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HomeANA PeriodicalsOJINColumnsEthicsCultural Values and Ethical Conflicts

Ethics: Nursing Around the World: Cultural Values and Ethical

Conflicts

^md
Ruth Ludwick, PhD, RN, C
Mary Cipriano Silva, PhD, RN, FAAN
Citatation: Ludwick, R., Silva, M.C., (August 14, 2000) "Ethics: Nursing Around the World: Cultural Values
and Ethical Conflicts" Online Journal of Issues in Nursing Vol. 5 No. 3 Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/CulturalV
aluesandEthicalConflicts.aspx
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 self-reliance 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.
Davis, A. J. (1999). Global influence of American nursing: Some ethical issues. Nursing Ethics: An
International Journal for Health Care Professionals, 6(2), 118-125.
Donnelly, P. L. (2000). Ethics and cross-cultural nursing. Journal of Transcultural Nursing, 11(2), 119-126.
Gibson, D. M. (2000). The internationalization of higher education. In M. L. Kelley & V. M. Fitzsimons
(Eds.), Understanding cultural diversity: Culture, curriculum, and community in nursing. Boston: Jones and
Bartlett.
Hegyvary, S. T. (2000). Scholarship for a new era. Journal of Nursing Scholarship, 32, 4-5.
Heller, B. R. , Oros, M. T., & Durney-Crowley, J. (2000). The future of nursing education: 10 trends to
watch. Nursing and Health Care Perspectives, 21(1), 9-13.
Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League
for Nursing Press.
Leininger, M. (1996). Culture care theory, research, and practice. Nursing Science Quarterly, 9 (2), 71-78.
Outlaw, F. (1997). A call for scholarly inquiry on human diversity. In V. D. Ferguson (Ed.), Educating the
21st century nurse: Challenges and opportunities (pp. 69-90). New York: National League for Nursing Press.
Silva, M. C. (1990). Ethical decision making in nursing administration (pp. 40-80). Norwalk, CT: Appleton &
Lange.
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12. trends and issues in nursingDocument Transcript

1. TRENDS AND ISSUES IN NURSING Ram Sharan Mehta, Associate Professor B.P.
Koirala Institute of Health Sciences Email: ramsharanmehta@hotmail.comNursing has been called
the oldest of the art, and the youngest of the profession. As such, it hasgone 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. 1

2. Progress in transportation, communication and other technological areas: e.g. automobile

likeaids e. g. telephone, motion pictures, radio, television, computer email and internet services,
useof ultrasound, CT Scan, MRI imaging machines, electronic microscope radio active isotopes
formedical research, artificial respirator ventilator, discovery of third generation antibiotics,findings of
new drugs e.g.; vitamins, penicillin, insulin, chemotherapy and invention of othermedical supplies like
cool air machine, refrigeration, air and water mattress, electric beds etc.Nursing has a tremendous
capacity to change people. The demands associated with nursingpractice require a broad knowledge
base and critical thinking abilities along with competentskills. The focus of nursing is shifting towards
viewing patients as collaborative beneficiariesrather than passive recipients of care. Nursing requires
psychological, social and physical skillsand certain attitudes, which are rooted in knowledge. The
demands associated with nursingpractice require a broad knowledge base for decision-making.
Critical thinking abilities andskills in the technological aspects of care.The function of the
professional nurse in the hospital is more comprehensive. She will beactively involved in direct
nursing care, health teaching, planning for care in home, rehabilitationand service to the outpatients.
She may have to teach the students also.The world health organization (WHO) has been considering
the future and predicts that by 2000the world experiences: Major growth in the elderly population,
Decline in birthrate, especially inwestern countries, Increases in chronic illness, Continuing social
unrest, AIDS a major problem,Many infectious diseases under control, Mental health a key issue and
Poverty continuing toplague mach of the world.Exposure to human ill, sick child and baby, dying
patients, cancer patients, renal failure patients,still birth etc., closer nurse patient relationship,
Helplessness, Felling of incompetence inemergency situation, Lack of support system, Lack of
resources, Often high unrealisticexpectations, High technology equipments, Communication
breakdown, and Heavy workload arethe causes of stress among nurses.Nurses are responsible for
public anger because: Nurses stay 24 hours with client, Nurses have togive answers fault made by
professionals of other discipline, Work load very high, Less time forcounseling and guidance to
patients, Unable to explain their own role in clients care and Poororientation to clients and
relativesProfessional judgment, Defining "Care", Information system or effective
communication,Electronic network or computer link, Problem based learning, Marketing or
privatization,Nursing standard, Nursing audit, Nursing research, Multidisciplinary health team,
Independentarea of practice, Community based nursing, Holistic care approach, Specialized
services(dialysis, Psychiatric etc.), Problem based learning, Distance learning (open university

system),Self directed learning, Continuing education, Use of advanced technology,

Consumerprotection act on action, Change in uniform and dress code, Utilization of married
nurses,Specialization, Leadership of nursing in 21st century, Human relation in nursing ,
Disastermanagement, Marketing strategies for nursing, Computer application in nursing, Space
nursing , 2
3. Nurse patient relationship and Provision for nursing consultant or specialist are the
emergingtrends in Nursing.Transitions taking place in health care are: Curative to Preventive
approaches, Specializedcare to Primary health care, Medical diagnosis to Patient emphasis,
Discipline stovepipes toProgramme stovepipes, Professional identity to Team identity, Trial and error
to Evidence basedpractice, Self regulation to Questioning of professions, and Focus on quality to
Focus oncosts.In the workplace the transitions taking place are: High tech to Humanistic,
Competition toCooperation, Need to supervise to Coaching, mentoring, and Hierarchies to
Decentralizedapproach.Transitions taking place in nursing are: Continued competencies to
Competencies a condition,Hospital environment to Community environment, Quality as excellence to
Quality as safe, andClear role to blurring rolesThe Major issues in nursing education are: Selection
of students: Lack of valid tool to selectproper students, Gap between theory and practice: There is
vast gap between actual theory taughtin classroom and the actual practice in clinical setting, Student
status: In most of institutionsstudents are vitalized for patient services, Nursing Competencies: To
develop nursingcompetencies knowledge, under standing skill and attitudes are essential factors,
Underutilization of clinical facilities in government colleges / schools, In adequate library
facilities,Poor transport facilities, Less stipend for nursing students, Poor supply of AV aids,
LessPromotional opportunities for teachers of both schools and colleges, Very few M. Sc. courses
isavailable, Few Ph. D. Courses in Nursing colleges, and In private Institutions: there is Lack
ofqualified teachers, Hired building, Most institutes has not own hospital for clinical practice,
Veryexpensive, In adequate hostel facilities for students and Poor provision of library.The Issues in
nursing service are: Poor working condition, Staffing level not based on standardnorms, Inadequate
quality In-service education programme, Less wages, Lacking in formalpractice guidelines, Work
activities roles not well defined, Deficiencies in Team work, Lackingadvanced extended nursing
practice, Professional relationship with doctors decreasing day byday, Inadequate use of modern
technologies, Inadequate availability of equipment and supplies,Poor team spirit among colleague,
Very few professional representations in higher authorities,Poor exposure of nurses in National
conferences workshop and forums, Inadequate availabilityof scientific research findings, As the
education raises the gap between nurses and patients alsoraises, Nurses are more busy in
administrative and paper works in compression to bed side care,Nurses are not research oriented,
Use of non professional manpower to deliver nursing service,Monitoring, supervision, recording,
deporting and evaluation system are poor in nursing service,Expert senior nurses are usually not
involved in planning nursing manpower in an institution,There is not a system for scheduling planned
annual leave for nurses, Lack of autonomy andempowerment for nursing leaders, Lack of
understanding of nursing professional roles andresponsibilities in general, and Gap in the latest
managerial knowledge and skills among seniornursing leadersCommon problems of nursing
administration are: Poor involvement of nursingadministrators in planning and decision making in the
government hospital administration, No 3

4. specific power has been assigned to nursing In charges but she has been made
Incharges of allinventories and linen of hospital, In many institutions nursing superintendent will have
noauthority to sanction leave to their subordinates, Lack of knowledge of management of
nursingadministration among nursing administrators, Administrators most of the time depends on
theadvice of clerical staff in all matters including technical aspects, Prevalence of role
ambiguityamong administration administrators, Unnecessary interferences of non nursing personnel
innursing administration, No clear cut written nursing policies and manuals, Poor job descriptionfor
various nursing cadres, Poor organized staff development programme, which includesorientation, inservice education, continuing education etc,. Poor provision of incentives like:awards, visits, praise,
conferences etc. Inefficiency of nursing councils to maintain standards,and inadequate efforts at
higher level for implementation of separate directorate of nursing.Less educational preparation,
Refuse to accept new role, Adhere to tradition, Failure to unityamong nurses, Failure to work with
consumers or public, and Failure to delivery nursing care tomeet (satisfy) public needs are the
common professional limitations in Nursing Profession.Conclusion: Transition generally occurs or
takes place in each and every individual of thisworld. Nurses as an individual, involved in caring
profession, also faces this transition arenothing but the passages or changes from one situation or
state to another that occurs over time.There are often wide ranges of emotions experienced during
the transition process that can affectthe emotional and physical well being.Some ways to Prepare for
transition process are: Positing thinking, flexible to adjust invarious situations, organized personal
life, practice healthy life style, find an ideal mentor, havesome fun and able to know what is expected
to learn to rules of road early.References 1. Celebrating nursing past claiming the future.
International nurses day 1999.International council of nurses, Geneva Switzerland. 2. International
nursing review 1999; 46 (1): 16 26 3. Jolley M, Allan P. Current issues in nursing. 1st edi.
Chapman and hall; London; 1989 4. Regu M Tabish SA. Nursing education in the new millennium
Journal of medical science 2002; 4 (2): 183 189. 5. Deloughery Issues and trends in nursing
Mosby year book, London; 1991 6. Oulton J. International trends in nursing profession development.
International nursing review 1997; 44 (2): 47 51 7. Shyamalamanivannan. Transition in nursing.
Journal of Nepal nursing council; 2000; 9:201 - 202 8. Hemanalini BE. Emerging trends in nursing
education in the third millennium Nursing journal of India Dec. 2000; 12: 267 268 9. Hamer J,
Wlder B. A. new curriculum for a new millennium. Nursing outlook. 2001; 49: 127 131. 4