Ensayo / Essay / Ensaio

Integrating Values in the Care Giving Activity from the Professional Point of View

Integrando los valores en la actividad cuidadora desde el punto de vista profesional

Integrando os valores na atividade cuidadora desde o ponto de vista profissional

Juan Carlos Delgado-Antolín¹

¹RN, Bioethics expert. President of Sociedad Madrileña de Ética Enfermera (SMETICAE), Madrid, España. email: jcdantolin@gmail.com.

Receipt date: Oct 7, 2013. Approval date: Juli 10, 2013.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Nurses trained more and more on scientific evidence, often focus their actions based fundamentally on scientific fact, leaving aside other important knowledge that intervene in the care giving relation: communication, personal relationships, respect in the relationship, and knowing all the values implied in said relationship. It is about these values and on their importance within care upon which the author reflects in this article, until concluding on how we can integrate values to the care giving activity.

Key words: social values; nursing care; professional practice. 

RESUMEN

Cada vez más, las enfermeras formadas en la evidencia científica enfocan su actuación basada, fundamentalmente, en el hecho científico, dejando de lado otros conocimientos importantes que intervienen en la relación del cuidado: la comunicación, las relaciones personales, el respeto en la relación y el conocer todos los valores implicados en ella. Con respecto a estos últimos y sobre su importancia dentro del cuidado, la autora realiza una reflexión en este artículo, hasta llegar a la conclusión de cómo podemos integrar los valores en la actividad cuidadora.

Palabras clave: valores sociales; atención de enfermería; práctica profesional. 

RESUMO

As enfermeiras formadas cada vez mais na evidência científica, enfocam muitas vezes sua atuação de uma maneira baseada fundamentalmente no fato científico, deixando de lado outros conhecimentos importantes que intervêm na relação do cuidado: a comunicação, as relações pessoais, o respeito na relação e o conhecer todos os valores implicados em dita relação. São destes últimos e de sua importância dentro do cuidado sobre os que o autor realiza uma reflexão neste artigo, até chegar à conclusão de como podemos integrar os valores à atividade cuidadora.

Palavras chave: valores sociais; cuidados de enfermagem; prática profissional. 

INTRODUCTION

When things are complex, and there is no doubt that value is, there is nothing better than to approach them from the beginning; the only way to see them in perspective. In the case of values, we are obligated to return to the very origin of the human species. Appraisement is in humans a natural necessity, a biological phenomenon. Without appraisement, our lives would be impossible; and this is strictly due to survival reasons. Appraising is a biological need as primary as perceiving, remembering, imagining, or thinking. Nobody can live without appraising; hence, the primary character of the notion of value. Values are more basic or elemental than norms, laws, or principles of action. We appraise because we cannot refrain from doing so. Everything is subjected to assessment or appraisal. The smallest of things, a grain of sand, is the object of appraisal or contempt and, hence, it has at least economic value, i.e., price. Diego Gracia Guillén. ''The Question of Value''. Acceptance speech to the Royal Academy of Moral and Political Sciences. Madrid, 11 January 2011.

Nurses are trained more and more on scientific evidence and with that formation and with the knowledge they acquire in Schools, they often focus their actions based fundamentally on scientific fact, leaving aside other important knowledge that intervene in the care giving relationship: communication, personal relationships, respect in the relationship, and knowing all the values implied in said relationship. I seek to talk about these values and of their importance in care. Of course, it can be argued that when during the appraisement of nursing we apply Gordon's patterns.¹ Pattern 11 also works patients' values and beliefs, but this pattern mostly only inquires on the spiritual and religious beliefs and on the support patients want to have in that life setting, above all at the end of their lives.^2-4 Religiosity is an eminently private and intimate matter with both private (praying, speaking with God) and public manifestations (performing some community manifestation of their beliefs, celebration of mass, religious rites, prayer in the mosque on Fridays, among others). But in that setting of the private sphere other aspects like values are found, which also intervene in people's decision making, as indicated in the quote heading this article. Values represent something broader and have a more continuous and constant manifestation in the lives of individuals and, thereby, contemplating those values during the care giving relationship is fundamental to improve the results we will obtain in our care. Bearing in mind the patients' autonomy in decision making, and knowing what values are implied in each pattern, is fundamental when applying our scientific knowledge to offer personalized care to patients, and conduct it within an ethical framework.

What are values?

Within health sciences and particularly nursing, which is the science that concerns us, it is increasingly accepted that we must practice our profession within scientific knowledge, seeking evidence, researching, and providing the most endorsed care at the moment and, hence, have more consensus within the profession. But we must not forget that both in Medicine as in Nursing certainties are difficult and, thus, the truths with which we operate are likely. History has taught us that assertions we made years ago have changed or have been modified, like: cholesterol and the blue fish diet, the position in which the infant must sleep and sudden death, introduction to foods in children. This invites us to ponder that a likely truth, we move within the terrain of uncertainty, is probably true. Of course, with investigation the percentages and the probabilities of truth in our statements, will increasingly be greater and we are in that path.

When a person has to be cared for because of a health problem, because of an altered necessity, or an illness, nurses as health professionals must provide an adequate scientific response to that problem posed. With this view of the relationship, most health professionals would agree in stating that during the healthcare relationship facts are managed mostly. But our activity, care giving, is carried out on individuals and these individuals are not mere biological entities; rather, they have a psyche and are immersed in a society and a culture and, hence, also have beliefs and values. Let us look at the importance of values for the people and how these are used during the daily development of their existence.

Every human being, when performing habitual tasks without noticing and without perceiving it, is constantly using and conducting values. When I go food shopping I select meat, fish, fruit, and vegetables because I have to feed myself. Nutrition is a physiological necessity I must meet; it is a scientific fact that if I do not feed myself adequately, I will end up sick or dying, but also among those options I purchase the foods I like most, those that please me more because of their flavor, those I value most. I am using an added value to taste, but also sometimes when I go shopping I look at prices and end up buying a food I like, but less so than another, and I buy it because it is cheaper, that is, I am using an economic value. Thus, without noticing, without perceiving it, when I buy fish or any other food, I am using a value of utility, it serves to nourish me; aesthetically pleasing, satisfying my gastronomic and economic taste, I look for the best price. As stated in the phrase heading this work, humans are appraising beings, managing values in multiple aspects of life: when purchasing, when comparing, when assessing, when desiring... Man has integrated values onto daily life, although unaware of it and manages said values, although these are of lower hierarchy, or material or economic values, as previously seen.

If speaking of values raises difficulties, reaching a definition of value is much more complex. When speaking of values we all know what we mean, but often have difficulties expressing it. Let us explore two distinct and complementary definitions to obtain more clarity:

a) Value is the quality of some realities, called goods, which is why they are appreciable.^5:29

b) Therefore, values are not a quality that our subjectivity makes of things, rather, it is a strange, subtle caste of objectivities our conscience finds beyond itself, as it finds trees and men.^5:38

Values are the foundations of our appraisement hierarchy. We measure the qualities of our desires, our projects, through the values that structure our way of being and our character. Values guide that life project and according to said values and the moment or environment, adapt our project and, hence, our personal life path. Thereby, values are like the fundamental pieces to measure my preferences, desires, and projects. This definition is quite practical and can be accused of utilitarian, but down deep it represents the main function of values: to guide my assessment, my personal preferences according to some hierarchical determinations that move my reasons, feelings and impulses. Of course, it is all mediated by the environment, by my circumstances, by the context of each moment and this makes me modify my hierarchy according to a given environment, which can produce a given consequence. These are theological moments of decision, of coping, of solving a particular problem or within a concrete and determined situation.

Also, as indicated by Ortega these are objective,⁵ they are beyond me although my interpretation can be subjective. Aesthetics, utility, health, ethics exist beyond the interpretation I have of those values, i.e., the interpretation I make of them is subjective, it is my interpretation, but they are found as reference points of that estimation, of that interpretation.

Values are linked to ethics and it is increasingly removed from imposing rigid solutions, of providing solutions and procedures that can serve for all cases, ever valid moral advice for acting, without stopping to weigh the consequences, that is, we must not confuse ethics with deontology. Ethics, on the contrary, seeks to furnish likely solutions to concrete situations. But the fact that they are likely does not mean they are useful. They are useful because they analyze the concrete situations where conflicts of values arise and they try to solve that concrete problem within that concrete circumstance. Surely, under other circumstances and another context, solutions could be different because the relationship among all the components of the conflict would also be different.

Let us now see how these values are organized, what is the hierarchy among them. For this, I have chosen the hierarchy proposed by Ortega y Gasset,⁵ which is influenced by the hierarchy proposed by Max Scheler:

• Religious values: Sacred/Profane, Divine/Demonic, Supreme/Derivate, and Miraculous/Mechanical.
• Spiritual values: a) Intellectual: Knowledge/Error, Exact/Approximate, and Evident/Probable; b) Moral ethical: Good/Bad, Kind/Evil, Fair/Unfair, Scrupulous/Relaxed, and Loyal/Disloyal; and c) Aesthetic: Beautiful/Ugly, Graceful/Rugged, Elegant/Inelegant, and Harmonious/Unharmonious.
• Vital values: Healthy/Sick, Select/Vulgar, Energetic/Inert, and Strong/Weak.
• Useful values: Capable/Incapable, Costly/Cheap; and Abundant/Scarce.

As noted, values are hierarchical, that is, they have hierarchy amongst themselves and some values are superior to others. There are most and least important values and the most important must prevail over the least important. In this case, the importance occurs in ascending order, but this hierarchy is not always carried out; often, the most important values are not considered when making decisions and it is the least important values, which are the ones used in making the final decision. For example, we purchase the least expensive dress, although it is uglier, but it serves to cover us (utility) and it is cheaper (economic); those values at that moment and within a given context are more important than the beauty (aesthetics).

Values are not always represented by the positive character of the value, like beauty, goodness, truth. Ugliness, badness, and falsehood are values of negative character, but also represent values on beauty, ethics, and logic. This is because values have polarity and move between two poles, positive and negative. Lastly, values – as taught by Diego Gracia – can be intrinsic and instrumental: ''Initially is the distinction between intrinsic and instrumental values. By intrinsic value we understand that quality that is valuable by itself, not by reference to any other, so that if it were to disappear, above all the rest will remain the same, we would think of having lost something important, that is, something valuable. Thus defined, it is differentiated from the notion of instrumental value or value through reference, in that it is not worth by itself, but through another thing or distinct quality, which grants it value.

Instrumental values are interchangeable amongst themselves. I can substitute a car for another, as long as it serves me to travel from one place to another, etc. Now, intrinsic values are not, in principle, permutable. People, for example, are not permutable; given that we consider that each one is respectable by itself. Hence, Kant's quotes that people ''have dignity and not price.'' And the same can be said of the beauty in a picture. Price is a measure of exchange and intrinsic values are not interchangeable, precisely because each one has value in and of itself. Precisely because it is the unit of measure of the instrumental values, economic rationality always seeks to optimize ''efficiency'', that is, the cost/benefit ratio, which does not occur in the order of intrinsic values. Those values are important, although not efficient''.

The first are appreciable in themselves and not by others (life, health, beauty, truth, etc.) and represent a good to retain. On the contrary, instrumental values are a means; they are at the service of intrinsic values (money, richness, that which is useful, etc.). The problem is when an instrumental value instead of being a means becomes an end and we seek as goal in our future to obtain the best car, the best house, the best wages, etc. Ethics must promote intrinsic values. The purpose of ethics is that of creating appreciative, reflexive, and autonomous humans, with clear life projects, that is, with a biographic purpose of personal development and self-government. As noted, values are somewhat more complex than the simple beliefs of the individual. Religious beliefs, according to this hierarchy by Ortega y Gasset,⁵ would be in the highest part, but there are other values that are continuous in our lives and which constantly influence our decisions.

Importance of culture in values

Values, without a doubt, are shaped by different events and personal experiences, but there is no doubt that they have an important cultural substrate and culture – in turn – has an important social substrate, that is, it can be said that mostly, we are what we are, because we were born where we were born and have been fed the ideas we have been fed. Of course, thereafter is the freedom each one has to think and be in a given manner, but our autonomy is not exerted within a setting of full and total freedom; rather, within a given spectrum of circumstances.⁶ Our selection will always take place within a given context in which we were born and in which we have been educated and formed, we will never be able to select within a total amplitude of elections, we will be confined to a nearby pre-established environment. Our beliefs are vitiated at their base by social status, family, and the geographic region where we are born. As stated by Professor Javier Sádaba: ''As demonstrated by neuroscience, areas of the brain exist that, if properly stimulated, produce emotions of a very special character and which, we reiterate, we would place in the section of the religious. But it must be understood that we are not insinuating that religion is, without further, a product of the brain. We will limit ourselves to confirm that we have a genetic base that enables or conditions our being religious. Then, it would be John or Mary who will decide, of their own free will, to be Mahometan, Buddhist, Christian, or simply atheist. What happens is that in the kingdom of culture other constraints shrink considerably John or Mary's freedom. It is quite difficult, not to say impossible, to be a Christian if you are born in Saudi Arabia or Jainist if you were born in Spain. Religion, in its softest of most rigid forms, consequently, has both a natural and cultural substrate. Although in the end, it is each one's issue''.⁷

Upon internalizing this reality, of our way of being and thinking, it is more surprising, that there are those who believe they own the truth with respect to values and who purport for their values and beliefs to have universal validity and serve, or worse, must serve for all human beings. This position, usually called ethnocentrism^8,9 and which can end up being fundamentalist, is dangerous and, additionally, the people who fall into it do not stop to think that if they had been born in Saudi Arabia, as indicated in the text, their ideas, values, and beliefs would be the same they now reject. Ethnocentrism is a practice occurring in all cultures, not only in those some would call ''developed'', given that the positivist, the religious, or members of any Amazon tribe are quite certain of their own truth.

Values are part of my truth, of my way of seeing my reality and it is composed of my culture, education, and religion; in other words, of my ideal of life. Besides, it is comprised of ideas and beliefs, that is, of ideas shared on a rational and logical basis and of beliefs composed by a base of faith and not logic. As stated by Ortega y Gasset in the essay ''Ideas and Belief'': we have ideas and we are in the beliefs.¹⁰ The first are debatable, argumentative, and demonstrable and the latter are believed or not believed, but cannot be shared with other people, unless under the setting of irrational adhesion to that belief. We all have our values and, hence, our preconceptions and our prejudice, the problem is not having them, but disavowing or forgetting that we have them, given that it is what hinders dialogue among individuals and reaching agreements.

Societies are always transforming their values and their signs of identity as they become more plural, less rigid, and more tolerant and mixed. Miscegenation, hybridization is truly the future of every society that progresses and is not anchored and unalterable. The mix of values and their co-participation in public and common life will enrich the perspectives and the judgments made; these will be more inter-subjective and plural than those made prior to the co-participation. But to accomplish that change, we must start transforming and transforming ourselves into that society and seek its evolution stemming from the monocultural, represented by a certain uniformity of values to the intercultural, where values coexist in dialogue and to transculturality,¹¹ where cultural demonstrations and their consequences can be understood by all, independent of the values had. As it is widely known, the theory of transcultural care and the importance culture has in care giving was elaborated by Madeleine Leininger back in the 1960s.¹²

Care giving

Among the health sciences, Nursing has always moved between technology and humanism^13,14 and it is sometimes difficult to reach consensus on this topic, but we could say without mistake that Nursing is the most humanist science, while Medicine is the most natural science, most ''scientific''. Most nursing theories were developed during the 1950s and 1960s and it seems that the ones gaining more importance in recent years have been the humanist theories: Virginia Henderson, Dorothea Orem, Madeleine Leiniger; Jean Watson.¹² But Nursing, as well as Medicine upon developing their ''science'' do not have bases of knowledge as rigid, replicable, and verifiable as the exact sciences. This does not mean that Nursing is not scientific. Of course, Nursing is based on scientific knowledge, but while nurses are not as concerned with the pathology and diagnosis of the subject, as they are with the individual's human responses to that diagnosis. On the contrary, Medicine normally prioritizes the diagnosis and treatment. Nurses are more interested in how we experience and integrate that particular pathology into our daily lives, into our way of being, our values; in a word, into our life project, given that our priority must be that of caring in holistic manner.

This coping with the patient's reality from different and complementary positions make values become vitally important to professionally perform a good care giving function. As nurses, we work seeking to modify life habits and we know how difficult and complicated this effort is. We can only have certain possibilities for success if the modification of life habits is integrated into their values and accepted by the very individuals; considering values in the broadest sense of the word.Care giving can only be offered from values, contemplating the human condition in its maximum extension, with all its circumstances, bearing in mind values and beliefs. The care giving action is focused on a given moment experienced by the person, by the patient; it is historic and must be appreciative. We can only care well if we know what is best for the patient, and that information can only be provided by the patient.

Watson¹² contemplates the importance of values in her theories; these have more to do with the nurses' values than with the patients' values. The values of a profession are important; in fact, they set its ethical commitment and favor the good exercise in the development of its professional performance, but even with those values being important, the real importance, to my understanding, lies in contemplating, knowing, and respecting within our care giving activity the patients' values in the broadest sense, not only their beliefs. We must arrive at our practice through the patient's autonomy. Doing the best for the patient from our point of view, is to again fall into the maternalism¹⁵ from which nurses do not manage to detach. By merely speaking with the patient and inquiring on what is best for the patient, that is, allowing him or her to voice an opinion and exert his or her own autonomy, we can conduct authentic care for the patient. We can practice our care giving for the authentic wellbeing of patients, according to their idea of what is good.

Lastly, we must be clear on that caring is always an intrinsic value and never an instrumental value. Caring is an irreplaceable human activity; the active subjects providing this care can change, but the activity is fundamental to develop as a person and evolve as a human being. This care giving circumstance is what provokes humanization on both sides of the relationship: as active agent (care giver) and as passive agent (person cared for), given that the first relation we have had with care is as passive agents; at birth we all need to be cared by our parents to grow and develop.

Conclusion; how to integrate values into the care giving activity

To conclude, the following recommendations may be useful, although many nurses may find it obvious, given that they take place on a daily basis; my experience in daily practice, from bedside exercise or during consultation, leads me to think that we sometimes emphasize more on delegated tasks than on our own tasks. Detracting from this procedure, the task eminently appertaining to nurses is care giving. The reason for this behavior may be due to different internal and external factors, which are not the subject of this article, but which would be suitable to study.

When we start to integrate values into care giving plans, our professional work is intricate and becomes more complex and difficult. If to establish a care plan, besides appraising the altered needs, I have to keep in mind the individual values of the person I am caring for and even engage said values to my own values, the process can be quite complicated and costly. But we must bear in mind that respecting the values of the person under our care and integrating these onto the process, is also covering a possible altered necessity of that person, it is confronting the process of the care plan in a more holistic manner.

To end, we will try to systematize, go step by step and, thus, establish a correct care giving methodology. Let us explore the following steps:

• First, establish what are the altered necessities and that must be cared for.
• Classify those necessities through priority by: seriousness (that places in danger the life and vitality of the subject under care), control great symptoms (which cause pain or extreme discomfort), comfort (necessities that alter the ''standard'' state of wellbeing), quality (placed at its maximum degree of excellence, a path of perfection of each life project, each ideal of life), ideality (maximum expression of personal values).
• Establish a care plan for said necessities, respecting the priority.
• Define the most recommended care without taking into consideration the implied values. What ''evidence'' are these based on (who stated them, what studies, could they be provisional)? Formation in knowledge and skills.
• Establish the implied values in each of said altered necessities and of their respective care plans and adapt them to the patient's values.
• Upon establishing the care plan and its implied values, propose it to the patient. Informed healthcare relationship.
• In case of confrontation with the person to be cared for, argument for and defend the suitability of the proposed plan. I must also think that I may be mistaken in my affirmations, especially if disagreement exists in the implied values.
• Speak, know the patient's posture and whenever possible adapt the patient's preferences to the scientific evidence of the care plan.
• In case of EMERGENCY and whenever the person under your care cannot exert his or her autonomy, that is, if unconscious and no guidelines or anticipated will exist, the priority must be to preserve the person's life.

We must never:

• Perform care that challenges scientific evidence.
• Create unperceived necessities in the persona cared for, which cannot be solved. We must reflect, be prudent, and always have the possibilities of the system in which I perform and the existence in every system of an insurmountable structural defect. Sometimes practicing as ''Good Samaritan'' can lead to future dissatisfaction of the person under care, for having created expectations impossible to carry out.

In summary: Do what has to be done when it can and should be done.

Surely, the implied values in care giving must be those of the person cared for; that person must reach the maximum level of ''Ideality''. We must also bear in mind that as we advance and especially in comfort, quality, and ideality, values are of vital importance to establish a perfect care plan.

I began this work with a paragraph from Professor Diego Gracia on values, which is why I want to end with a dialogue on values between two globally recognized comic-strip characters, which although from the world of entertainment, many times express big truths. It is a dialogue between Mafalda and Manolito by humorist Quino:

Mafalda: What is that newspaper clipping, Manolito?

Manolito: The quotation of the Market of Values – answers Manolito.

Mafalda: Of moral, spiritual, artistic, human values?

Manolito: No, no, of the useful ones.

I hope that after reading this article, we have a broader vision of values than Manolito's vision.

REFERENCES

1. Gordon M. Manual de Diagnóstico de Enfermería. 11th ed. Madrid: McGrawHill/ Interamericana de España SA.; 2007.         [ Links ]

2. Bernalte A, Miret MT. Manual de Enfermería Comunitaria. Madrid: LibrosEnRed; 2005.         [ Links ]

3. Ministerio de Sanidad y Consumo MSC. Proyecto NIPE. Normalización de las intervenciones para la práctica de la enfermería. Madrid: MSC; 2002.         [ Links ]