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Exploring values in nursing
s nurses, we are dedicated to the art of caring, helping, and healing. We read that we must be willing to understand and appreciate the uniqueness of each patient and to use this awareness in the helping relationship. This kind of quality nursing begins with the nurse’s ability to identify and clarify values that facilitate and enhance the helping and healing relationship. My belief in this kind of ministry and in these values has led me to explore values clarification as a tool for expanding my awareness of self and clarifying personal and professional values. Any discussion of caring and excellence in nursing must consider one’s values. In nursing, values clarification is a new technique for helping us to examine our beliefs, goals, and direction. We frequently raise questions about values: “Who am I? What makes me unique? What do I want to accomplish in my life? What do I believe in most strongly?”On a professional level, we may ask: “How do I define a ‘good’nurse? Am I a good nurse? How do I know if my nursing actions are ‘right’? How do my values influence my attitudes and behavior toward a patient?’ Nursing issues confront us, forcing us to reevaluate our professional role and values. How do you feel about the 1985 Proposal? Do you believe the entry level into nursing practice should be a BS in nursing? What’s your position on unions in nursing? Do you want continuing education in nursing to be mandatory or voluntary? What should the role of the first assistant in the OR be?
A
Exploring values . in nursing I
Diann B Uustal, RN
Diann B Uustal, R N , MSN, is consultant on values and ethics in nursing in Amherst, Mass, and assistant professor, Worcester (Mass) State College. A baccalaureate graduate of the University of Rhode Island, Kingston, she received a master’s from the University of Massachusetts,Amherst.
AORN Journal,February 1980, V o l 3 1 , NO2
183
Do you believe in life after death, and do your beliefs influence your approach toward critically ill patients? How do you explain the concepts of “death with dignity” and the “quality of life”? Which statements in the nurse’s code of ethics help you answer these questions? These are just some of the questions and issues in nursing. We make many decisions and value judgments daily. Value decisions such as these tug at our heart, create emotional turmoil, and demand our personal involvement. Your responses to these value dilemmas are largely predicated on your values. In fact, how you perform as a nurse depends on your values, and these values form your philosophy of nursing.’ For most of us, however, there is a gap between what we say is of value and what we demonstrate is of value through our performance. For example, we may say professional organizations are important in nursing, yet fail to belong to a professional group or attend meetings. We may state our belief in treating people as individuals; yet our teaching plans, content, and style reflect no response to the person’s unique needs and questions. I believe it is each nurse’s responsibility to clarify and develop a system ofvalues that will reduce the gap each of us has between what we claim is of value and the values represented in our actions and lifestyles. What are our value judgments and decisions based on? One difficult thing about value dilemmas is that we often form our opinions prematurely from emotional reactions. But often, we find our initial reaction does not reflect our true beliefs when we think through our responses critically. Why? One major reason is that our feelings change as we become more involved with the issue. Our ability to make a decision based on our values becomes blurred. Many of our values are largely unconscious and difficult to identify. As a result, our be-
184
havior and attitudes are inconsistent at best. Therefore, as nurses we must take the time to identify, examine, and articulate our values. We must fully realize the significant impact they have on our behavior. The clearer you are about what you value, the more able you are to choose and initiate a response consistent with what you say you believe in.2 I believe no nurse can hope to minister to a patient in an optimal way without first understanding his or her own feelings or values related to such concepts as the quality of life, the meaning of illness as a growth experience, health values, and dying and death. Values clarification has helped me examine issues in nursing, facilitated my personal and professional growth, and helped me understand how my values affect my behavior. What is values clarification? It is a simple tool with profound implications for helping you examine and clarify your values. It is a theory, a process for decision making, and a collection of exercises that can help you act on your values in your professional setting. Values clarification is an exciting process that can help each of us to become more aware of our emerging, changing, and fundamental values and how they color our actions and decisions. It is a dynamic approach to decision making that challenges each of us to identify our own values rather than to accept a prefabricated or “correct” set of rules, beliefs, or values. Values clarification is firmly rooted in the belief that no one set of values is “right” for all situations and all of us. For me, it is a style of communication that affirms one’s self and others. It is an attitude of respect that can help each of us feel better about ourselves by focusing on our values and our value. What is a “value”?That was one of the first questions posed in a university
AORN Journal, February 1980,V o l 3 1 , No 2
belief is not a value unless it is freely chosen.
A
class by Sidney B Simon, whose name is synonymous with values clarification. My mind associated the word with True Value Hardware Stores and the best “value” as the item on sale. Then the word took on more meaning. A value is something I feel strongly about. It’s a belief that is important to me. Values provide me with a frame of reference for my behavior. They are standards that I esteem. At this point, Simon shared his definition of a value: A value is a personal belief or attitude about the truth, beauty, or worth of any thought, object, or behavior. A value is important to human existence because it is action oriented and produ~ing.~ A common thread was apparent in my definition and his. Value as a noun represented something prized a n d cherished. Value as a verb implied action. It also became clear that most values are always changing. An example of a changing value might beyour attitude toward spending and saving money or your stand on the issue of unions in nursing. Other values are stable and unchanging, such as your commitment to your faith or your view on active euthanasia. Values are interwoven. As we examine them, we discover how difficult it is to view them as separate concepts. They influence each other and how we choose values. They do not arise from or exist in a vacuum but are constructed from dif-
ferent experiences and are modified as these experiences continue and change. Values evolve as a n individual matures in the ability to think critically, logically, and morally. But all these definitions did not help me to answer the questions, “What are m y values? How have I developed and chosen values? and What’s the difference between values and “value indicators”? Value indicators include goals, attitudes, interests, feelings, convictions, and even beliefs. They are not considered values because they do not fully meet the seven steps of the valuing process that describe and define a value. The values clarification theory can assist each of us in determining if our beliefs or attitudes are truly values. The theory of values clarification. The seven valuing steps that make up the theory of values clarification are simple, but complex when critically examined. The steps are divided into three main categories: When one values something, one chooses 1. freely 2. from among alternatives 3. after carefully considering the consequences of each alternative prizes 4. is proud of and happy with the choice 5. is willing to affirm and share the choice in a public manner 6. the choice is reflected in acts
AORN Journal, February 1980, Vol31, No 2
185
behavior 7. the choice is a consistent pattern of behavior. A belief, attitude, goal, or feeling (or any other value indicator) becomes a value when all seven steps of the valuing process are satisfied, according to Louis Raths, the author of this the01-y.~ Let’s examine these steps more carefully. If you take the time to write down a t least one belief you have in nursing, you will find the practical application of this theory is more clearly demonstrated. According to the first step, a belief, attitude, or other indicator is not a value unless it is freely chosen. This concept assumes the individual is in control of choosing what to value and is consciously choosing to take on a belief as a personal principle. We often feel we have freely chosen what to value. On closer research, however, we discover we have been taught specific values through such methods as moralizing and modeling. (No value judgment is placed on these means of teaching values.) We have consciously to decide which beliefs are suitable guides for our own life before we can claim they are values. The second step in determining if a belief is a value is to ask yourself, “Have Z considered all the alternatiues?” The theory holds that when choices are examined, a value can emerge. Many of us approach value issues emotionally rather than logically and critically. As a result, it is unlikely that we will identify the various alternatives and approaches to the issue. The more difficult the issue and the more emotionally involved we become, the more necessary it becomes to have a tool for viewing the situation from as many angles as possible. This second step suggests we review all the options before we decide a course of action. It is suprising to discover how often we commit ourselves to an ideal before we have critically sorted through
186
all the alternatives. Step three indicates that a value exists only after we have considered the consequences of the alternative we have selected. We are encouraged to understand the “price” of that belief. There a r e consequences i n selecting any value; however, there a r e greater problems and more risks in taking a stand on a values issue without first considering the consequences. For a belief t o be a value, it must be something we are proud of-the fourth step. The fifth step is sharing in some public way what is of value to us. These two steps together suggest that if a belief is really a value, we will feel good about it and committed enough to it to share our views. This may include public speaking, consciousness raising, writing a letter to the editor, teaching a n inservice program, o r becoming politically active in support of your value. Traditionally, nurses have not spoken out for their values. We have been told, “Sit down, you’re rocking the boat!” and we have politely obeyed. It is time we speak out clearly, cogently, and publically for what we prize and cherish. Unless we as nurses are willing to disclose our values individually and collectively, we will effect little change in the holistic health care movement and in redefining ourselves, our role, and our values. If an attitude or belief is truly a value, we will act on it. This is the sixth step. In other words, we will demonstrate in our behavior that the belief is important enough to be an integral part of our actions and lifestyle. The last and seventh step of the valuing process is the most difficult for most of us. This step states that a value is reflected in one’s behavior in a consistent, repetitive fashion. These last two steps suggest that there must be a shift from inszght about your values to a behavioral change based on these values.
AORN Journal, February 1980, V o l 3 1 , No 2
These seven steps are demanding. Many of our attitudes, goals, and beliefs do not fully meet this definition. They are only value indicators. I find I have many more value indicators than values, and I use the theory as a tool to effect change. Checking a feeling or belief with the seven steps, I determine which steps I need t o consider more carefully before I can claim the belief as a true value for guiding my decisions and actions. Clarifying values does not imply that all our values will become clear or that values, once clarified, remain in an ideal static state. Except for a precious few, most of our values are in a process of development-being repeatedly tested, altered, and reapplied. As new information is received and processed about an issue, our beliefs and values may change. Just as our nursing diagnosis changes as we collect new data about a patient, so does our values “diagnosis” of a nursing issue. The aim of values clarification is not prefabricated “high” values or “right” beliefs but a meaningful process to assist you in defining what you value. Values clarification is relevant t o nurses because it facilitates and enhances our knowledge of self. Why is this important? The answer lies in a Biblical truth: to love one’s neighbor as one’s self. Not more than yourself, as yourself. This principle suggests that before we can care for others we must first care for ourselves. One of my favorite quotes sums this up: “It is precisely those with a low sense of selfesteem who find it necessary to reject others. It is not that as ye judge so shall ye be judged, but as you judge yourself, so shall you judge other^."^ If you do not care for yourself and feel healthy about yourself, you will not constantly be able to give significantly to patients. I believe we need to think positively about ourselves and affirm ourselves, our colleagues, and our patients out of this
positive sense of self-esteem. People who feel good about themselves are better decision makers-a large part of our role in nursing. They are more willing to take risks and try new and creative approaches. They are more willing to question situations that do not seem to affirm individual rights and values. Slowly but surely there is a revolution going on. It is grounded in the holistic health movement, which is nudging us toward a reevaluation of ourselves and of our role in the helping professions. We form the largest group of health personnel in the country; yet, tragically we have played a secondary role. With the evolution of new directions in health care, it is appropriate and necessary that nurses emerge in a new leadership role with a new image. I believe values clarification offers a process for examining change and our traditional and emerging roles and values. Notes 1. Diann Uustal, Values and Ethics: Considerations in Nursing Practice: A Workbook for Nurses, 2nd ed (Amherst, Mass, 1979) 7. (Privately published. For information, write her at 8 Moss Lane, Amherst, Mass 01002. $5.95 plus $1 postage and handling.) 2. Diann Uustal, “Values clarification in nursing: Application to practice,” American Journal of Nursing 78 (December 1978) 2058-2063. 3. Louis Raths, Merrill Harmin, Sidney Simon, Values and Teaching (Columbus, Ohio: Charles E Merrill, 1966) 28. 4. /bid, 27. 5. William Wilmot, Dyadic Communication: A Transactional Perspective (St Louis: AddisonWesley, 1975) 39. Suggested reading Read, Donald; Uustal, Diann. Being and Caring in Nursing. Philadelphia: J B Lippincott, in press. Available 1980. Uustal, Diann. “Searching for value.” Image 9 (February 1977) 15-17. Uustal, Diann. “The use of values clarification in nursing practice,” Journal of Continuing fducation in Nursing 8 (May-June 1977) 8-13.
AORN Journal, February 1980, Vol31, No 2
187
A
Exploring values . in nursing I
Diann B Uustal, RN
Diann B Uustal, R N , MSN, is consultant on values and ethics in nursing in Amherst, Mass, and assistant professor, Worcester (Mass) State College. A baccalaureate graduate of the University of Rhode Island, Kingston, she received a master’s from the University of Massachusetts,Amherst.
AORN Journal,February 1980, V o l 3 1 , NO2
183
Do you believe in life after death, and do your beliefs influence your approach toward critically ill patients? How do you explain the concepts of “death with dignity” and the “quality of life”? Which statements in the nurse’s code of ethics help you answer these questions? These are just some of the questions and issues in nursing. We make many decisions and value judgments daily. Value decisions such as these tug at our heart, create emotional turmoil, and demand our personal involvement. Your responses to these value dilemmas are largely predicated on your values. In fact, how you perform as a nurse depends on your values, and these values form your philosophy of nursing.’ For most of us, however, there is a gap between what we say is of value and what we demonstrate is of value through our performance. For example, we may say professional organizations are important in nursing, yet fail to belong to a professional group or attend meetings. We may state our belief in treating people as individuals; yet our teaching plans, content, and style reflect no response to the person’s unique needs and questions. I believe it is each nurse’s responsibility to clarify and develop a system ofvalues that will reduce the gap each of us has between what we claim is of value and the values represented in our actions and lifestyles. What are our value judgments and decisions based on? One difficult thing about value dilemmas is that we often form our opinions prematurely from emotional reactions. But often, we find our initial reaction does not reflect our true beliefs when we think through our responses critically. Why? One major reason is that our feelings change as we become more involved with the issue. Our ability to make a decision based on our values becomes blurred. Many of our values are largely unconscious and difficult to identify. As a result, our be-
184
havior and attitudes are inconsistent at best. Therefore, as nurses we must take the time to identify, examine, and articulate our values. We must fully realize the significant impact they have on our behavior. The clearer you are about what you value, the more able you are to choose and initiate a response consistent with what you say you believe in.2 I believe no nurse can hope to minister to a patient in an optimal way without first understanding his or her own feelings or values related to such concepts as the quality of life, the meaning of illness as a growth experience, health values, and dying and death. Values clarification has helped me examine issues in nursing, facilitated my personal and professional growth, and helped me understand how my values affect my behavior. What is values clarification? It is a simple tool with profound implications for helping you examine and clarify your values. It is a theory, a process for decision making, and a collection of exercises that can help you act on your values in your professional setting. Values clarification is an exciting process that can help each of us to become more aware of our emerging, changing, and fundamental values and how they color our actions and decisions. It is a dynamic approach to decision making that challenges each of us to identify our own values rather than to accept a prefabricated or “correct” set of rules, beliefs, or values. Values clarification is firmly rooted in the belief that no one set of values is “right” for all situations and all of us. For me, it is a style of communication that affirms one’s self and others. It is an attitude of respect that can help each of us feel better about ourselves by focusing on our values and our value. What is a “value”?That was one of the first questions posed in a university
AORN Journal, February 1980,V o l 3 1 , No 2
belief is not a value unless it is freely chosen.
A
class by Sidney B Simon, whose name is synonymous with values clarification. My mind associated the word with True Value Hardware Stores and the best “value” as the item on sale. Then the word took on more meaning. A value is something I feel strongly about. It’s a belief that is important to me. Values provide me with a frame of reference for my behavior. They are standards that I esteem. At this point, Simon shared his definition of a value: A value is a personal belief or attitude about the truth, beauty, or worth of any thought, object, or behavior. A value is important to human existence because it is action oriented and produ~ing.~ A common thread was apparent in my definition and his. Value as a noun represented something prized a n d cherished. Value as a verb implied action. It also became clear that most values are always changing. An example of a changing value might beyour attitude toward spending and saving money or your stand on the issue of unions in nursing. Other values are stable and unchanging, such as your commitment to your faith or your view on active euthanasia. Values are interwoven. As we examine them, we discover how difficult it is to view them as separate concepts. They influence each other and how we choose values. They do not arise from or exist in a vacuum but are constructed from dif-
ferent experiences and are modified as these experiences continue and change. Values evolve as a n individual matures in the ability to think critically, logically, and morally. But all these definitions did not help me to answer the questions, “What are m y values? How have I developed and chosen values? and What’s the difference between values and “value indicators”? Value indicators include goals, attitudes, interests, feelings, convictions, and even beliefs. They are not considered values because they do not fully meet the seven steps of the valuing process that describe and define a value. The values clarification theory can assist each of us in determining if our beliefs or attitudes are truly values. The theory of values clarification. The seven valuing steps that make up the theory of values clarification are simple, but complex when critically examined. The steps are divided into three main categories: When one values something, one chooses 1. freely 2. from among alternatives 3. after carefully considering the consequences of each alternative prizes 4. is proud of and happy with the choice 5. is willing to affirm and share the choice in a public manner 6. the choice is reflected in acts
AORN Journal, February 1980, Vol31, No 2
185
behavior 7. the choice is a consistent pattern of behavior. A belief, attitude, goal, or feeling (or any other value indicator) becomes a value when all seven steps of the valuing process are satisfied, according to Louis Raths, the author of this the01-y.~ Let’s examine these steps more carefully. If you take the time to write down a t least one belief you have in nursing, you will find the practical application of this theory is more clearly demonstrated. According to the first step, a belief, attitude, or other indicator is not a value unless it is freely chosen. This concept assumes the individual is in control of choosing what to value and is consciously choosing to take on a belief as a personal principle. We often feel we have freely chosen what to value. On closer research, however, we discover we have been taught specific values through such methods as moralizing and modeling. (No value judgment is placed on these means of teaching values.) We have consciously to decide which beliefs are suitable guides for our own life before we can claim they are values. The second step in determining if a belief is a value is to ask yourself, “Have Z considered all the alternatiues?” The theory holds that when choices are examined, a value can emerge. Many of us approach value issues emotionally rather than logically and critically. As a result, it is unlikely that we will identify the various alternatives and approaches to the issue. The more difficult the issue and the more emotionally involved we become, the more necessary it becomes to have a tool for viewing the situation from as many angles as possible. This second step suggests we review all the options before we decide a course of action. It is suprising to discover how often we commit ourselves to an ideal before we have critically sorted through
186
all the alternatives. Step three indicates that a value exists only after we have considered the consequences of the alternative we have selected. We are encouraged to understand the “price” of that belief. There a r e consequences i n selecting any value; however, there a r e greater problems and more risks in taking a stand on a values issue without first considering the consequences. For a belief t o be a value, it must be something we are proud of-the fourth step. The fifth step is sharing in some public way what is of value to us. These two steps together suggest that if a belief is really a value, we will feel good about it and committed enough to it to share our views. This may include public speaking, consciousness raising, writing a letter to the editor, teaching a n inservice program, o r becoming politically active in support of your value. Traditionally, nurses have not spoken out for their values. We have been told, “Sit down, you’re rocking the boat!” and we have politely obeyed. It is time we speak out clearly, cogently, and publically for what we prize and cherish. Unless we as nurses are willing to disclose our values individually and collectively, we will effect little change in the holistic health care movement and in redefining ourselves, our role, and our values. If an attitude or belief is truly a value, we will act on it. This is the sixth step. In other words, we will demonstrate in our behavior that the belief is important enough to be an integral part of our actions and lifestyle. The last and seventh step of the valuing process is the most difficult for most of us. This step states that a value is reflected in one’s behavior in a consistent, repetitive fashion. These last two steps suggest that there must be a shift from inszght about your values to a behavioral change based on these values.
AORN Journal, February 1980, V o l 3 1 , No 2
These seven steps are demanding. Many of our attitudes, goals, and beliefs do not fully meet this definition. They are only value indicators. I find I have many more value indicators than values, and I use the theory as a tool to effect change. Checking a feeling or belief with the seven steps, I determine which steps I need t o consider more carefully before I can claim the belief as a true value for guiding my decisions and actions. Clarifying values does not imply that all our values will become clear or that values, once clarified, remain in an ideal static state. Except for a precious few, most of our values are in a process of development-being repeatedly tested, altered, and reapplied. As new information is received and processed about an issue, our beliefs and values may change. Just as our nursing diagnosis changes as we collect new data about a patient, so does our values “diagnosis” of a nursing issue. The aim of values clarification is not prefabricated “high” values or “right” beliefs but a meaningful process to assist you in defining what you value. Values clarification is relevant t o nurses because it facilitates and enhances our knowledge of self. Why is this important? The answer lies in a Biblical truth: to love one’s neighbor as one’s self. Not more than yourself, as yourself. This principle suggests that before we can care for others we must first care for ourselves. One of my favorite quotes sums this up: “It is precisely those with a low sense of selfesteem who find it necessary to reject others. It is not that as ye judge so shall ye be judged, but as you judge yourself, so shall you judge other^."^ If you do not care for yourself and feel healthy about yourself, you will not constantly be able to give significantly to patients. I believe we need to think positively about ourselves and affirm ourselves, our colleagues, and our patients out of this
positive sense of self-esteem. People who feel good about themselves are better decision makers-a large part of our role in nursing. They are more willing to take risks and try new and creative approaches. They are more willing to question situations that do not seem to affirm individual rights and values. Slowly but surely there is a revolution going on. It is grounded in the holistic health movement, which is nudging us toward a reevaluation of ourselves and of our role in the helping professions. We form the largest group of health personnel in the country; yet, tragically we have played a secondary role. With the evolution of new directions in health care, it is appropriate and necessary that nurses emerge in a new leadership role with a new image. I believe values clarification offers a process for examining change and our traditional and emerging roles and values. Notes 1. Diann Uustal, Values and Ethics: Considerations in Nursing Practice: A Workbook for Nurses, 2nd ed (Amherst, Mass, 1979) 7. (Privately published. For information, write her at 8 Moss Lane, Amherst, Mass 01002. $5.95 plus $1 postage and handling.) 2. Diann Uustal, “Values clarification in nursing: Application to practice,” American Journal of Nursing 78 (December 1978) 2058-2063. 3. Louis Raths, Merrill Harmin, Sidney Simon, Values and Teaching (Columbus, Ohio: Charles E Merrill, 1966) 28. 4. /bid, 27. 5. William Wilmot, Dyadic Communication: A Transactional Perspective (St Louis: AddisonWesley, 1975) 39. Suggested reading Read, Donald; Uustal, Diann. Being and Caring in Nursing. Philadelphia: J B Lippincott, in press. Available 1980. Uustal, Diann. “Searching for value.” Image 9 (February 1977) 15-17. Uustal, Diann. “The use of values clarification in nursing practice,” Journal of Continuing fducation in Nursing 8 (May-June 1977) 8-13.
AORN Journal, February 1980, Vol31, No 2
187