If there is any lesson to be gained from my clinical experience in Ghana thus far, it is this: be prepared to wrangle with yourself and challenge your nursing ideals in the face of cultural differences. There has been much debate on whether the ethical principles of nursing should be universal or relative across the continuum of nursing and in various cultural practice settings. My position with regards to the above has always been firm – universal, absolutely. Nursing ideals are often discussed within the topic of professional ethics in terms of what are considered the “good values” and the implications for clinical practice and policy development (Snellman & Gedda, 2012, p. 714). Core nursing values that are frequently highlighted in the literature include compassion, empathy, knowledge, trust, safety, support, empowerment, and responsibility (p. 714).
I can remember a few instances as a student in Canada where I have felt that some of my core values were challenged by a situation or that one value conflicted with another. In Ghana, my core values are challenged on a daily basis to point where a simple dressing change is enough to sketch me out. What is different from my nursing practice here in Ghana compared with my practice in Canada? It goes beyond confidence or the challenge of working in a resource-scarce environment. It seems as though my actual valuation process is in flux in light of the marked differences between the two health-care systems.
According to Snellman & Gedda (2012), a positive valuation is achieved via “appreciation and approbation” (p. 717). Society and individuals will approve and assign a positive valuation to something or not given multiple factors including culture, socio-economic status, the group of individuals involved, etc.… (p. 717). “Everybody has opinions about what is good or bad in our shared reality, what is better or worse than anything else, of what ought to be different and how we ought to respond in fluctuating situations” (p. 717).
Valuation almost sounds synonymous with nursing right? Well maybe not, but it certainly plays a major role in the profession. Valuations can stem from self-reflection (or a lack thereof) or strict adherence to a theoretical point of view (p. 717). While not every nursing value is left entirely to an individual’s personal valuation (thank you professional nursing regulatory bodies!) it appears that culture differences between collectivistic (i.e. loyalties of a person to a group exceed the rights of the individual) and individualistic societies (i.e. the rights of the individual exceed those of the group) is deep rooted in nursing practice.
A study conducted in Ghana to survey nurses’ perceptions of different ethical dilemmas found a strong belief in the ethical principles of non-maleficence and beneficence which were further complemented by local cultural beliefs (Donkor & Andrews, 2011, p. 113). “However, the relevance of the principles of autonomy (self-determination), social justice and confidentiality was not supported by local cultural values” (p. 113). Despite the cultural differences that exist in practice, it is important to note that the same authors recognized the importance of using a professional codes of ethics “as the cornerstone of nurses’ ethical knowledge” and acknowledge the cultural environment of the practice setting (p. 113).
So what can be done to minimize the ethical stress created when cultures collide? The best method so far has been to initiate dialogue with the Ghanaian nurses, physicians, clients, anyone who is open to talk about it and share their own valuation process. It is also extremely helpful to continue to advance your education given any opportunity; even if the opportunity is not the most ideal, there is a way to make it work to your advantage and advocate/model best practice standards. If you are too afraid to practice at all or even attempt to negotiate how to accomplish a task during an international placement, you may miss out on several unique experiences, including the opportunity to advocate and defend best-practice and challenge others to do the same.
Donkor, N. T., & Andrews, L. D. (2011). Ethics, culture and nursing practice in Ghana. International Nursing Review, 58, 109-114. Retrieved from CINAHL Database.
Snellman, I., & Gedda, K. (2012). The value ground of nursing. Nursing Ethics, 19(6), 714–726. Retrieved from CINAHL Database.