ETHICAL VALUES AND

MORALS FOR NURSING

PRACTICE
INTRODUCTION
• Nurses deal with intimate and fundamental human events such as
birth, death, and suffering.
• They must decide the morality of their own actions when they face
the many ethical issues that surround such sensitive areas.
• Because of the special nurse–client relationship, nurses are the ones
who are there to support and advocate for clients and families who
are facing difficult choices.
• The present environment of cost containment and the nursing
shortage tends to emphasize business values. This creates new moral
problems and intensifies old ones, making it more critical than ever
for nurses to make sound moral decisions.
Therefore, nurses need to
(a) develop sensitivity to the ethical dimensions of nursing practice,
(b) examine their own and clients’ values,
(c) understand how values influence their decisions, and
(d) think ahead about the kinds of moral problems they are likely to face.

VALUES
• Values are enduring beliefs or attitudes about the worth of a person, object, idea, or action.
• Values are important -they influence decisions and actions, including nurses’ ethical
decision making.
• they may be unspoken
• unconsciously held, questions of value underlie all moral dilemmas.
• Not all values are moral values. For example, people hold values about work, family,
religion, politics, money, and relationships.
• Values are often taken for granted. In the same way that people are not aware of their
breathing, they usually do not think about their values; they simply accept them and act on
them.
VALUE SYSTEM
• People organize their values internally along a continuum from most important to least
important, forming a value system.
• Value systems are basic to a way of life, give direction to life, and form the basis of
behavior—especially behavior that is based on decisions or choices.

BELIEFS
• Beliefs and attitudes are related, but not identical, to values.
• People have many different beliefs and attitudes, but a smaller number of values.
• Beliefs (or opinions) are interpretations or conclusions that people accept as true. They
are based more on faith than fact.
• Beliefs do not necessarily involve values. For example, the statement “If I study hard I
will get a good grade” expresses a belief that does not involve a value.
• By contrast, the statement “Good grades are really important to me. I must study hard
to obtain good grades” involves both a value and a belief.
ATTITUDES
• Are mental positions or feelings toward a person, object, or idea (e.g.,
acceptance, compassion, openness).
• Typically, an attitude lasts over time, whereas a belief may last only
briefly.
• Attitudes are often judged as bad or good, positive or negative,
whereas beliefs are judged as correct or incorrect.
• Attitudes have thinking and behavioral aspects. Attitudes vary greatly
among individuals.
• For example, some clients may feel strongly about their need for
privacy, whereas others may dismiss it as unimportant.
VALUES TRANSMISSION:
• Values are learned through observation and experience. As a result,
they are heavily influenced by a person’s sociocultural environment—
that is, by societal traditions; by cultural, ethnic, and religious groups;
and by family and peer groups.
• Nurses should keep in mind the influence of values on health. For
example, some cultures value treatment by a folk healer over that by
a physician.
PERSONAL VALUES
• Although people derive values from society and their individual subgroups,
they internalize some or all of these values as personal values.
• People need societal values to feel accepted, and they need personal
values to have a sense of individuality.
PROFESSIONAL VALUES
• Nurses’ professional values are acquired during socialization into nursing
from codes of ethics, nursing experiences, teachers, and peers.
• The American Association of Colleges of Nursing (2008) identified five
values essential for the professional nurse: altruism, autonomy, human
dignity, integrity, and social justice
ESSENTIAL NURSING VALUES
• Altruism is a concern for the welfare and well-being of others. In professional practice,
altruism is reflected by the nurse’s concern for the welfare of patients, other nurses, and
other health care providers.
• Autonomy is the right to self-determination. Professional practice reflects autonomy
when the nurse respects patients’ rights to make decisions about their health care.
• Human dignity is respect for the inherent worth and uniqueness of individuals and
populations. In professional practice, human dignity is reflected when the nurse values
and respects all patients and colleagues.
• Integrity is acting in accordance with an appropriate code of ethics and accepted
standards of practice. Integrity is reflected in professional practice when the nurse is
honest and provides care based on an ethical framework that is accepted within the
profession.
• Social justice is acting in accordance with fair treatment regardless of economic status,
race, ethnicity, age, citizenship, disability, or sexual orientation.
VALUES CLARIFICATION
• Values clarification is a process by which people identify, examine,
and develop their own individual values. A principle of values
clarification is that no one set of values is right for everyone.
• When people can identify their values, they can retain or change
them and thus act based on freely chosen, rather than unconscious,
values.
• Values clarification promotes personal growth by fostering awareness,
empathy, and insight.
• it is an important step for nurses to take in dealing with ethical
problems.
• One widely used theory of values clarification was developed by
Raths, Harmin, and Simon (1978). They described a “valuing process”
of thinking, feeling, and behavior that they termed “choosing,” “prizing,”
and “acting”.
Choosing (Cognitive)
Beliefs are chosen
• Freely, without outside pressure
• From among alternatives
• After reflecting and considering consequences.
Example: A person learns about energy resources, production, and
consumption; the greenhouse effect; and other environmental issues,
including ways to minimize use of and to recycle limited resources.
Prizing (Affective) Chosen beliefs are prized and cherished.

• Example: The person is proud of the belief that he or she has an obligation to participate in
some way in reducing environmental waste.

Acting (Behavioral) Chosen beliefs are

• Affirmed to others

• Incorporated into one’s behavior

• Repeated consistently in one’s life.

Example: The person participates in the city recycling program for household waste, uses public
transportation rather than driving a personal car when possible, helps organize recycling in the
workplace, and is active in legislative and political activities related to environmental issues.
CLARIFYING THE NURSE’S VALUES

• Nurses and nursing students reflect on the values they hold about life, death, health, and
illness. Nurses hold both personal and professional values.

• One strategy for gaining awareness of personal values is to consider attitudes about specific
issues such as abortion or euthanasia, asking: “Can I accept this, or live with this?” “What
would I do or want done in this situation?”

• As is true with all people, nurses’ values are influenced by culture, education, and age.

• However, research shows that fundamental professional nursing values of human dignity,
equality, and prevention of suffering have not varied over time or across groups (Snellman &
Gedda, 2012).
CLARIFYING CLIENT VALUES

• To plan effective client-centered care, nurses need to identify clients’ values as they influence
and relate to a particular health problem.

• For example, a client with failing eyesight will probably place a high value on the ability to see,
and a client with chronic pain will value comfort. Normally, people take such things for granted.

• The nurse should never assume that the client has any particular values. Rather, the nurse
explores client values through discussion.

• As described in the Quality and Safety Education for Nurses (QSEN) competencies, the client’s
values, and thus their preferences, are assessed and used in each step of nursing care,
including the communication of these values to other members of the health care team
(Cronenwett et al., 2007).
• When it seems as if clients hold unclear or conflicting values that are detrimental to their
health, the nurse should use values clarification as an intervention.
The following process may help clients clarify their values:
1. List alternatives:
Make sure that the client is aware of all alternative actions. Ask “Are you considering other
courses of action?” “Tell me about them.”
2. Examine possible consequences of choices:
Make sure the client has thought about possible results of each action. Ask “What do you
think you will gain from doing that?” “What benefits do you foresee from doing that?”
3. Choose freely:
To determine whether the client chose freely, ask “Did you have any say in that decision?”
“Do you have a choice?”
4. Feeling about the choice:
Some clients may not feel satisfied with their decision. A sensitive question
may be “Some people feel good after a decision is made; others feel bad.
How do you feel?”
5. Affirm the choice:
Ask “How will you discuss this with others (family, friends)?”
6. Act with a pattern:
To determine whether the client consistently behaves in a certain way, ask
“How many times have you done that before?” or “Would you act that way
again?”
ETHICS AND MORALITY
Ethics:
It has several meanings in common use.
• It refers to
(a) a method of inquiry that helps people to understand the morality of human
behavior (i.e., it is the study of morality),
(b) the practices or beliefs of a certain group (e.g., medical ethics, nursing ethics),
and
(c) the expected standards of moral behavior of a particular group as described in
the group’s formal code of professional ethics.
Nurses have been viewed as the most honest and ethical professionals in
U.S.
Bioethics is ethics as applied to human life or health (e.g., to decisions about abortion or
euthanasia).
Nursing ethics refers to ethical issues that occur in nursing practice.
Morality (or morals) It is similar to ethics.
• Many people use the terms interchangeably.
• Morality usually refers to private, personal standards of what is right and wrong in
conduct, character, and attitude.
• Sometimes the first clue to the moral nature of a situation is an active conscience or an
awareness of feelings such as guilt, hope, or shame.
• Another indicator is the tendency to respond to the situation with words such as ought,
should, right, wrong, good, and bad.
• Moral issues are concerned with important social values and norms; they are not about
trivial things.
• Nurses should distinguish between morality and law.
• Laws reflect the moral values of a society, and they offer guidance in determining
what is moral.
• However, an action can be legal but not moral For example, an order for full
resuscitation of a dying client is legal. but one could still question whether the act
is moral. On the other hand, an action can be moral but illegal.
• For example, if a child at home stops breathing, it is moral but not legal to exceed
the speed limit when driving to the hospital.
• Nurses should also distinguish between morality and religion as they relate to
health practices, although the two concepts are related.
 MORAL DEVELOPMENT
• Ethical decisions require persons to think and reason.
• Reasoning is a cognitive function and is, therefore, developmental. Moral development
is the process of learning to tell the difference between right and wrong and of
learning what ought and ought not to be done.
• It is a complex process that begins in childhood and continues throughout life.
• Theories of moral development attempt to answer questions such as these:
• How does a person become moral?
• What factors influence the way a person behaves in a moral situation?
• Two well-known theorists of moral development are Lawrence Kohlberg (1969) and
Carol Gilligan (1982).
• Kohlberg’s theory emphasizes rights and formal reasoning; Gilligan’s theory emphasizes
care and responsibility, although it points out that people use the concepts of both
theorists in their moral reasoning.
MORAL FRAMEWORKS
• Moral theories provide different frameworks through which nurses
can view and clarify disturbing client care situations.
• Nurses can use moral theories in developing explanations for their
ethical decisions and actions and in discussing problem situations
with others.
• Three types of moral theories are widely used, and they can be
differentiated by their emphasis on
(a) consequences,
(b) principles and duties, or
(c) relationships.
Consequence-based (teleological) theories
• look to the outcomes (consequences) of an action in judging whether that action
is right or wrong.
• Utilitarianism, one form of consequentialist theory, views a good act as one that
is the most useful—that is, one that brings the most good and the least harm to
the greatest number of people. This is called the principle of utility.
• This approach is often used in making decisions about the funding and delivery of
health care.
• Teleological theories focus on issues of fairness.
Principles-based (deontological) theories
• involve logical and formal processes and emphasize individual rights, duties, and
obligations.
• The morality of an action is determined not by its consequences.
• but by whether it is done according to an impartial, objective principle.
• For example, following the rule “Do not lie,” a nurse might believe he or she should tell the
truth to a dying client, even though the physician has given instructions not to do so. There
are many deontological theories; each justifies the rules of acceptable behavior differently.
Relationships-based (caring) theories
• stress courage, generosity, commitment, and the need to nurture and maintain relationships.
• Unlike the two preceding theories, which frame problems in terms of justice (fairness) and
formal reasoning, caring theories judge actions according to a perspective of caring and
responsibility.
• Principles-based theories stress individual rights, but caring theories promote the common
good or the welfare of the group.
A moral framework guides moral decisions, but it does not determine
the outcome.
 MORAL PRINCIPLES
• Moral principles are statements about broad, general, philosophical concepts such as
autonomy and justice. They provide the foundation for moral rules, which are specific
prescriptions for actions. For example, the rule “Do not lie” is based on the moral
principle of respect for persons (autonomy).

Autonomy refers to the right to make one’s own decisions. Nurses who follow this principle
recognize that each client is unique, has the right to be who that individual is, and has the
right to choose personal goals. People have “inward autonomy” if they have the ability to
make choices; they have “outward autonomy” if their choices are not limited or imposed by
others.
• the nurse respects a client’s right to make decisions even when those choices seem
to the nurse not to be in the client’s best interest. It also means treating others with
consideration.
• In a health care setting, this principle is violated, for example, when a nurse
disregards clients’ subjective accounts of their symptoms (e.g., pain).
• Finally, respect for autonomy means that people should not be treated as
impersonal sources of knowledge or training. This principle comes into play, for
example, in the requirement that clients provide informed consent before tests,
procedures, or participation in a research project can be carried out.
Nonmaleficence
• is the duty to “do no harm.” Although this would seem to be a simple principle to
follow, in reality it is complex.
• Harm can mean intentionally causing harm, placing someone at risk of harm, and
unintentionally causing harm. In nursing, intentional harm is never acceptable.
• A client may be at risk of harm as a known consequence of a nursing
intervention that is intended to be helpful. For example, a client may
react adversely to a medication.
• Unintentional harm occurs when the risk could not have been
anticipated.
Beneficence
• means “doing good.”
• Nurses are obligated to do good, that is, to implement actions that
benefit clients and their support persons.
• However, doing good can also pose a risk of doing harm. For example,
a nurse may advise a client about a strenuous exercise program to
improve general health, but should not do so if the client is at risk of a
heart attack.
Justice:
• It is frequently referred to as fairness. Nurses often face decisions in which a sense
of justice should prevail. For example, a nurse making home visits finds one client
tearful and depressed, and knows she could help by staying for 30 more minutes to
talk. However, that would take time from her next client, who has diabetes and
needs a great deal of teaching and observation.
• The nurse will need to weigh the facts carefully in order to divide her time justly
among her clients.
Fidelity:
• It means to be faithful to agreements and promises.
• By virtue of their standing as professional caregivers, nurses have responsibilities to
clients, employers, government, and society, as well as to themselves.
• Nurses often make promises such as “I’ll be right back with your pain medication”
or “I’ll find out for you.” Clients take such promises seriously, and so should nurses.
Veracity
• refers to telling the truth.
• Although this seems straightforward, in practice, choices are not always clear. Should a
nurse tell the truth when it is known that it will cause harm? Does a nurse tell a lie
when it is known that the lie will relieve anxiety and fear? Lying to sick or dying people
is rarely justified.
• The loss of trust in the nurse and the anxiety caused by not knowing the truth, for
example, usually outweigh any benefits derived from lying.
• Nurses must also have professional accountability and responsibility.
• According to the Code of Ethics for Nurses (Fowler, 2010), accountability means
“answerable to oneself and others for one’s own actions”, whereas responsibility refers
to “the specific accountability or liability associated with the performance of duties of a
particular role”.
BIBILIOGRAPHY
• Kozier & Erbs, Fundamentals of Nursing, 10th Edition, Julie Levin
Alexander Publishers, 2016, P.No:73-77.