16.2 Ethics in Nursing Practice

Nursing Ethical Virtues

A character trait or habit that is considered morally good is called a virtue. They are learned behaviors and attitudes and can be taught in school and through experiences, such as caring for older relatives, siblings, or pets. Many consider virtues, such as caring, compassion, discretion, trust, integrity, and consciousness, fundamental to nursing practice and ethics (Kosmidis et al., 2021). Note that virtues can also be values; however, a value is an internal belief in a concept, while a virtue is the execution of that belief. Consider the concept of integrity. The value of integrity is a belief in honesty, moral consistency, and commitment. The virtue of integrity is acting on that belief with honesty and clarity, even in the face of one’s failure. For example, a nurse who goes to their nurse manager after making an error and informs the nurse manager of their error is acting with the virtue of integrity (Kosmidis et al., 2021). In this sense, nursing virtues are the outward expressions of inner nursing values. Another example of a nursing ethical virtue is moral courage, the willingness to stand up for what is moral and ethical even when it may negatively impact the nurse (Pajakoski et al., 2021). Moral courage helps to safeguard patients and protect nursing standards.

Ethical Principles in Nursing

The background concepts that underlie the essence of ethics and can also guide behavior are known as ethical principles (Weiss et al., 2019). As with values and virtues, there is some overlap between principles, values, and virtues. The main ethical principles that underpin the nursing Standards of Practice and Code of Ethics for Nurses are as follows (Weiss et al., 2019):

• Autonomy: Patients should have the right to make their own decisions.
• Justice: As an ethical principle, justice is somehow both the same and yet bigger than the value of social justice. It is a principle that requires nurses to treat all people equally and judge them on the same criteria, no matter who they are, what their illness is, or how much money they have.
• Confidentiality: The principle of confidentiality focuses on maintaining patient privacy in terms of both health and personal information. It is both an ethical principle and a legal issue (discussed in 16.3 Legal Dimensions of Care).
• Accountability: The principle of accountability means that nurses accept responsibility for their own actions. Standards of care, policies, and procedures help maintain accountability by ensuring that there is a template of what should have been done to compare against what was done.
• Nonmaleficence: The principle of nonmaleficence means that nurses should do no harm either intentionally or unintentionally. They are expected to protect those who cannot protect themselves.
• Fidelity: A principle of faithfulness and loyalty is fidelity. Nursing requires fidelity to the profession and patients and is an underlying principle in accountability.
• Beneficence: The principle of beneficence is that nurses should do good for the benefit of others. Beyond simply providing competent care, nurses should truly care for their patients and seek to meet their physical, social, or emotional needs.
• Veracity: The principle of truthfulness is veracity. Nurses are expected to be honest with their patients. Veracity is also an underlying principle behind integrity.

Standards of Professional Nursing Practice

The Standards of Professional Nursing Practice are statements of functions and conduct that all nurses, in every setting, are expected to execute capably (ANA, 2021). They are not, in and of themselves, ethical statements. However, they are informed by nursing professional values, virtues, and morals. Further, their proficiency requires an understanding and appreciation of the body of nursing ethics. Each set of standards includes several competencies registered nurses are expected to meet upon graduation from nursing school and additional competencies expected of advanced practice and graduate level–prepared nurses.

There are two sets of nursing standards (ANA, 2021). The first set, the Standards of Practice (referring to ANA’s Nursing: Scope and Standards of Practice) is based on the nursing process. The Standards of Practice form the basis of rules regarding decision-making, care provision, and practice behaviors. They include the standards of assessment, diagnosis, outcome identification, planning, implementation, care coordination, patient education, and evaluation. Similar to how nursing values become incorporated into practice through the nursing process, nursing ethics are interwoven throughout the Standards of Practice despite not being explicitly about ethics.

The second set of professional standards is the Standards of Professional Performance. These standards represent professional nursing behaviors and mindsets. The Standards of Professional Performance include advocacy, respect, communication, collaboration, leadership, research, and environmental health. As with the Standards of Practice, the Standards of Professional Performance are informed by and grow out of the nursing professional values. One additional standard of professional performance, the Code of Ethics for Nurses, is a set of specific provisions registered nurses are expected to use to guide their practice (ANA, 2021).

The Code of Ethics for Nurses

Values, ethical virtues, and ethical principles are all related to the development of nursing professional practice and practice standards. Now, let us look at the Code of Ethics for Nurses. Table 16.2 provides the nine Code of Ethics for Nurses provisions and a brief discussion of each provision's interpretation.

Principle-Based Approach

The principle-based approach, also called principlism, draws strongly from deontology and is perhaps the most dominant approach to ethical decision-making in nursing (ANA, 2021). This approach assumes that ethical principles can guide all actions and decisions for nurses (De Panfilis et al., 2019). Refer to provision two of the Code of Ethics for Nurses (Table 16.2), and consider it in terms of the principle-based approach. The primary commitment of the nurse is to the patient, and the patient can be an individual, group, family, or community. When providing nursing care, the guiding principles should be based on the needs of the patient (De Panfilis et al., 2019). For example, engaging in conversations about risks and benefits or ensuring patients have name or alert bracelets to reduce medical errors are all ways to support principles of ethical decision-making (Vearrier & Henderson, 2021).

Care-Based Approach

The care-based approach combines the action of offering physical care for another human being and the value of caring about the individual, recognizing their frailty and vulnerability (De Panfilis et al., 2019). It carries an underlying assumption that as a species, human beings are mutually dependent on each other and need respect, protection, and caring. It further recognizes the state of being ill and the experience of being ill are connected, and patients are treated both through physical care and therapeutic relationships between providers and patients (De Panfilis et al., 2019).

The care-based approach draws a strong sense of morality in action from virtue ethics. A nurse using the care-based approach employs virtues such as respect to actively build their therapeutic relationships with patients. They also use deontology for many of the same reasons, because actively supplying care in all ways is morally right (De Panfilis et al., 2019). The care-based approach also requires authenticity and genuineness—legitimate care for the individual patient, not one that is faked by the nurse.

Feminist Ethics

Over 90 percent of the international nursing workforce is female, and nursing has been a dominantly female occupation since the days of Florence Nightingale. Feminist ethics arose out of a desire to provide a feminist lens to the male-dominated field of philosophy and ethics and to relocate an understanding of women’s roles in health care as careers (Kohlen & McCarthy, 2020). As a result, feminist ethics arose out of a need to critically appraise the gendered nature of traditionally held theoretical perspectives: to challenge the status quo and explore ethics from a female perspective. Because, historically in Western societies, men and male-dominated professions have had more power than women and female-dominated professions, feminist ethics in nursing initially sought to shine a light on how distorted and institutionalized understandings of male/female differences impacted health care (Kohlen & McCarthy, 2020). Thus, from its earliest beginnings, feminist ethics explored relationships and power, with an underlying recognition that society has internalized understandings of gender that marginalize and disempower women.

In the four plus decades since feminist ethics initially arose, the overarching understanding of internalized prejudices inherent in areas such as institutionalized racism, sexism, ageism, and classism, have become cornerstones of what began as simple feminist ethics. It seeks to unpack the social, cultural, economic, and even political issues that impact healthcare affordability, accessibility, equity, and even justice (Kohlen & McCarthy, 2020). No longer simply focused on gendered roles, today’s feminist ethics could perhaps more accurately be called the ethics of social justice. Today’s feminist ethics draws on its history to situate nursing care in relation to oppression and power, not only of male versus female, but in all healthcare relationships where a difference in power impacts the individual’s ability to receive the care they need.

Moral Distress

Knowing an ethically correct action but being unable to perform it, due to either internal or external forces, or being forced to act outside one’s personal and professional values is known as moral distress (Weiss et al., 2019). It is a sign of moral attentiveness in nurses, an indication of how important the nurse holds the values and ideals of the nursing profession (Rushton, 2023). Nurses are in a unique position when it comes to moral distress. They may be directed to act in ways they perceive as immoral based on orders from providers (Kennedy et al., 2023). Also, as part of the healthcare workforce that spends the greatest amount of time with patients, nurses immediately observe the impacts of ethically questionable decisions.

Nurses experiencing moral distress often report emotional and physical problems such as headaches, abdominal upset, anger, frustration, and depression (American Association of Critical-Care Nurses [AACN], n.d.). Some nurses leave the profession as a result (Weiss et al., 2019). During times of crisis, nurses are more likely to experience moral distress as they are exposed to breakdowns in the system and resource difficulties (AACN, n.d.). For example, many nurses experienced substantial moral distress during the COVID-19 pandemic as facilities were forced to ration care, were forced to work with dangerously low staffing levels, and found it difficult to uphold their duty to care. Nurses and other healthcare workers knew what patients needed but were unable to provide that care. In many instances, the conditions faced during the pandemic lasted long enough to cause moral injury (Ĉartolovni et al., 2021). If an individual cannot manage that distress or if it is sustained over time, it can become moral injury, in which they are psychologically harmed by being forced to act outside of their value system, resulting in conditions such as major depression and post-traumatic stress disorder (British Medical Association, 2021).

The AACN offers a position statement on moral distress during times of crisis (2020). The statement offers several strategies nurses can use to prevent and manage moral distress, including the following:

• Paying attention to your internal compass to recognize when you are being asked to perform outside of your comfort zone
• Expanding your knowledge of ethics through reviewing the various Codes of Ethics for nurses as well as your facility’s ethics policies
• Recognizing the signs and symptoms of moral distress in yourself and your coworkers
• Seeking out trusted mentors to talk through issues with
• Using resources such as employee assistance programs and/or counseling to work through moral distress
• Maintaining one’s work-life balance and leaning on loved ones

Conscientious Objection

The inner feeling or voice inside an individual’s head that tells them whether actions, thoughts, or behaviors are right or wrong, is called one's conscience or moral compass. A related concept is conscientious objection, the act of voicing an objection or refusing to act or behave in a manner that is allowable by one’s practice act but which the nurse finds objectionable or moral on religious grounds (ANA, 2022). The right of nurses to act on their conscience is internationally recognized (Lamb & Pesut, 2021). Most professional organizations, including the ANA, agree that a clinician should not be forced into performing therapies and interventions they find morally unacceptable (Kennedy et al., 2023). Thus, while nurses should always respect and value the autonomy and values of their patients, they also have the right to act in ways that are morally affirming for themselves (Lamb & Pesut, 2021).

When determining whether to raise a claim of conscientious objection, a nurse’s first consideration must be the patient. How will the patient be impacted by their claim? How will the rest of the healthcare team be impacted? When experiencing a conscientious objection, it is critical to disclose it as soon as possible to someone with the authority to change assignments in order to mitigate any potential compromise to patient care (Anderson & Henriksen, 2019). In the same vein, it is essential to never make a conscientious objection against a person. A conscientious objection is objection against an action, intervention, or therapy, never an individual (Anderson & Henriksen, 2019). Further, nurses must never abandon a patient without ensuring another nurse has assumed their care, as doing so is considered abandonment and is an ethical violation, contrary to the fundamental principles of nursing (Anderson & Henriksen, 2019; Kennedy et al., 2023). When a nurse leaves or abandons a patient’s care without making sure another qualified nurse is ready to take over and continue providing necessary medical attention and support, that is called abandonment. Beyond the immediate impact on patient well-being, abandonment carries serious consequences for the nurse, such as legal ramifications (including potential lawsuits), disciplinary actions from regulatory bodies, and termination of employment.

Common causes for conscientious objection include medically assisted dying, abortion, and gender-affirming surgeries (sex reassignment surgery). Nurses in organizations in which conscientious objection is unacceptable show higher levels of stress and burnout (Lamb & Pesut, 2021). By contrast, some agencies request information from staff about situations in which some may experience conscientious objections in advance of such situations occurring. This decreases the risk of having to negotiate last-minute staffing changes and potentially compromise patient care (Anderson & Henriksen, 2019). For example, a nurse manager on a palliative care unit might ask staff members how they feel about medical aid in dying (in a state in which it is legal), to determine which nurses may not be willing to participate in these procedures.

Ethical Considerations

Most of the day-in and day-out decisions a nurse makes are very clear-cut in terms of their ethics. However, all nurses will have occasions when they must consider the ethics of a situation. A circumstance that causes a nurse to stop to think through the ethics of a situation is called an ethical consideration. The choices are not necessarily difficult ones; however, they are ones for which the nurse must think about whether one decision is more ethical than another. A nurse may find themself unable to keep the provisions of the Code of Ethics for Nurses equally and must decide how best to manage a situation.

Ethical Dilemmas

A dilemma is a choice between two or more potentially correct answers. An ethical dilemma occurs when there must be a choice between two or more or more actions, both of which are equally good, both of which are equally bad, or for which the benefits of both actions are unknown (Rich, 2023; Weiss et al., 2019). They also occur when members of the healthcare team have different ideas concerning what is ethical or unethical in treatment situations (Manderius et al., 2023). Dilemmas are more complicated than considerations. In an ethical consideration, the nurse must consider the ethics of a situation, whereas in a dilemma, the nurse must practice some decision-making strategies to determine the most appropriate course of action. When faced with ethical dilemmas, nurses should always keep in mind the nursing values, standards, and Code of Ethics to guide them (Kosmidis et al., 2021). The MORAL model of ethical decision-making is a helpful option for managing ethical dilemmas (Figure 16.5) (ANA, 2021; Center for Public Health Practice, 2022).

Figure 16.5 The MORAL model of ethical decision-making can be used by individuals or groups. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Ethics Committees

There may be times when an individual or healthcare team is unable to make an appropriate ethical determination. In these situations, a facility’s ethics committee, a group that works together on a regular basis to address ethical issues within the organization, might be able to help. These committees usually include employees such as providers, nurses, and chaplains, as well as the facility’s legal representation and perhaps even community members (Rich, 2023). Ethics committees can assist with clarification when there is confusion about ethical solutions, or they can become involved in making ethical decisions when teams are unable to come to a resolution. Additionally, when patients do not have a surrogate to speak for them and cannot speak for themselves, it is generally an agency’s ethics committee that acts on their behalf. Nurses should use their agency’s ethics committee when they have questions or concerns about whether situations are appropriate and fully ethical.