Nurses face many occasions when they need to call on ethical principles in nursing to deal with difficult situations and resolve common ethical dilemmas.
“Every day, nurses in all hospital departments face a variety of ethical issues and they need to reconcile their own values with their nursing professional obligation,” said Marian Altman, RN, MS, CNS-BC, CCRN-K, clinical practice specialist with the American Association of Critical-Care Nurses (AACN).
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“There are a variety of reasons that nurses are not able to reconcile this conflict, such as lack of resources to do so and lack of time,” she added. “Not addressing ethical issues is a problem. If the nurse ignores the issue, it may lead to burnout and their leaving the unit and/or the nursing profession.”
Nurses who do not heed the nursing Code of Ethics could also find themselves with disciplinary charges or in legal trouble.
Every nurse should become familiar with the Code of Ethics for Nurses, developed and released by the American Nurses Association (ANA). It provides ethical principles in nursing.
“It’s a framework for helping nurses with issues that might arise,” said Connie M. Ulrich, PhD, RN, professor of bioethics and nursing at the University of Pennsylvania School of Nursing and Medicine in Philadelphia and author of Nursing Ethics in Everyday Practice.
Additionally, Altman suggested nurses contact “the hospital’s ethics committee, the hospital code of conduct or a variety of educational resources. Some organizations have an ethics consultation service whose members round and proactively assist staff to discuss potential and/or real ethical issues.”
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Addressing 4 Dilemmas in Nursing Ethics
1. Informed Consent
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Informed consent requires the patient or surrogate know about the risks, benefits and other options for treatment. The person signing the form must freely agree to the treatment plan. It pertains to the nursing Code of Ethics’ “Right to Self-Determination.”
Apprehension that patients and their families have not been fully informed about their treatments or clinical prognosis is a common ethical dilemma in nursing, Ulrich reported.
“It can create great concern for nurses,” Ulrich said. “Patients feel more comfortable asking the nurse to decipher what was said [by the doctor]. But it’s an ethical issue about how much they should convey.’
This is especially true about end-of-life decision making, she said. Nurses play a role in helping their patients understand and achieve their treatment goals, whether aggressive treatment or comfort care. They must respect a patient’s decision making, even if they disagree.
However, nurses may not feel prepared to have this discussion. Ulrich suggested building a strong interdisciplinary team to help deal with these ethical issues in nursing.
2. Disclosing Medical Conditions
Another example of an ethical dilemma in nursing is telling the truth to a patient vs. being deceptive, Altman said.
“Sometimes families request that patients not be told about their medical condition or diagnosis,” Altman added. “The nurse must consider the patient’s right to know. How does the nurse know what the family is saying is true?”
The nurse has an obligation to the patient and the ethical principles of nonmaleficence and fidelity—the obligation to prevent harm and the obligation to be faithful to your colleagues, Altman said, adding, “The nurse’s own value of truth-telling must also be considered.”
The nursing Code of Ethics requires truth-telling, promise-keeping and fulfilling commitments.
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A 2004 article in Journal of Hospice & Palliative Nursing reported, “Patients and their families want to know the truth about their illness” regardless of whether it is good or bad news, and healthcare professionals have an ethical obligation to share with them the truth, which allows the patient to make informed decisions.
3. Incompetence Among Peers
Another ethical issue in nursing occurs when a nurse notes incompetence in a fellow health care team member and struggles with speaking up or staying silent, said Sarah Delgado, RN, MSN, ACNP, clinical practice specialist with AACN.
“They may feel the behavior should be reported because of the threat to patient safety but hesitate to do so because it would worsen inadequate staffing,” Delgado said. “Some dilemmas can be framed as competing obligations, such as protecting the patient on one hand and protecting the staff on the other.”
The nursing Code of Ethics states that “nurses must protect the patient, the public, and the profession from potential harm when practice appears to be impaired.” It goes on to say nurses should reach out to supervisory personnel, follow organization policies, and show compassion to colleagues.
The ethical principles in nursing to consider are nonmaleficence and fidelity. Resolving what appear to be competing obligations often requires thinking creatively, Delgado added.
“Solutions often become apparent when we stop and consider all the possible actions available to us,” she explained. “Beyond report or don’t report, may be an option to talk to the individual in question, assess his or her awareness of the incompetence, and encourage further training, education or practice.”
4. Broader Ethical issues
According to Liz Stokes, JD, MA, RN, senior policy advisor at the ANA’s Center for Ethics and Human Rights, other ethical issues in nursing include:
- Creating and maintaining an ethical work environment. Provision 6 of the nursing Code of Ethics states that the nurse holds a responsibility individually and collectively to maintain and improve ethical work environments, which are “conducive to safe, quality healthcare.”
- Supporting social justice, such as opposing capital punishment, within provision 9 of the Code of Ethics. It encourages nurses to take action to influence legislatures, government agencies and other entities to address social determinants of health, and unjust systems and structures.
- Recognizing moral distress and building moral resilience. Moral distress occurs when nurses’ integrity is compromised or the ethical environment has eroded. Nurses must build resilience and develop moral courage to speak up for the ethical principles in nursing.
The Call to Nursing Ethics
Ethical practice is a constant challenge. Every day, nurses may face any of these or other ethical issues in nursing. Nurses should refer to the nursing Code of Ethics for guidance. The code makes clear nurses’ duty to protect people’s health.
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