1. Colbert, Alison PhD, PHCNS-BC

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NURSES FACE ETHICAL Situations-from the relatively minor to major life-and-death issues-every day. Technology and treatment advances have made patient care more complex. Additionally, nursing practice has grown more autonomous. And the financial challenges of the healthcare industry often demand tough choices in a climate of scarce resources. To better equip nurses to deal with the ethical issues they routinely face in the modern healthcare setting, we've revamped our ethics column. Welcome to the first installment of Ethics in Action.


The new column title was chosen to convey the translation of ethical principles and decision making to their application in clinical practice. Authors of future columns will include nurses, ethicists, and researchers, all of whom seek to further our understanding of these issues and maintain a strong ethical culture in nursing practice. We encourage readers to join the conversation by sending us their questions about the ethical situations they're facing at work. The goal is to provide relevant material to nurses that challenges our thinking so we can more clearly define what our own ethical practice looks like.


Let's talk

Ethics refers to principles that guide actions. Nursing ethics encompass the application of ethical principles to care for patients and families. Ethical dilemmas, which occur when ethical principles conflict, can be quite concrete for nurses in practice. They include conversations with patients who refuse to eat; questions from family about genetic testing and precision medicine (using personal information, including genetic and genomic data, to plan and provide care); and family demands that a nurse "do something" for a coding patient who has a do-not-resuscitate order.1


It's not difficult to grasp how ethical decisions in nursing and healthcare directly impact patients and their families, but making those decisions also has indirect effects on nurses themselves. For example, we now know that moral distress-experienced when our actions are incongruent with our ethics-is related to important outcomes for healthcare providers, such as job satisfaction and staff turnover.2-4 A recent review of the literature revealed that moral distress negatively affects both well-being and job retention.5 Clinicians, educators, administrators, and researchers must bring ethics to the forefront of care and provide the skills necessary to navigate those often-murky waters.


It's tempting to think that we should just "know" right from wrong, and that if nurses have a strong moral foundation we'll be immune to ethical dilemmas. But this is simply not true, and if we continue to endorse this misconception, nurses will be inadequately prepared to face ethical conflicts. Ethical decision making must be taught, learned, and practiced. It should also be discussed, debated, and allowed to evolve in a changing world. That means bringing issues out in the open and working to establish a shared language to work through them.


Nursing has rightly been challenged to ensure that ours is an evidence-based practice. Questions about how we know what we know (or what we think we know) and demands for practice guidelines based on the best and most rigorous evidence have driven change. Credible evidence-based practice requires a framework for action that includes a systematic approach, from an original clinical question to final recommendations for change. Using that same approach, this column will challenge nurses to think about how they can develop and maintain an ethically based practice that will ensure high-quality patient care and a greater confidence in their own decision making in complicated situations.


What we'll cover

This shift toward a more deliberate ethically based practice demands a specific set of tools for the practicing nurse. That's where this column comes in. Every other month, we'll cover a new topic, ranging from the practical to the theoretical. For example:


* What do I do if I receive an order I disagree with from a healthcare provider?


* What can I do when concern about patient satisfaction scores and ethics collide?


* A family member wants to withhold information from a patient. How should I proceed?


* Do I work in an "ethical climate?" What does that mean, and how can individual nurses create change?


* Why does ethical practice mean evidence-based practice?


* Moral distress-what is it, and how can I develop coping strategies to manage this seemingly unavoidable circumstance?



Find the right tools for the job

One important step in a deliberate approach to ethical decision making is being informed about the situation. That means gathering resources and finding sources that can be trusted. We hope this column will add to your skill set, but there are other key components you'll need.


* Start with the American Nurses Association and International Council of Nurses Codes of Ethics. You've likely read them before (certainly in nursing school), but reading them again now, in the context of your practice and workplace, will provide new relevance and application. Don't just read the code alone; read interpretations and examples of application.


* Turn to a professional organization, such as the American Association of Critical Care Nurses or the Emergency Nurses Association, for guidance. Most will have resources specifically dedicated to ethical issues commonly faced in the specialty. These will include everything from informal discussions to formal white papers, where the organization and its members take a specific stance on an issue.


* Go local, to your workplace and your unit. Find out what resources you have available to you on the job. Find out if your workplace has an ethics board or council and how it's used. Learn how ethical issues are addressed at the systems level and where patients and clinicians can turn for help.


* Read as much as you can. As with evidence-based practice, we should go to the published literature to learn about what others have done, what new developments are on the horizon, and what works (and arguably more important, what doesn't). Read professional journals and publications, but also branch out to newspapers, websites, and books on topics related to ethics in healthcare. Sign up for listservs and professional newsletters, so content will come to your inbox.


* Start talking about ethics with your colleagues and peers. If you encounter a difficult situation, ask others how they've handled similar situations. Encourage them to share their best resources and strategies. Make it okay to talk to one another about challenging topics, and create an atmosphere of trust where ethical debate can flourish. If we work on "normalizing" the uncomfortable part of ethical decision making-being clear that the ambivalence or uncertainty is a shared experience-we can all benefit from more open communication.


* Finally, develop your own version of reflective practice. Learning through reflection occurs when we examine contradictions between what we believe our practice ought to be and what it really is, and explore ways to resolve those contradictions.6



Engaging in the conversation

To grow and enrich our ethically based practice, we need to engage in active discussion. Please join the conversation via e-mail (mailto:[email protected]), Twitter (@NsgJournal #nursingethicsinaction #ethicallybasedpractice), Facebook (@NsgJournal), or Share your questions, comments, and ideas. We can learn so much from one another.


See you next time!




1. Raby BA. Personalized medicine. 2017. [Context Link]


2. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNs Clin Issues Perinat Womens Health Nurs. 1993;4(4):542-551. [Context Link]


3. de Veer AJ, Francke AL, Struijs A, Willems DL. Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud. 2013;50(1):100-108.


4. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-125. [Context Link]


5. Lamiani G, Borghi L, Argentero P. When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. J Health Psychol. 2015;22(1):51-67. [Context Link]


6. Johns C. Becoming a Reflective Practitioner. Oxford, UK: John Wiley & Sons; 2017. [Context Link]