• Marcia Sue DeWolf Bosek DNSc, RN


ABSTRACT A review of the formal ethics consultations performed at a rural academic medical center during 2006 revealed that only 5 of 72 consultations were initiated by nurses. A descriptive exploratory convenience study used a 3-item survey to collect information from registered nurses who provide direct patient care at the rural academic medical center. The purpose of this study was to (1) identify and describe the ethical issues perceived by registered nurses employed at a rural academic medical center and (2) analyze the variables influencing the registered nurses' ethical decision making and the process used by these registered nurses when resolving ethical issues. The 17 registered nurses who completed the survey identified a total of 21 ethical issues that they had experienced during the last year. The ethical issues that nurses recalled were significantly more likely to be relationship issues, whereas issues documented within the ethics consultation service were significantly more likely to involve limiting treatment. Communication was a major variable influencing nurse's ethical decision making. Nurses felt the ethical issue resolved satisfactorily when the patient's needs were met, communication occurred with the patient and/or family, the entire healthcare team was involved and in agreement, and there was sufficient time available to make a decision. The nurses did not feel that the ethical situation was resolved satisfactorily when not handled from the patient's perspective; the patient suffered; there was a lack of teamwork, agreement, and/or support; and the process took too long. The nurses' recommendations for resources needed to assist with the resolution of ethical issues included accessible ethics mechanisms, education, improved interprofessional relationships and collaboration, and unbiased support for patient and family decision making. Implications for nurse managers are discussed and future research questions are identified.

Article Content


Clinical ethics consultation may be provided through a variety of methods including an institutional ethics committee, ethics team, or a clinical ethicist. A clinical ethicist typically has completed graduate level or specialty training (such as a certificate or fellowship program) in healthcare ethics. Individuals serving as clinical ethicists often hold professional healthcare roles (such as physicians, nurses, or physical therapists), whereas others come with educational and professional backgrounds in philosophy or religion. Currently, there is no ethics consultation specialty certification.


A healthcare organization may choose to create an ethics consultation service composed of a variety of clinical ethicists with varying professional and educational backgrounds as a means for maximizing clinical involvement as well as ethics education and research throughout the entire interdisciplinary healthcare team. Recently, a rural academic medical center expanded its ethics consultation service to include a clinical "nurse ethicist." "Collaborate with nursing leadership to address clinical and organizational ethical issues experienced by nurses" was one responsibility for this newly created nurse ethicist position. During introductory meetings with various stakeholders in the organization, each stakeholder was asked, "What changes would you like to see as a result of this new role?" Although excited about the possibilities associated with the new nurse ethicist role, stakeholders in the organization had difficulty identifying specific ethical issues that were impacting the nurses practicing in the hospital's various inpatient or outpatient settings.


Ethical assistance in the hospital is provided 24/7 through an individual ethics consultant model. A review of the ethics consultations provided during the previous year revealed that 72 ethics consultations had been completed, but only 5 of these consultations were initiated by nurses. As the new nurse ethicist, I began to wonder whether the registered nursing staff was experiencing ethical issues but not requesting assistance from the institution's ethics mechanism.

Review of the Literature


There has been limited research focused on describing the ethical issues actually experienced by registered nurses. Cooper et al1 surveyed by mail staff nurses who were members of the American Nurses Association (ANA). The nurses were asked to rank 33 ethics-related statements as to what level of importance the issue represented for healthcare organizations. The 295 responding nurses identified the top 5 ethical issues for healthcare organizations to be the following:


1. Failure to provide service of the highest quality owing to economic constraints determined by the organization


2. Failure to provide service of the highest quality consistent with the standards of the nursing profession


3. (Tied) Failure to provide services of the highest quality in the eyes of the consumer, regardless of social or economic status, personal attributes, or the nature of health problems and


4. Conflict between organizational and professional philosophy and standards


5. Failure to provide service of the highest quality consistent with the ANA Code of Ethics.1(p151)



However, it is unclear what specific clinical ethical issues these nurses perceived as illustrating each statement.


The findings from this 2004 study are limited by the fact that the 33 issues were gleaned from a previous study conducted with nurse executives,2 which took a broad organizational approach to evaluating ethical issues. It is unknown how frequently staff nurses experience the 33 ethical issues included in this survey. When provided the opportunity to identify "the most important ethical issue/problem faced by those who work as a staff nurse,"1(p152) 68% of the participants described "various causes and effects of short staffing."1(p152) Cooper et al1 note that because of the 15% response rate, the ability to generalize the findings from this study to all nurses or organizations is limited. Thus, there is a need for further research focusing on the staff nurse's description of ethical issues and recommendations for resolution of these issues.

Ethical Issues


An OVID-Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) literature review for 2006 using the key word nursing ethics was conducted. The abstracts and/or articles of US publications were reviewed to identify a list of ethical issues experienced by or of interest to American nurses. Ethical issues experienced by or impacting nurses include, but are not limited to, clinical issues involving the patient's rights and care, professionalism, philosophical issues, and organizational/societal issues.

Clinical Ethical Issues


Examples of clinical ethical issues include patient autonomy,3-6 use of restraints,5 pain management,7,8 determining best interest,9-11 Health Insurance Portability and Accountability Act (HIPAA)/confidentiality,12 organ donation,13 noncompliant patients,14 life-sustaining treatment/end-of-life care,15,16 and medical futility.17

Professional Ethical Issues


Ethical issues involving the nurse as a professional include professional autonomy to carry out the work of nursing,18 handling conflicts and respect,19 reporting errors,16,20,21 whistleblowing,22 professional obligations to provide care,16,23,24 professional obligations during a disaster,25 advocacy,26,27 the impaired nurse,28 professional autonomy,18 and conflicts of interest.18,29

Philosophical Ethical Issues


Philosophical ethical issues involve questions of caring,16,18 trustworthiness,30 truthtelling,31-33 moral distress,16,34 and moral decision making.16

Organizational and Societal Ethical Issues


Organizational and societal ethical issues impacting the staff nurse's role include social justice for persons with disabilities,35 globalization and cultural competency,36 the organization's ethical climate,37 use of information technology and confidentiality,38,39 gift giving,40 staffing issues/managed care,16,18,41,42 assisted death,43,44 mandated vaccinations,23,45 ethics of clinical research,46 organizational ethics,22 and the "impact of war and conflict on nursing."16(p70) Although numerous ethical issues have been identified in the literature, little is known about the extent that nurses in a small rural state are faced with these clinical, professional, philosophical, or organizational/societal ethical or other ethical issues while engaged in clinical nursing or the resources needed to resolve these clinical ethical issues.



The purpose of this study was to (1) identify and describe the ethical issues perceived by registered nurses employed at a rural academic medical center and (2) analyze the variables influencing the registered nurses' ethical decision making and the process used by these registered nurses when resolving ethical issues.


The specific aims for this study are the following:


1. Compare the ethical issues perceived by registered nurses to the formal ethics consultations performed at the hospital and the Cooper et al1 findings.


2. Describe the environment surrounding the ethical issue.


3. Identify the variables that influence decision making by registered nurses during a clinical ethical issue.


4. Discuss recommendations that the registered nurse participants have for resolving ethical issues in the clinical setting.




This descriptive exploratory convenience study used a 3-item survey (see Figure 1) to collect information from registered nurses who provide direct patient care in the hospital's inpatient or ambulatory care settings. A descriptive design is appropriate for "elaboration of the context of a situation, as well as the retrospective happenings and prospective plans surrounding a life event,"47(p91) such as the ethical issues experienced by nurses.

Figure 1 - Click to enlarge in new windowFigure 1 Survey.

The study was advertised in the hospital's nursing newsletter before the beginning of data collection. In addition, flyers were posted in the nursing lounge on each inpatient unit. Registered nurses were contacted via their hospital e-mail. Participants had the option of returning the completed survey as an e-mail attachment or via interdepartment mail. Data were collected over a 3-week period during July 2007.

Ethical Considerations


The risk to persons choosing to participate in this study is similar to the daily risk that a nurse incurs when discussing the events of the day with a coworker or manager. The study was approved by the hospital's institutional review board and Nursing Research Practice Council. Registered nurses are not typically considered to be a vulnerable population as defined by the Department of Health and Human Services.48 However, when conducting research on employees from a specific institution, the researcher must be aware that these participants could be perceived as being vulnerable if these potential participants are "susceptible to coercive or undue influence,"49(p125) which could impact the voluntariness of their consent to participate. To minimize the potential for the registered nurses to feel compelled to participate, all invitations to participate were given electronically by the researcher. Potential participants completed the survey at their own convenience. No demographic data were collected. Consent to participate was implied by the nurse completing and returning the survey.


Potential participants were notified that the possibility existed that a person's handwriting might be recognizable by others if seen on a completed survey or a handwritten address on an interdepartmental mail delivery envelope. Surveys (after transcribed) and envelopes (upon delivery) with participant handwriting were destroyed via the hospital's document shredding system.


In addition, potential participants were informed that choosing to return the survey via e-mail would create a link between the completed survey and the nurse's identity. Upon receipt of an electronic survey submission, the researcher cut and pasted the survey into a data file then deleted the e-mail message and any attachments from the researcher's e-mail account. Although potential participants were instructed to delete the communication from their e-mail accounts, it may not be possible to erase every trace of the communication from the hospital computer system. Finally, codes were assigned to any identities disclosed as a means to minimize the recognition of a participant or the participant's specialty location.



Participants were self-selected from a population of all registered nurses (including traveling nurses) employed at the time of data collection, which was estimated to be around 770 registered nurses. Seventeen registered nurses completed the survey, which represents approximately a 2.2% response rate. Ten surveys (58.8%) were submitted electronically, whereas 7 (41.2%) were submitted as hard copies delivered through interdepartmental mail.



The narrative responses were coded line by line for major concepts. Codes were identified from the review of the literature as well as from the participant's exact words. The coded interviews were compared for similarities and differences in coding. As coding progressed, a group of substantive codes evolved. Statistical analysis was done using SPSS.



When completing the survey, the nurse participants identified at least 1 ethical issue they had experienced as a nurse during the past year. In total, 21 different ethical issues were described by the 17 participants. Quotations from these ethical issues will be used as descriptive illustrations for the various themes and concepts presented as findings from this study.

Comparison With Formal Ethics Consultation


These ethical issues were categorized using the classification system used by the hospital's ethics department for quality reports. This classification system reflects 3 types of ethical issues involving (1) limiting treatment, (2) relationship issues, and (3) other issues, including social/religious/cultural issues, ethical standards, and ethics education. When the ethical issues that the nurse participants recalled were compared with the formal ethics consultations provided the previous year, the issues that the nurse particpants recalled were significantly more likely to be relationship issues, whereas issues documented within the consultation service were significantly more likely to involve limiting treatment (see Table 1).

Table 1 - Click to enlarge in new windowTable 1. Types of Ethical Issues Identified

Comparison to Cooper et al


Of the 5 top ethical issues of Cooper et al,1 4 were not described by the nurse participants in this study. None of the 21 described ethical issues involving economic constraints, impaired practitioners, organizational ethics, or safety issues. Although none of the nurse participants specifically highlighted a concern that there was a "failure to provide services consistent with the ANA Code of Ethics,"1(p151) theoretically, each of the ethical issues identified in this study and the study of Cooper et al1 could fit under this label because the ANA Code of Ethics for Nurses With Interpretive Statements50 provides ethical guidance for all nurses despite the nurse's specific role or specialty.


However, "Failure to provide services of the highest quality in the eyes of the consumer, regardless of social or economic status, personal attributes, or the nature of health problems,"1(p151) which was tied as the third ethical issue in the study of Cooper et al,1 was the most frequently described ethical issue in this study (5/21 ethical issues). For example,


The anesthesiologist had just completed the intubation. It was described as a difficult airway and the anesthesiologist agreed it was necessary. He then left. As we prepped the patient for transport, I had the patient's family come in so they could see the patient and to educate them as to the transport plan. The patient remained sedated[horizontal ellipsis]The patient's daughter and significant other immediately complained that the patient had advance directives and specifically DNR/DNI. (Nurse 1)


This description illustrates how failure to individualize care based on the patient's wishes (or through the family's eyes) can impact the perception of the quality of care provided.


Two ethical issues described by Cooper et al1 tied for second place related to frequency (3 ethical issues each) of description in this study. "Failure to identify the consumer's needs and provide services that meet those needs" (ranked 16th in Cooper et al1) was illustrated by nurse 10.


Patient [from a] Buddhist Congregation needed assistance with advocacy for her healthcare needs while an inpatient at [the hospital][horizontal ellipsis]. She had no family nearby, and her children has disowned her years before. Toward the end of her stay here, which was also the end of her life, she would drift in and out of lucidity[horizontal ellipsis]she had end-of-life decisions to make.


"Failure to be objective with others in discharging one's professional responsibilities" (ranked 18th in Cooper et al1) was described by nurse 17.


Patient was diagnosed with stage 4 colon cancer with mets to the lung[horizontal ellipsis]. During the year, as one chemotherapy wasn't effective, the drugs were changed and explained to the patient clearly. When the last CAT scan was done and the oncologist reported the results to the patient and family and chemo was stopped[horizontal ellipsis] I feel the oncologist was not as direct with offering hospice or palliative care and take the time to cover these services as well as he had previously covered chemotherapy.


In this scenario, the nurse seems to be describing the perception that the informed consent process may have been more thorough when the focus of care was on cure rather than palliation.


The list of ethical issues generated by Cooper et al1 may be a reflection of the participants' perception of how important the various ethical issues should be rather than describing the reality of importance or frequency of occurrence experienced by the participants in their daily nursing practice. In contrast, the nurse participants in this study were asked to describe their actual ethical experiences without cues or suggestions, such as the list of issues used by Cooper et al.1 Further investigation is needed to better understand the full spectrum of ethical issues that are perceived and experienced by nurses in the clinical setting.

Variables Influencing Participant Ethical Decision Making


The nurse participants described a variety of variables that influence the nurse participants' ethical decision making.



Every participant recalled how communication impacted the ethical situation that he/she experienced as a nurse at the hospital. Sometimes, the communication was effective.


I had an order to place a PICC line in a patient who, although a bit overreactive, was refusing to have it done. She was elderly and I felt she wasn't confused, just a hysterical personality. She eventually agreed to have it placed[horizontal ellipsis]. The patient just needed time and a different approach. I think sometimes we are in too much of a rush (sometimes justifiably so), and if we take a little extra time to explain things especially to someone with that type of personality, the outcome is usually better. (Nurse 9)


However, other times, the communication did not go smoothly.


Advance directives are rarely in place, and even if they are, they carry no clout. Sometimes, the patient has decided to withhold or end treatment but the family disagrees and overrides their decision. Sometimes, the medical situation is futile, but the physicians cannot or won't clearly relay that information to families and patients and help them with their options. (Nurse 2)


Nurse 6 recalled, "The mom asked us to lie to the father regarding the reason for the baby's admission."



The nurse participants perceived that the ethical situation they described experiencing was resolved satisfactorily when the patient's needs were met, communication with the patient and/or family occurred, there was team involvement and agreement, and sufficient time was available.


The ethics team [was] all very responsive when I called with questions. The patient had her needs met, and usually fairly promptly. (Nurse 10)


Eventually, the situation was resolved satisfactorily, but it took a while to get to that point[horizontal ellipsis]. The team, including social work, met with the mom and let her know that her request was not something we could comply with and told her that we would give her support in informing the dad. (Nurse 6)


In contrast, the nurse participants did not feel that the ethical situation was resolved satisfactorily when the situation was not handled from the patient's perspective; the patient suffered; there was a lack of teamwork, agreement, and/or support; or too much time was needed to make a decision or for education to occur.


If the family member has overridden the patient's decision, then their rights have been violated. If we begin or prolong treatment when we shouldn't, then often precious end-of-life time between family members is lost, pain and suffering is prolonged, and enormous money is wasted. (Nurse 2)


When a patient is in denial[horizontal ellipsis] I feel more time is needed with the patient to explain all options. The patient would have accepted hospice/palliative care sooner if the oncologist had suggested it and explained the service. (Nurse 17)


It is difficult to report ethical issues because management tends to discourage this reporting actively because they seem to feel that ethical issues reflect poorly on them. (Nurse 16)

Environment Surrounding the Ethical Issue



Several of the ethical issues described by the nurse participants reflected an organizational climate that may not have thoroughly embraced the assistance provided through an ethical consultation.


Unable to answer because I don't want the details to reveal who I am or what floor I'm on[horizontal ellipsis] Anytime we report issues of possible abuse our management team acts like they don't want to hear it and they discourage us from talking about it and/or advocating for the patient. (Nurse 16)


Eight weeks or so after the heart surgery, one of the nurses requested an ethics consult. The surgeon responded angrily and defensively and attempted to prevent the ethicist from meeting with the patient or family. (Nurse 4)


In addition, nurse participants described how requests for ethics consultation initiated by a nurse may not be viewed positively by other members of the healthcare team.


I did end up doing the SAFE report and I let both providers know my intentions. The surgeon was furious with me[horizontal ellipsis]the cardiologist was not happy about it but understood. (Nurse 15)


Nurse participant 3 suggested that there be an "ability to ask for an anonymous consult-meaning that their name is not disclosed to the doctor. Many nurses are afraid of consequences." This suggestion seems grounded in an appreciation for ethical assistance; however, anonymous consultations may perpetuate and possibly escalate an adversarial environment without promoting collaboration or communication.

Recommendations for Resolving Ethical Issues


The nurse participants identified a variety of resources that they believed were needed to assist registered nurses to resolve ethical situations in the clinical setting.



The nurses desired a clearly communicated Ethics Consultation Policy that included the expectation that nurses can and will initiate ethics consultations. The participants also stated that timely ethics consultations should be accessible through the hospital's page system.


I think many RN's may not know that they can order a clinical ethics consult or the importance of requesting ethics help[horizontal ellipsis]. I've even asked for help from the on-call ethics person when there was a staff-staff dilemma. (Nurse 10)


Interestingly, the organization's current ethics consultation policy did stipulate that anyone involved in the patient's care may initiate an ethics consultation and that the preferred process to initiate a consultation is through the hospital on-call paging system. Thus, further investigation is needed to ascertain whether healthcare professionals are unaware of the current policy or disagree with the current policy.


In addition, the nurse participants discussed the importance of having unbiased support for patient and family decision making.


Patient advocates should be assigned to patients on admission to the hospital. Families should be present for procedures and rounds to see actual care and treatment. Patients and families need guidance in making end-of-life decisions. Realism should be encouraged from our physicians. (Nurse 2)



When asked to identify resources needed to assist registered nurses to resolve ethical situations in the clinical setting, nurse 7 stated, "Education is number 1." "Debriefing/brainstorming/support sessions for floor nurses on a regular basis" (nurse 16) was also identified as a needed resource for assisting nurses to be active participants in resolving ethical issues in the clinical setting.



Several of the nurse participants discussed the importance of collaboration when working to resolve clinical ethical situations. Specifically, the nurse participants desired to be viewed as valued and knowledgeable members of the healthcare team.


We need to work as true teams. [The hospital] has a lot of paternalistic behaviors unfortunately. Nurses need to be recognized for the professional talents they offer patients as well. (Nurse 7)


Freedom to report and seek assistance without permission/support of management. (Nurse 16)


Finally, nurse 9 noted, "At the very least, we need to LISTEN to the patient." This seemingly simple statement is a clear reminder that the patient's voice and perspective can easily get lost or ignored during clinical ethical issues. A commitment to listening to the patient reflects a wise understanding that the patient should be used as the primary resource when seeking to resolve any ethical issue in the clinical setting.

Implications for Nurse Managers


Because of the low response rate (2.2%), the ability to generalize the findings of this study to other organizations may be limited. Nurse managers should be aware that the ethical issues perceived and experienced by staff nurses on a specific unit or at a specific agency may be unique to that practice setting. For example, "a situation that comes up repeatedly in the medical intensive care unit is in making end-of-life decisions" (nurse 2). Nurse managers may want to assess the types of ethical issues their staff are experiencing through informal face-to-face conversations and/or staff meetings. However, nurse managers should be sensitive to the fact that individual staff nurses may not feel safe or empowered to discuss their ethical concerns directly with management. Thus, nurse managers may want to partner with the organization's ethics mechanism and/or nurse researcher to anonymously survey the organization's nurses and other members of the interdisciplinary healthcare team about the ethical issues occurring in their organization.


Based on the findings from this study, nurse managers may want to be attentive to ethical issues involving relationship issues and questions. These relationship issues may include (but are not limited to) questions about surrogate decision making (nurses 3 and 10), confidentiality (nurse 5), truthtelling (nurse 6), conflict within the healthcare team (nurse 9), conflict of interests (nurses 7, 15, and 16), and issues within the patient's family (nurse 16). Nurses may be more likely to experience ethical issues with relationship concerns because of spending many consecutive hours with patients and their families. Nurse managers need to be especially aware and involved when relationship-based ethical issues involve team conflict or questions of professional conflict of interest because these may be ethical issues, which a staff nurse may have difficulty raising independently during interdisciplinary rounds.

Empowering Staff Nurses


Several of the nurse participants commented about the perceived lack of support for nurses to initiate ethics consultations and/or participate in ethical deliberations. This is an area where nurse managers can be instrumental in changing the unit and/or organization ethics culture. Nurse managers should be alert to reoccurring patterns related to ethical issues. For example, are nurses approaching management for assistance in initiating an ethics consultation more frequently? Is there an increased incidence of complaints being communicated to management about specific individuals or ethical issues? Finally, are nurses using the organization's conflict of care policy more frequently to invoke their right to refuse to participate in a specific patient's care based on ethical concerns?


Nurse managers may want to review their organization's ethics mechanism (ie, consultation service or ethics committee) policy and procedure to ensure that the policy reflects an interdisciplinary, collaborative approach that includes the staff nurse's perspective and involvement. In addition, nurse managers can collaborate with the organization's ethics mechanism to educate the nursing staff and other members of the healthcare team about how to best use the organization's ethics mechanism.


Nurse managers can also empower their nursing staff through education. Staff nurses can be encouraged to develop their ethics knowledge base through unit-based journal club discussions or bulletin board and/or in-service presentations on ethical topics relevant to the nursing unit and/or organization or by attending professional nursing organization annual conventions. Follow-up debriefing sessions may also be useful educational mechanisms for clarifying ethical content and ensuring that individual staff nurses have processed the ethical issue and have experienced closure.


Mentoring activities can also be used by nurse managers and advanced practice nurses to empower staff nurse involvement during ethical issues. Mentoring activities could include role modeling communication strategies when identifying and discussing ethical concerns with other members of the interdisciplinary team. Nurse managers could also empower the staff nurse's communication abilities by providing a safe environment where the nurse could practice role playing specific ethics conversations with other healthcare team members or family members.


Finally, staff nurses may feel more empowered when experiencing an ethical issue if they perceive that their nurse managers are accessible and visible on the unit. A nurse manager may want to be physically visible on the unit and/or participate in interdisciplinary rounds when discussions about ethical issues and the need for ethics assistance are anticipated. Accessibility involves more than just physical proximity and an "open-door" policy. Staff nurses must perceive that their manager and/or ethics mechanism wants to be involved, has time available, is receptive to learning about the nurse's values and concerns, and demonstrates the ability to be a strong proponent for the nurse's role during ethical decision making.

Recommendations for Future Research


1. Is the organization's ethical climate perceived differently by various healthcare professionals?


2. What are the barriers and facilitators for initiating an ethics consultation perceived by the various members of the healthcare team and/or patient and family?


3. What are the common elements of retaliation experienced by nurses who independently initiate an ethics consultation and what are the long-term professional and personal consequences experienced?


4. How are advance directives used to guide decision making for patients who lack decisional capacity?


5. How are do-not-resuscitate orders interpreted by healthcare professionals, patients, and significant others?




Nurses experience a variety of clinical ethical issues. The participants in this study were more likely to report ethical issues related to relationships. The ethical issues reported by this nurse sample do not reflect the ethical issues perceived as important by a national survey of ANA members. Further investigation is needed to assess the communication and ethical climate impacting ethical issues. There are a variety of steps nurse managers could implement to promote an organizational climate that embraces interprofessional ethical dialogue.


Addendum: During 2008 (the calendar year following this research study), 82 formal ethics consultations were completed. Interestingly, 18 (22%) of these consultations were initiated by nurses, which represents a clinically significant increase in nursing involvement over a 2-year period.



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