Journal of Advanced Nursing, 1990,15,504-509

Can knowledge be promoted and values ignored? Implications for nursing education Afroditi Raya RN BSN MA MEd EdD Professor, Department of Nursing, School of Health Sciences, University of Athens, Greece

Accepted for publication 1 August 1989

RAYA A (1990) Journal of Advanced Nursing 1 5 , 504-509

Can knowledge be promoted and values ignored? Implications for nursing education This paper aims to reflect upon the educational task of the university, to consider whether knowledge can be promoted and values ignored, and thus to explore the imphcations for nursing education The university is the cradle which nurtures intellectuals, professionals and scientists as whole human beings Paced by the spint and the ideals of patdeta, it cannot be limited merely to developing the student's mind It should also inspire the student with a behef in the higher values of life, as a compass in his profession {Patdeta is an ancient Greek conception of the ideal human education It includes modem notions such as avilization, culture, tradition, literature, philosophy and education It means formation of the human being of any age, as an independent, free and virtuous whole person) Values, when transmitted by all teachers of all subjects within the educational structures of the university, can increase the student's respect for truth, for the worth and the rights of other f>ersons, his appreciation of his own worth, assets and limitations, his love of wisdom and desire to serve humanity, his outlook about man's position m the world and his mquinng mind m order to discover higher perspectives of hfe Only m this way does uruversity become a worthy centre of paideta for educating nurses committed and aspinng to provide holistic, personahzed, quality nursing care to people, as well as to determine and shape the future of nursing education m the midst of our technological, computenzed, and some would say dehumanized era, propelling itself into the twenty-first century

THE UNIVERSITY

uaXXiaxcov' (Plato, Laws 644b) It is a fonnative power

The university IS the cradle which nurtures the intellectuals,

shaping personalities and cultivating the desire of _,- . „, , , perfection Plato wntes

professionals, researchers, leaders, state servants, academic scientists, and others It promotes the whole cycle of sciences and is a source of spintual and cultural radiation The university is a laboratory of learning and education Its course is paced and niled by the spmt and the ideals of paideia Paideia ,s defined by the Greeks as 'the , , , ,, , , J , . , highest blessmg bestowed on mankmd — npibxov X(OV Correspondence Dr Afroditi Raya, U FrangMhsias Street GR 15125 Maroussi, Athens Greece

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education is that schooling from boyhood in goodness which inspires the reapient with passionate and ardent desire ^ ^"bmit to nghteous mle Our argument, I take it, would '"^^^^ ^^' ^^'"""S f^^"" °^^"* ^*^ *=°"^^ * ^ "''"^ «*"" cation exclusn^ely to it, any h-aining which has as its end wealth or perhaps bodily strength, or some other accomplishL ^ ^ i nL 7 J L n ^L i. ment, it counts vulgar, lUiberal, and wholly unworthy to be "lied education (Plato, Laws)

Nursing education

The supreme end of education is the creation of human beings, who have a sincere and deep belief in the higher ideals, in the infinite values of life (XEEA 1983) Concerning the university, Plato said 'All knowledge, when separated from justice and virtue, is seen to be cunning and not wisdom' {Menexenus 246e) Truth, beauty, justice, morality and diviruty are values everlasting and ever valid The education which transmits those values, according to Isigonis, connects 'the being with what ought to be, the becoming with what ought to become, the real with the ideal' (IaiydvTis 1955) Patdeta which takes place withm the university is trifold transmission, cntique and creation (noXuxpov6jiouXos 1978) Paideia communicates to youth the humanistic values, knowledge, life styles, etc, which are considered worthwhile achievements as well as the conquests of all previous generations in the form of cultural wealth Paideta also offers opportunities for cntical examination of values, knowledge and life styles which lead to informed choices, differentiations, alterations, adaptations, completions and even to embracing these after a consaous acceptance Furthermore, paideta builds up the appropnate environment and conditions for the creation of new values, knowledge, life styles, etc, which will ensure the survival of contemporary and future generations with an improved quality of life (AaiKOS 1970) Thus, the educational task of the university carmot and should not be limited to the purely intellectual domain by merely nounshing and developing the student's mind even to the highest level, as m the case of scientists and researchers of high calibre The student — dealt with m this article as a male, but what IS said applies equally to the female — should leam to think and to reason, to compare, to discnmmate and to analyze, to refine his taste, to form his judgement and sharpen his mental vision (Newman 1955) Furthermore, the student should embrace certain values which will represent not only the ideals for which he would live but more importantly those for which, if necessary, he would die They give stabihty to his being What the student should carry with him from the uruversity IS not mere knowledge, but that which should direct the use of his knowledge He should consider his culture which Ccin be used to illuminate science, research emd the technicalities of his special profession It is imperative that

self-definihon Knowledge has a moral character, thus a pedagogical mission and purpose Education of virtue is almost always education for knowledge as well Blaise Pascal (1962) has wntten 'nous connaissons la vente, non seulement par la raison, mais encore par le coeur' — we know the truth not only by the mtellect, but also by the heart

P U R P O S E O F THE U N I V E R S I T Y

The purpose of the uruversity is to cultivate the attitudes and the traits of character which symbolize the educated mind This is the responsibility of all teachers of all subjects Any subject can be taught creatively which will increase the student's respect for truth and for the worth and the nghts of other persons, his appreciation of own worth, his awareness of his ignorance and smallness withm the vast universe, his love of wisdom and desire to leam, his philosophical outlook about man's position and destination in the world, and his desire for an mquinng mmd m order to discover higher perspectives of life (Williams 1968) The student as a unique, mdivisible and unrefjeatable biopsychosocial and spintual human being is an axiologic entity Thus, he cannot transcend his inadequacy and natural weaknesses to reach higher levels of spintual hfe and creation only by knowledge He cannot become really educated and integrated if his inner tendencies and predispositions are not fulfilled by livmg and actualizing the fundamental values, properly balanced and ordered Indeed, education does not achieve its purpose as a human development faalitator by merely transmitting cognitive information Education should provide each student with opportunities which broaden and deepen a developmg philosophy of hfe 'Knowledge and values, or epistemology and axiology, are separable only conceptually, never behaviorally' (Carr 1970) Values are valid whether there are people who understand them or not, just as the mathematical truths stand independently whether they are understood or not Just as Pythagoras' theorem was valid before he discovered it, values exist even though the mdividual may not have developed a value sensitivity and value-guided consaence to live by The fact that someone has impaired vision and cannot distinguish the colours at all does not mean that the harmony of colours in nature or m fine artifacts does not exist (XpuadqjTis 1982) pnnaples, values and philosophy be used for more than the The university cannot ignore the need to provide gmdsimple recalling, like a tape-recorder, of knowledge, and the ance in developing the student's will toward the ideals of application of saence (Carr 1970) human life by using the excuse that such a pedagogy Knowledge is a psychic phenomenon It is not only may mean a kmd of compulsory dnving of consaence and knowledge of thmgs and defirution of objects It is also restnction of human freedom 505

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Ereedom and values

knowledge, interpersonal, intellectual and technical-artistic Freedom and values are interdependent concepts They competences and skills, but also a set of human values cannot live separately, one from the other Without values, accepted and actualized by every nurse (Mackenzie & Ed human lives have no direction, for, if a man does not know 1971, La Monica 1979, Potter & Perry 1985) Thus, nursing to what port he is sailing, no wind is favourable Values, philosophy can serve as a reservoir of values such as which thnll the emotions and motivate human will, act responsibility, respect for human dignity, sacnfice, faith upon them not as powers of compulsion but as target and love, which may inspire nursing heroism (Lanara 1981), nurturance and unconditional acceptance (Enckson pointers et al 1983) Indeed, to deal effectively with the suffenng The acknowledgement of the need for values which patient is not easy It requires knowledge, extreme courage, direct our behaviour does not exclude but presupposes patience, strength to withstand frustration, conviction, freedom The course of a vessel on the sea is not deterhuman sensitivity, illuminating and useful pnnciples, mined obhgatonly by the stars or the compass These ethical decision-making and adherence to that decision simply help the captain to find and to choose deliberately (Callahan 1971, Bevis 1982, Lindell 1985, Lanara 1988) The the course for the ship ICN Ethical Code for Nurses (ICN 1977) provides a basis Values do not determine the human personality Rather affirming professional regard for high ideals of conduct it IS the free acceptance of the deontological calls of values Watson's theory of nursing as a human science and which determine it Actualization of values means selfactualization and self-formation of mcin Only m this way human care implies that a combined study of the saences does man really become man and the bearer of a genuine and the humanities is imperative (Watson 1985) Care is considered as the essence of nursing by Letnmger (1984) spint of civilization The intangible values act like drops of rain when trans- The ethic of canng m nursing is professed and exemplified mitted in co-ordmahon with all agents and forms of patdeta, by Fry (1988), and the image of the psychotherapeutically without restnction of the autonomy of any agent (branch effective nurse depicted by Bransfield (1969) m an ideograph includes attnbutes such as mothenng, receptiveness, or school) As water enters various plants, it enables the blossoms responsiveness, sensitivity and empathy The message is to appear as white m lilies, red in roses, purple m violets and that mere mtellectualizations and meaningless mechanical hyacinths, and multiform m vanous plants However, they implementations cannot effect healmg Moreover, the may appeeir in a different colour or form m the peJmtree transformative and integrative power of canng is discussed or the climbing vine, but it takes all kinds of forms in all by Benner (1984) Daily, nurses encounter situations which present ethical things to give us the beauty of nature (KOpi^A.os questions and dilemmas These dilemmas often require IepOCToXOncov 1969) Similarly, values can be activated nurses to make ethical judgements and to live with the fruitfully and vitally within the educational structures of the university and create multiple chromatic tones, such as outcome of their deasions The moral-ethical issues that light, truth, real beauty, true freedom, love, social justice, nurses regularly face, seem to increase in proportion to the condemnation of injustice and exploitation of men by increased success of technology m health care without fellow men, honesty, sincenty, true feminism, respect of increased sensitivity to the ethical implications of the human nghts, solidanty, tme democratic conscience, and process (Fenner 1980) So each nurse should try to develop a rational basis and a value system for making ethical real peace (0Eo8d)pou 1985) deasions that will further the ends of the profession tmd enable her to live with her own conscience One can ask if IMPLICATIONS FOR NURSING the nurse's values and ethical standards prohibit the nurse EDUCATION from partiapating in certam surgical procedures or tenderThe nursing profession addresses itself to man as a bio- ing certain types of care, what may be the consequences of psychosoaal and spintual human being It is rooted in the her deasions? Loss of money, loss of position, or other needs of humanity and focused on the ideal of service losses? Nursing is a sacred endeavour (0e65(opos DxouSixTis 1860), a loving art (Payid 1972) Nursing is heroism and Ethical issues sacnfice (Lanara 1981) Nursing is science, art and spmt (Pnce 1965) It is considered as a form of moral activity and The major ethical issues for nurses and the other health a moral art, an ethical force in soaety (Sarvimaki 1988) professionals are identified as the following (Sorensen & As such, nursing practice requires not only saentific Luckman 1979, Kelly 1981) 506

Nursing education 1 2 3 4 5 6 7

The quality of life versus the sanctity of life The nght to live versus the nght to die (if there is such a nght) Euthanasia Confidentiality Informed consent Abortion, birth control, genetic control The nghts of the patient, of the pregnant patient, of the fetus, of the child Behaviour control and modification Unethical behaviour of other practitioners Role conflict Health policy-making and the allocation of scarce resources (who shall live?)

When moral reasoning is enhanced by systematic educational strategies, a person is more likely to behave adequately in ethical conflicts

Textbooks

In the students' educational preparation one of the components which plays a cntical role is the textbooks, 8 the first of which is a nursing fundamentals book KiUeen 9 (1986) evaluated 42 nursing fundamentals texts pub10 lished from 1965 to 1985 for their coverage of ethically relevant content She found that 45% of the texts con11 tained no content on ethics cind the remainder reflected an increasing awareness of the relevance of ethics m Davis & Aroskar (1978) propose adherence to the nursing and the inclusion of greater amounts of content 'Golden Rule' m situations of ethical dilemmas They on ethics advise that each nurse should regard the nghts of Felton & Parsons (1987) studied 227 baccalaureate and others as precious as she would want her own regarded 111 masters students to determine the influence of the level (implied of course the nght to be bom and the nght to of formal education on three selected factors ethical/moral live even with a deformity) and that within this context reasoning, attnbuhon of responsibility and ethical/moral she view her obligations to herself, to the patient, to dilemma resolution The results of the study show that nursing and to her place of employment Benner & students with more formal education reason moreilly at Wrubel (1988) make the point that expert canng, how- higher levels Thus nursing education has a responsibility ever nsky and costly that may be, liberates and facih- to prepjire practitioners for the many moral dilemmas, tates m such a way that the one who is canng is also vaned viewpoints and conflicts encountered m nursing ennched m the process practice The nature of the nursing profession makes it indispensAnother study investigated what were the most importable that certain values be taught and expenenced by nurs- ant values held by student nurses from the time they ing students along with and together with their saentific entered an upper division nursing major and again pnor to curriculum core Styles (1982), in her famous declaration of graduation It has been shown that the educational process belief about the nature and purpose of nursing, states that influenced the positive development of students' attitudes nursing as an occupational force for social good and as a and values (Shupe et al 1988) humanistic field provides a value onentation As a conseIncreasingly, it is evident that nurses need a holistic quence the schools of nursing should soaalize students to education to achieve the fullest development of their the norms, values and roles of the profession along with intellectual, physical, emotional, spintual and cultural providing them with the essential knowledge and potentials if they are to function effectively in the modem sblls world, in the year 2000 and beyond, and to take and act Our nursing cumcula aim to transmit the canng saence, upon a philosophic position regarding the nature of proart and spmt of nursing to the students The pnmacy of fessional nursmg (Sakalys & Watson 1985, 1986, King canng must be central, prevailing, mspmng, pacing and 1986, NLN 1986) imbue our nursing cumcula, nursing practice, nursing In an effort to put the foregoing ideas mto the nursmg research and our nursing visions of the future cumculum, Watson (1987) designed the ideal canng What about actual values education in nursing? In a time curriculum a holographic professional/academic eduwhen professional nurses are increasingly overwhelmed cational model which includes canng knowledge, theory, with dilemmas in moral deasion makmg, Ketefian's research ethics and skills and which first prepares a liberally edu(1983) IS extremely relevant She focused on approaches to cated person and then an advanced knowledgeable values education — speafically the development of moral professional for canng practice reasoning as a tool to measure moral behaviour She found It remains to be seen what teachmg strategies seem to be that the type of educational preparation is an important and effective and have been tned to promote the development crucial vanable in relation to the mentioned development of values by the nursmg students 507

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Workshops Fowler & Levine-Anff (1987) suggest the method of workshops and group exerases for nursing students, to explore, identify, danfy, cultivate and embrace important nursing values, to distinguish the contemporary megatrends m nursing values and determine which values have precedence when they conflict This task can be actualized by having either to work with given hsts of nursing values or to generate such bsts, and try to rank them, to balance choices among them, and discuss their importance and relevance m different concrete nursing situations Some of the nursing values to be explored may be nonjudgemental attitude, dignity of the patient, canng for the whole person as well as freedom, brotherhood, and equality (Raatikamen 1989) Other suggestions emd tnals are 1

2 3 4

5

6

7

Inclusion of ethics as a cumcular thread, sending a clear and consistent message to students that ethics is important Choice and use of a nursing fundamentals text which addresses ethics in nursmg Setting up an obligatory or, if not possible, an elective course m nursing ethics Organizing group discussions on descnbed madents or case studies that involve ethical problems and dilemmas (Bermosk & Corsmi 1973, ICN 1977, Davis & Aroskar 1978) Use of photo-language with pictures and diagrams as well as video cassettes, i e for the fecundity m vttro which present the technical aspect or for individuals with AIDS, and then have the students discuss the ethical problems involved (Bonsart & Peycheng 1987) Planning and providing expenential learning opporturuhes for the students to make nursing care decisions consistent with pnnapled moral reasonmg Giving opportunities to the students to leam essential values through observation, expenence and interaction with others, noting the responses evoked by one's own and others' behaviours (Potter & Perry 1985)

In Greek university nursing education we strongly believe that knowledge cannot be transmitted and values Ignored We try to help our students to develop important nursing values denvmg from the Greek philosophy, religion, tradition and culture as well as from the national and lntemahonal/transcultural nursmg ethical codes, realities, problems and perspectives The course, basic nursingdeontology, first sensitizes students in matters of ethics and values (Payid 1987), and from then on, all nursmg 508

courses throughout the total cumculum contain teachmg and exploration of ethical issues speafic to the course subject There are some plans for including in our cumculum a course on bioethics Almost all the teaching strategies mentioned above are tned, but the most frequently used is group discussions on clinical case studies or cntical incidents (scenanos) involving ethical reasonmg and deasion making on the part of the nurse

CONCLUSION A tnptych of fundamental nursing values is highlighted in the Greek nursing cumcula 1 2 3

Holistic view of man as a biopsychosocial and spintual uruque human being Belief m, and respect for, the mtnnsic worth of man, the sanctity of life and human nghts Canng for the sick and the disabled with unconditional nursmg love and compassion

Only m the way presented does the uruversity become a worthy centre of paideia for educating nurses committed and aspmng to provide holistic personalized quality nursmg care to people, as well as to determine and shape the future of nursing education in the midst of our technological computenzed, and, as some say, dehumanized era, propelling itself into the twenty-first century References Benner P (1984) From Novice to Expert Excellence and Power in Clinical Nursing Practice Addison-Wesley, Menlo Park, CA, p 49, p 171, p 210 Benner P & Wrubel J (1988) Canng is the candle that lights the dark, that permits us to find answers where others see none Amencan Journal of Nursmg 7,1073-1075 Bermosk L S & Corsmi R. (1973) Cntical Incidents m Nursmg Saunders, Philadelphia Bevis O (1982) Cumculum Building in Nursmg A Process 3rd edn Mosby, St Louis, p 42, p 50 Bonsart M & Paycheng O (1987) Integration de l'Etbque dans le projet pedagogique de l'ecole d'lnfirmieres de Pontoise L'Infirmtere Ensetgnante 2,13-22 Bransfield A H (1969) (W)Holistic Nursmg Some theoretical and practical effects of structuralist concepts in psychiatnc nursing Doctoral dissertation, Boston University, p 37, p 94 Callahan D (1971) Values, facts and deasion-making Hastings Cent Rep, June, 1 Carr W (1970) Values and Cumculum National Education Association, Washington DC, p 76 AaiKoi) r (1970) T o v6r\yia zr{s latpiufjs naiSeias Daikos, Athens, p 11

Nursmg education Davis A & Aroskar M (1978) Ethical Dilemmas and Nursing Plato Laws A 643e, 644a, b and Menexenus 246e Practice Appleton-Century-Crofts, New York n (1978) Eiaayayi] otrj Enckson H C, Tomlin E M & Swam M A (1983) Modelling and Selete, Athens, p 42 Role-Modellmg A Theory and Paradigm for Nursmg Prentice- Potter P & Perry A (1985) Fundamentals of Nursing — Concepts, Hall, Englewood Cliffs, NJ, p 53 Process and Practice Mosby, St Louis, p 237 Felton G M & Parsons M A (1987) The impact of nursing edu- Pnce A (1965) The Art, Science and Spmt of Nursing 3rd edn cation on ethical/moral decision making Journal of Nursing Saunders, Philadelphia Education 26(1), 7-11 Raatikamen R (1989) Values and ethical prmaples m nursing Fenner K M (1980) Ethics and Law in Nursing Van Nostrand, Journal of Advanced Nursing 14(2), 92-96 New York, p 7 Payid A (1972) Hla5eX

Can knowledge be promoted and values ignored? Implications for nursing education.

This paper aims to reflect upon the educational task of the university, to consider whether knowledge can be promoted and values ignored, and thus to ...
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