions. For this discussion, we focus on two conflicting material principles of justice that cause ethical conflict: 1)
"to each person according to what can be obtained in a free market, " 2) "to each person based on need."
The first material principle of justice has autonomy as its underpinning. It is in keeping with a supply and demand
situation where some persons will possess or benefit more than other persons. A problem with this principle is that it
can lead to inequalities in societys burdens and benefits.
The second material principle of justice has fairness as its underpinning. It is sensitive to individual differences and to
factors over which the person has no control. A problem with this principle is how to honor it when resources are finite
or scarce.
While we have only examined ethical conflicts that evolve from the U. S. cultural emphasis on individualism and the
related ethical principles of autonomy and justice, there are many other examples of conflicts that can be and should
be examined, but go beyond the scope and purpose of this column. However, we leave the reader with two questions
to consider that are particularly cogent to a discussion on ethical conflicts: "is it justified to strive for uniformity of
nursing practice on the basis of ethics across all cultures?" and "are there ethical notions of caring, ethical principles
and virtues, that could be endorsed as true for all nurses everywhere?" (Davis, 1999, p. 123).
Nursing Strategies to Decrease Ethical Conflicts Related to Cultural Values and Diversity
Of the many nursing theories used in the United States today, the one most associated with culture and cultural values
is Leiningers (1991) Culture Care Diversity and Universality: A Theory of Nursing. In the mid-1950s she first observed
that nursing practice lacked attention to cultural and humanistic factors. It was from these observations and from
further writing and research on the topic that the preceding book was written (Leininger, 1996). Implicit to her theory is
the importance of communication between patient/client and the provider(s) of care. As Donnelly (2000) succinctly
states, "...ethical issues become more prominent when a lack of communication occurs" (p. 124). Lack of
communication is more likely to occur when nurses care for international and culturally diverse persons. The resultant
misunderstandings can lead to lack of respect for persons whose cultural values are different from ones own and to
potential and real harm to those persons, whether culturally, psychologically, physically, or spiritually.
How can the situation be improved? Here are some suggestions to improve communication and nursing care and,
thus, decrease ethical conflicts:
1. Recognize that values and beliefs vary not only among different cultures but also within cultures.
2. View values and beliefs from different cultures within historical, health care, cultural, spiritual, and religious
contexts.
3. Learn as much as you can about the language, customs, beliefs and values of cultural groups, especially
those which you have the most contact. Related Links from Transcultural Nursing: Basic Concepts and Case
StudiesAvailable: www.culturediversity.org/links.htm.
4. Be aware of your own cultural values and biases, a major step to decreasing ethnocentrism and cultural
imposition. (A questionnaire that can help you with this goal can be found in Andrews and Herberg, 1999).

5. Be alert to and try to understand the nonverbal communications of your own and various cultures such as
personal space preferences, body language, and style of hair and clothing.
6. Be aware of biocultural differences manifested in the physical exam, in types of illness, in response to drugs,
and in health care practices.
Terms & Definitions
Ethnocentrism - A persons belief in the inherent superiority of ones own culture over that of other cultures.
Cultural Imposition - A situation where one culture forces their values and beliefs onto another culture or subculture.
Cultural Importation - A situation where one culture buys or brings in products and goods from foreign countries
(cultures) to be used or sold in the importing culture.
Cultural Exportation - A situation where one culture sends products or goods to foreign countries (cultures) to be
used or sold in the exporting culture.
Belief Systems - A totality of enduring facts, principles and values that a person or a culture deems to be true or to
be trusted.
Norms - Standards that are accepted, often implicitly, by a culture.
Assumptions
1. Goods or products imported/exported intact to another culture may not meet the needs of that culture or
therefore, may need modification.
2. Both ethnocentrism and cultural imposition show insensitivity to the culture(s) who receive them.
3. Both belief systems and norms are needed for a stable culture.
Authors
Ruth Ludwick, PhD, RN, C
Mary Cipriano Silva, PhD, RN, FAAN
References
Andrews, M. M. (1999). Cultural diversity in the health care workforce. In M. A. Andrews & J. S. Boyle, Transcultural
concepts in nursing care (3rd ed., pp 471-506). Philadelphia: Lippincott.
Andrews, M. M., & Herberg, P. (1999). Transcultural nursing care. In M. A. Andrews & J. S. Boyle, Transcultural
concepts in nursing care (3rd ed., pp 25-27). Philadelphia: Lippincott.
Bellack, J. P., & ONeil, E. H. (2000). Recreating nursing practice for a new century: Recommendations and
implications of the PEW health professions commissions final report. Nursing and Health Care Perspectives, 21(1),
14-21.