Values influencing nursing practice: responses from neonatal nurses. (continuing education article; includes test)

Nursing is an inherently value-based endeavor, with a long and rich tradition. As a discipline, nursing encompasses the complex interaction of technical skill and professional conviction with the welfare of other humans. The concepts central to the practice of nursing are caring, coordination, and advocacy, and are based on the special relationship between the nurse and the patient. Traditionally, nurses are the healthcare providers with continuous contact with the client and responsibility for the implementation of professional standards of care. However, as Reilly (1989) identifies, the nurse in 1930 did not have any difficulty with what was right or wrong. In that era, technology was limited, and the knowledge that influenced norms and behaviors was clearly defined. However, as a result of technologic/scientific advances, social forces, and healthcare environment changes, the nurse of the 1990s is confronted with uncertainty, unknown boundaries, and new questions with unclear or unknown alternatives. Because of the nurse's unique role in patient care, value-based decision-making is an integral part of the nurse's daily practice. The nurse, as a professional, has responsibility to make judgments as an individual clinician responsible for quality nursing care for individuals, families, and groups (Fowler & Levine-Ariff, 1987). To be a professional requires the willing assumption of responsibility in every dimension of nursing practice. The nurse's professional responsibility encompasses a willingness to act on one's beliefs and to accept accountability for one's actions and behaviors.

The profession of nursing takes a strong stand on the duty to respect autonomy and to keep promises. Cooper (1988) describes the quality of the relationship between nurses and patients as "covenantal grounded in ethical principles and characterized by mutuality, reciprocity, and responsiveness" (p. 49). These prima facie duties are recognized in the ANA Code for Nurses (1985) as services provided by the nurse with respect for human dignity and unrestricted by other circumstances. Accordingly, a dominant theme in everyday nursing practice is one of care and responsibility, focused on the patient. Cooper (1991) refers to an ethic of care as focused on the patient's needs and the nurse's corresponding responsibility within the context of the nurse-patient relationship. Within an ethic of caring, the acknowledgment of human relationships is valued, and rules and principles play a secondary role.

The practice of neonatal nurses has been directly and extensively changed by the expansion of very specialized and high-technology-oriented care, culminating in the expectation that even the tiniest and sickest of neonates can be saved and cured. Uncertainty regarding the risks or benefits of particular approaches to care compounds the difficulty faced by nurses. In practice settings such as the Neonatal Intensive Care Unit (NICU), time is critical and "gut-level decisions" are made with inadequate information about the immediate and the long-term consequences of an intervention and limited knowledge about the potential outcomes (Hemphill & Freeman, 1976). Decisions in nursing practice are complex and nurses need to identify their own values and become aware of their personal biases. This article reports the analysis of narrative comments from neonatal nurses, and illustrates the values that motivate the behaviors of nurses practicing in neonatal settings.

Values Concept

The theoretical framework guiding this analysis was Rokeach's (1973) theory on the nature of values and values systems. Rokeach's theory is based on the perspective that a person has values and a value system, and values serve as motivators or guides to behavior. Rokeach defines a value as "an enduring belief that a specific mode of conduct or an end-state of existence is personally or socially preferable to an opposite or converse mode of conduct or end-state of existence" (p. 5). Thus, a value is a prescriptive or a proscriptive belief, specifying that something is preferable to something else. In other words, a value is a belief upon which a person acts by preference (Rokeach), or a representation of an earlier behavior that serves as a guide in the execution of a new behavior (McKinney, 1975). Values that guide behavior are the result of judgments made based on a number of interacting forces and the influence of variables that impact one's perception of the …