Institute for Christian
Teaching
Education Department of Seventh-day Adventists
VALUES IN
NURSING:
WHAT CAN
SEVENTH-DAY ADVENTIST CONTRIBUTE?
By
Gwen M. Wilkinson, R.N., M.A.
Head of Nursing Department
Avondale College
Australia
303-97 Institute for Christian Teaching
12501 Old Columbia Pike
Silver Spring, MD 20904 USA
20th International Faith and Learning Seminar
held at
Loma Linda University
California, USA
June 15-26, 1997
This paper sets out to examine the values which nursing has identified as being
Fundamental to the profession in the 1990s. Two major areas of interest to Seventh-day Adventist nursing educators are explored:
1. What influence do Christian values have on nursing as we approach the year 2000?
2. Does the Seventh-day Adventist Church have anything unique it can contribute to the nursing profession if the values which are basic to Christianity and nursing coincide"
Values can also be held by professional groups. Such values provide a framework for the development of standards and expectations within the profession (Weis, Schank, Eddy and Elfrink 1993,336). Potter and Perry (1997, 310) point out that, "Because values give identity, influence actions, and sustain what is meaningful, professions are as strong as the values on which they are based".
Values differ from attitudes and beliefs. Attitudes, which are made up of several beliefs, are "dispositions or feelings towards a person, object, or idea," with "cognitive, affective, and behavior components" (Steele and Harmon 1983, 3). Beliefs are a type of attitude where "the cognitive component is based more on faith than on fact" (Steele and Harmon 1983, 3). So although a belief goes further than that which is obvious, it is at least initiated in some fact (Tschudin 1992, 28). As a result of the motivational element usually involved, values tend to be less fixed than attitudes and beliefs (Tschudin 1992,29).
It is expected that each individual within a profession will revere the fundamental values of the particular profession. However, it is possible that personal and profession values may at times conflict. When this situation arises a dilemma exists and the nurse is forced to make a choice between the values, therefore values clarification is an important process for ethical decision making.
Nursing history reveals that Christianity had a profound impact on the development of organized nursing. Actual records of nursing and how it was carried out are somewhat incomplete before the Christian church; there has been a continuous record of nursing (Donahue 1985, 93). Although nursing was carried out before this time, it was usually done as part of the role of mothering or performed by slaves or performed by slaves, therefore tended to be a forced rather than voluntary role. With a motive to carry out Christian acts of caring, inspired by Christ's teachings, some of the women in the early church chose to work among the sick (Mellish 1984, 35). Thus the first organized group of nurses was instituted (Dolan 1978, 43).
Care of the sick by these early Christians evolved from their value of altruism, defined by Donahue 1985,94) as "disinterested service to humanity, devotion to others without hope of any sort of reward (material or spiritual) but done for the love of God and desire to be like Him". Such commitment stemmed from Christ's teachings and example, and the care of those who were infirmed became an activity, which was valued, rather than a necessary duty performed by slaves our household members. Both men and women responded and "the and women responded and "the foundations of the 'nurses'calling' and of all modern works of charity were laid and perpetuated" (Donahue 1985, 101). Emphasized in Christ's teachings was the need to relieve suffering rather than leaving it alone because it was deserved, a view held by other religions (Donahue 1985, 102). These early nurses were therefore "hospitable, pious, and committed to the relief of the afflicted" (Donahue 1985, 103).
Donahue (1985, 98) does point out that the early Christian church also brought some handicaps to the development of nursing. In particular, because of its close association with religion, strict discipline was emphasized, so that those involved in nursing were "trained in docility, passivity, humility, and total disregard for self" (Donahue 1985, 99). Submissive obedience to those at a higher rank 9eg the physician) rather than autonomy and independence were therefore promoted. Nevertheless, these were characteristics valued by nursing during this early era. It was through the early Christian church that the reality of organized nursing transpired. In summary, nursing in that era valued caring for the sick, hospitality, dedication, commitment to the relief of the afflicted, obedience, passivity, modesty and selflessness.
Caring is now commonly recognized within nursing as the profession's central value in all health care settings (Potter and Perry 1997, 310). Defined by Swanson (1991, 165) as 'a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility", nurse are being challenged to "ensure the ethic of caring remains a central, essential, and unique focus of nursing" (Kurtz 1991, 8).
The American Association of Colleges of Nursing (AACN) (1986, citied by Potter and Perry 1997, 311) published, in 1986, a document entitled of College and University Education for Professional Nursing in which it identified the values (as well as the knowledge and skilled practice) which were consider essential for nursing. There was consensus amongst nursing professionals throughout the United States that the following seven consensuses amongst nursing professionals throughout the United States that the following seven values are necessary: "altruism, equality, esthetics, freedom, human dignity, justice, and truth" (Potter and Perry 1997, 311). The values are listed alphabetically rather than in any order of priority. Caring as a value is not included in the list. However the AACN identifies it as an attitude or personal quality, which nurses will demonstrate as a result of the value altruism (Potter and Perry 1997, 311). Between four and six attitudes and personal qualities are listed for each of the seven values.
In July 1993, the Australian Nursing Council Incorporated (ANCI) published the newly developed Code of Ethics for Nurses in Australia. Its development was motivated by the Australasian Nurse Registering Authorities Conference of 1990 and it evolved under the auspices of the ANCI, The Royal College of Nursing (Australia), and The Nursing Federation. The Code has been developed within a framework of six broad value statements (see Appendix I) and its stated purpose is to:
· Identify the fundamental moral commitments of the profession;
· Provide nurses with a basis for professional and self reflection an d a guide to ethical practice; and
· Indicate to the community the values which nurses hold (ANCI 1993).
The code therefore identifies the contemporary values common to the nursing profession in Australia. In summary these value statements identify that nurses value individual uniqueness, freedom of choice, justice with quality care, confidentiality, accountability/responsibility, and an environment supportive of health and well-being.
As previously mentioned, Christianity played an important role in the initial development of organized nursing. A comparison of what was identified as being valued by nursing 200o years ago with nursing values now indicates that some change has occurred. Considering the changes, which have occurred in the provision of health care, this is not surprising. Nevertheless, some values remain, particularly those of caring, hospitality, dedication, and commitment, it could be argued that obedience is also still valued but it is obedience to legal and professional standards for the good of the client rather than the obedience to authority, in servitude, expected in early nursing.
Salladay (1998, 20) poses an important question when she asks" Are the moral values embodied in nursing distinctively Christian?" An analysis of the contemporary values now found within nursing suggests that they are consistent with values which would be held by mainstream Christian. It is possible to show support, from a Christian perspective, for each of the current values identified, and to provide scriptural based for them.
The values listed by the AACN and by the ANCI are listed below, matched where applicable, and the reasons why it is anticipated a Christian nurse would support each one identified.
Altruism: "Concern for the welfare of
others" (AACN).
The nurse who has a personal relationship with God is motivated, primarily through a sense of gratitude to God and His loving act of salvation. To respond, with compassion and care, to the needs of all people (Shelly 1994,3). See: Matthew 25:31-46; Luke 10: 31-37; Philippians 2: 1-4.
Equality: "Having the same
rights, privileges, or status" (AACN).
"Nurses promote and uphold
the provision of quality nursing care for all people" (ANCI). The Christian nurse is concerned for all
people irrespective of any individual difference, because each person is viewed
as being created with equal status in the image of God, and equally deserving
of His gift of salvation. See: Gen. 1:27; Gen. 5:1,2; Jn 3:16; Gal. 3:26-29
Esthetics: "Qualities of
objects, events, and persons that provide satisfaction" (AACN). "Nurses value the promotion of an
ecological, social and economic environment which supports and sustains health
and well being" (ANCI).
Acknowledging God as both the Creator and Savior of the world and life, the Christian nurse will be motivated to create a physical and rational environment which is conducive to health and well being for both clients and work colleagues. See: Gen 1:1; Phil 2:14; Col 1:16-20; Col 3:12-17.
Freedom: Capacity to exercise
choice (AACN).
"Nurses respect the rights of persons to make informed choices in relation to their care" (ANCI)
In recognition that God created humans with the capacity to make choices, the Christian nurse will support each individual's right to make an informed choices in relation to treatment and health care. See: Psalm 199; Galatians 5:1.
Human Dignity: "Inherent
worth and uniqueness of an individual" (AACN).
"Nurses respect persons' individual needs, values and culture in the provision of nursing care" (ANCI).
Each individual has inherent worth because he/she has been created by God. In recognition of such the Christian nurse will value each person and respect their uniqueness and specific needs. See: Psalm 139:13-17; John 3:16.
Justice: "Upholding moral
and legal principles" (AACN).
"Nurses promote and uphold the provision of quality nursing care for all people" and "Nurses hold in confidence any information obtained in a professional capacity, and use professional judgment in sharing such information" (ANCI).
Following Jesus' example, the Christian nurse will ensure that social justice is maintained and will therefore encourage stewardship of resources ensuring health care is provided in an ethical and fair way, act with integrity, and respect the privacy of clients (Shelly 1994, 3). See: Proverbs 11:13; Isaiah 58:6-8; Philippians 2:4.
Truth: "Faithfulness to fact
or reality" (AACN).
"Nurses respect the accountability and responsibility inherent in their roles" (ANCI). God is acknowledged as the source of all truth. He also has commanded that His followers not give false testimony, therefore the Christian nurse will endeavor to be honest and truthful in all situations. See: Exodus 3:9-10; Exodus 20:16; Philippians 4:8-9; Colossians 3:9-10.
In addition to the professional values identified above, Christian nurses can contribute much to health care by adding other values, which are fundamental to Christian philosophy. The core value for Christians is love. Love as demonstrated by Jesus in His ministry (John 15:12,13) must be the value, which guides all actions. This value relates to some degree to the value of altruism described above, however, from a Christian perspective the motivation for love is what should make the difference. The reason why the Christian nurse will want to serve, in love, for fellow humans is summed up in I john 4:19 (NIV): "We love because He first loved us". Carson (1989, 54) suggests that identifying nursing as a service may not be an attractive idea to all nurses, after-all, "the idea of serving and servant hood are not popular notions in today's world, which values self-fulfillment above all else". Christian's nurses are motivated to look beyond the self and care for others with selfless, unconditional love.
A second value which Christian nurses can bring to nursing is the value of hope. Thompson (1994, 10), who suggests that hope gives opportunity not to give up when an individual is facing an apparently despairing situation, identifies that there are several reasons it makes a difference to nursing. These include the fact that illness and all that accompanies it can be destructive to hope, lack of hope thwarts healing, and it is a powerful motivator of life (Thompson 1994, 12). These are all important considerations in a client's current situation. However, because there is a spiritual dimension to hope, and God is the ultimate source of that, Christian nurses have an important ministry in helping clients to develop realistic hope in times of illness or despair, as well as giving them insight into the hope of life eternal as a gift from God.
A study by Hall and Lanig (1993, 730) identified an important benefit to clients which appears to occur when nurses integrate Christian values and beliefs into their care. A positive correlation was found between the "degree of integration of Christian values and beliefs" and the degree of comfort in handling spiritual concerns". Although further study to explore relationships between variables such as age, belief and value development, and readiness to provide care is suggested, it does highlight the important contribution to spiritual care which Christian nurses can make. With increasing evidence that religious commitment appears to have some health benefits (Matthews 1997, 9), nurses need to ensure that they give particular focus to spiritual care of clients. Christian nurses have a major contribution to make in this capacity.
WHAT CAN SEVENTH-DAY ADVENTIST CONTRIBUTE? : THE VALUE ADDED FACTORS
Seventh-day Adventist (SDA) nurses, as Christian, should be supportive of the values already outlined. However, there are additional values they can contribute which may make them distinct as health care providers. Two in particular are apparent - wholeness and rest/restoration.
Wholeness: Currently there is much in nursing literature about holistic health, holistic nursing, and holistic caring. An examination of recently published, commonly used, fundamental nursing text (Bolander 1994; Craven and Hirnle 1996; Kozier, Erb, Blains and Wilkinson 1995; Potter and Perry 1997; Taylor et al. 1993) revealed holistic care and holistic nursing as matters of increasing importance in the provision of health care. The focus of this care relates to holistic health which "involves the total person: the whole of person's being and overall quality of life-style" (Kozier at al). Holistic nursing advocates care of the whole person which includes the biologic, the physiologic, and the spiritual" (Bolander 1994, 1510). Craven and Hirnle (1996, 252) point out that a holistic nurse will be a "caring colleague" to clients, helping them "toward high-level wellness while acknowledging that each has a right to choose his or her own path". Another dimension of the concept in contemporary health care I outlined by Potter and Perry (1997, 1173) who identify holistic health as "an ongoing state of wellness" involving self care, appropriate expressions of emotions, constructive use of the mind, creative involvement with others, and increasing awareness of consciousness at higher levels. Approaches incorporated into holistic health care commonly include "wellness education, regular exercise, and management of interpersonal relationships" (Potter and Perry 1997, 1173).
SDA nurses would certainly support these aspects of the concept of holistic care as they are components of wholeness as advocated by SDAs. One could therefore question whether SDA nurses have any unique contribution to make in relation to wholeness. However, holism is often approached from a humanistic or Eastern philosophy, therefore it is important to contrast the SDA concept of wholeness to determine what it can contribute as an additional value.
Some may challenge whether wholeness is a value. Wholeness is living which gives consideration to all dimensions of one's being, as a total individual rather than separate entities, and which focuses on, connects with, and recognizes God as the creator and source of life. Therefore it can be argued that to live a life of wholeness is something to be sought and valued. SDAs have incorporated the concept in both heath care and education as a result of counsel from Ellen White who promoted its value, based on a biblical view of wholeness, in writing in Ministry of Healing and Education over a century ago. An ongoing interest in a support for wholeness has been claimed by SDAs since. White (1942, 17) strongly advocated the vital relationship which exists between the physical, mental, and spiritual dimensions in an individual, arguing that "from Him flowed a stream of healing power, and in body and mind and soul men arguing that "from Him flowed a stream of healing power, and in body and mind and soul men were made whole". More pointedly, she asserted, "the relationship that exists between the mind and the body is very intimate. When one is affected, the other sympathizes Courage, hope, faith, sympathy, love, promote health and prolong life" (White 1942, 241). As a result of this emphasis, SDAs have developed a reputation as a group who, generally enjoy healthier lives and live longer than the national average in countries where comparative studies have been dome (Strunk 1993, 150). The advantages of living a wholistic life, based on biblical principles, are therefore evident.
Wholeness directs humanity to consider the meaning of life and existence. It therefore encourages a focus on the creation of life and the Creator, and an awareness of being created in His image physically, mentally, emotionally, morally, and spiritually. Although sin has attempted to destroy the created image, fostering a relationship with God the Creator can help to restore the image and give it the purpose intended. To have such connectedness to one's creator is to be highly valued.
It would be inappropriate to maintain that SDAs have a monopoly on such an understanding of wholeness. Identification of wholeness as a value to be pursued is starting to emerge from Christian writers in other faith traditions. For example, Bakken (1992, 90) physician and administrator at St. Luke Medical Center, Bellevue, Washington, points out that:
We are now beginning to realize that the functions that are crucial to our health and well-being integrative activities and interactions with the environment do not lend themselves to a reductions description. By concentrating on smaller and smaller fragments of the body, we have not been able to cure, or even to understand, most of today's prevalent diseases and problems. A whole-person, ecological systems approach is needed.
Walsh (1997) identifies implications, which the present postmodern cultural context has for Christian education. Included is the point that, because of its support for heterogeneity, postmodernity is biased against integration and wholeness. Walsh (1997, 18) challenges Christians to face fragmentation "with an audacious vision of wholeness". Christian education must therefore ensure that it is based on "a pedagogy directed to wholeness (which) will be self-consciously integrated and interdisciplinary, inviting students to experience the world in all of its interrelated multidimensionality" (Walsh 1997, 18).
SDAs need not feel threatened or dispossessed by other Christians espousing such a view, rather they should encourage discussion about wholeness and promote it as a value to be universally adopted. SDA health care workers have an opportunity to be leaders in this area. Nevertheless, Jones (1993, 79) challenges SDAs when she comments that although we identify a subscription to the concept, "we have continued, to a large extent, to study, treat and develop separately the mental, physical and spiritual aspects of our being". Such an approach, because it is dualistic and reductionistic, accentuates fragmentation and is therefore counter to wholeness. If SDA are to continue valuing wholeness, it is imperative that the concept of wholeness receives focused attention. Jones (1993, 79), points out that limited work has occurred by SDAs scholars in developing a theology or theory of wholeness. She has herself taken steps in this direction and has published a model to help guide professional practice, which promotes wholeness. Although acknowledging work by Drs. Alexander, Hardinge, and Provonsha, she encourages further work be done in this area. If SDAs wish to be seen as leaders in an understanding of wholeness, it is essential that this be done.
Perhaps SDA heath care is uniquely situated to promote wholeness because of its dual resources in analytical - reductionist health science (the orthodox approach) along with its willingness to retain resources such as hydrotherapy, massage, vegetarian diet, regular exercise, and prayer. This allows opportunities to extend client understanding of what illness and wellness mean, opening the possibility for clients to own their own health care and therefore to have more control, to consider more options, and to take on an active rather than passive role in decision making. Encouraging clients to think and to do extends to them a degree of creative power which enhances their wholeness and helps them develop further toward the image of God as He intended it to be.
The way in which SDA nurses can additionally contribute in relation to wholeness is to model a life which itself values wholeness, and to encourage their clients to also value it. The nurse who puts who value of wholeness into action will views others as being made in the image of God, and will give compassionate consideration to all aspects of their being and live. This goes beyond humanistic holistic care.
Rest/Restoration: One of the fundamental doctrines of SDAs is their beliefs in the seventh day (Saturday) as a special day for rest, restoration and worship. Stemming from their understanding of the fourth commandment (Exodus 20:8-11) they have a distinctive understanding of the value of setting aside time to rest their bodies and minds to allow for restoration, and to give more focus to their relationship with God for spiritual restoration. God Himself gave an example of this to Adam and Eve when, following creation, He rested (Genesis 2:7).
Allen (1991, 12-13) suggests that the Sabbath is more than a doctrine it is an experience which "instead of inviting mere intellectual assent offers time for physical, mental, emotional and spiritual regeneration". Thus it has an important link with wholeness. Identifying rest as a spiritual discipline, Allen (1991, 16) asserts that, "it gives us time to affirm our worth apart from what we do". The Sabbath as a time of rest is a model of how time can be specifically designated to connect with God and experience His grace, despite busy lives. It is time that has both "personal and community benefit" (Allent 1991, 16).
Weariness is something, which can easily beset both nurses and clients. In the fast pace which many seem to live in the 1990s, it is imperative that time be programmed for rest and restoration. Burger (1989, 11) challenges nurses to "set aside time for rest and retreat, time to be with your family, to nourish your dearest friendships and to fill yourself with the beauty of God's world". All could gain from such a prescription. It is acknowledged that SDAs are by no means the only group who set aside a Sabbath day of rest, however they historically have quality understanding of such a practice and the benefits, which derive from it. SDA nurses should be able to role model to their clients the benefits of following such counsel.
Another aspect of rest which should also be shared with clients is that found in Matthew 11:12 (NIV) where Jesus extends the invitation to "Come to me, all you who are weary and burdened, and I will give your rest" Rest in this context could be associated with feelings of peace, purpose, restoration, reassurance, comfort, and rejuvenation, all of which can have rich meaning to health care clients. It is an invitation to rest, which can offer a change of perspective in a different context, allowing the possibility for lateral thought, and seeking to find solutions based on a different set of values. Nurses, because of the roles in which they function in the heath care arena often have unique opportunity to minister to clients at such times, encouraging them to have a relationship with God. SDA nurses should be attentive to such opportunities and respond to them as is appropriate in each situation.
It needs to be noted that, "considerable evidence supports the view that the predominant philosophy of nursing upon which nursing curricula are currently based is that of humanistic existentialism" (Cartwright, Davson-Galle and Holden 1992, 225). However, Cartwright et al. (1992, 228) contend that present educational practices are not sufficiently equipping nurses with the skills required to deal with the various situations they meet, particularly in circumstances where ethical dilemmas exist.
Most contemporary nursing textbooks make reference to professional nursing values. They are values, which are consistent with Christian values, and therefore they should be included in nursing programs offered at SDA institutions. However, they need to be examined from a Christian perspective rather than humanistic existentialism. Cartwright et al. (1992, 227) point out that "while the application of humanistic principles such as the intrinsic value of every individual might be allowed, there are circumstances in which this ethic does not seem to provide adequate moral guidance the allocation of limited resources is an example of this".
Such a gap presents a challenge to SDA nurse educators. It is crucial that nurses educated in SDA institutions be equipped to deal with the increasingly complex bioethical issues, which occur, as well as the daily challenges they face in relation to their professional decisions and relationships. Integrating into the curriculum a Christian based value system, which includes the SDA value-added factors outlined above, is an important starting point. In additions, encouraging each member of the nursing faculty in SDA educational institutions to live lives, which sincerely indicate a commitment to these values, will provide positive role-models for the nursing students. In turn, it is hoped that nurses who have been educated in such an environment will then be positive role models to their clients.
Whenever nurses interact with people, whether they be clients or other health professionals, values are relevant. They provide a guide to the way in which each individual nurse will behave irrespective of the professional setting. To be guided therefore by values which have their core in Jesus Christ and His love, and which are motivated by a personal relationship with Him and a desire to live a Christ-like life, should be the goal of every Christian nurse. To educate nurses to that end should be the goal of every SDA institution offering a nursing program.
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The six value statements identified in the Australian Nursing Council Incorporated (1993) Code of Ethics for Nurses in Australia are: