Nursing Ethics: Ethical Decision-Making for Nurse Leaders

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At a time of unprecedented change, one constant remains: Nurses rate the highest of all professionals for honesty and ethics.

According to a 2019 Gallup poll of U.S. residents, 85% of respondents rated nurses’ ethical standards and honesty as “very high” or “high.” That marked the 18th year in a row that nurses received the highest rating in the survey of consumer impressions of various professions’ ethics. The next highest-rated professions for honesty and ethics were engineers (66%), medical doctors (65%), and pharmacists (64%).

The trust patients put in their nurses has only grown stronger as a result of the ongoing COVID-19 pandemic. A Harris Poll conducted in August 2020 found that 88% of U.S. adults surveyed trust the COVID-19 information they receive from doctors and nurses, compared to 73% who trust information from the U.S. Centers for Disease Control and Prevention (CDC).

Ethics are a cornerstone of the nursing profession. Their importance highlights the role nurses play as advocates for patients’ rights and equitable patient outcomes. This guide explains the genesis of nursing ethics and how nurses put ethics into practice daily to promote the health and well-being of all their patients.

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Ethics are defined as the moral principles that determine how a person or group of people will act or behave in specific situations. Strong ethics are vital to nursing, as moral dilemmas can frequently arise while attending to patients. Nurses and other healthcare professionals must recognize these ethical problems when they occur and apply the profession’s ethics and core values in their judgment and decision-making.

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Health equity’s goal is to ensure that all have the opportunity to “live the healthiest life possible”, as the Robert Wood Johnson Foundation explains, regardless of who they are, where they live, or how much money they make. Daily Nurse describes the four interrelated factors that influence how nurses approach health equity:

• Health disparities are the variations in health and healthcare among segments of the population, including ethnic minorities, immigrants, and people with low income.
• Social determinants of health are the nonmedical and nongenetic factors that account for about 80% of individual health outcomes, according to the National Academy of Medicine.
• Culturally competent healthcare involves respecting and understanding how a segment of the population’s beliefs, language, customs, and behaviors affect disease epidemiology and manifestation. It also considers medication’s effects on various ethnic, cultural, and sexual minorities.
• Social justice highlights nurses’ professional responsibility to respond to systemic injustice and promote and protect human rights.

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To address health inequity factors, nurses are encouraged to be aware of health disparities that could impair treatment outcomes. They can then refer patients to social workers, case managers, and other healthcare team members for additional services. Nurses should be mindful of the social and economic factors that affect patient and community health.

Trust is key to ensure that patients are comfortable sharing information about their culture and socioeconomic status with nurses and other healthcare professionals. This can be especially challenging when the patient and nurse come from different racial, gender, or ethnic backgrounds.

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Ethical principles are general by nature because they’re intended to serve as a framework that people use to weigh the facts of a situation that presents a moral or an ethical dilemma. The Oncology Nursing Society describes the principles of nursing ethics that serve as guideposts for ethical decision-making in healthcare settings.

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Nurses have an obligation not to inflict harm and not to allow others to inflict harm. They must also promote good actions on behalf of their patients. Examples of nonmaleficence are always being truthful to patients and never allowing one patient to be harmed for the benefit of another.

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Nurses have a strong duty to act in ways that benefit individuals, communities, and society. Beneficence is rooted in the innate love we feel for humanity and the drive to demonstrate that love through our actions. Beneficence is exemplified by the kindness nurses show their patients in all their interactions and in the willingness to abide by a patient’s wishes, as long as the patient is competent and fully informed.

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Nurses must respect their patients at all times, but they’re not required to accept the actions their patients take and the consequences of those actions. Autonomy is the ability to explain one’s needs and make fully informed decisions about one’s health. Illness may threaten a patient’s autonomy. However, nurses are obligated to honor a patient’s autonomous actions.

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Nurses are responsible for ensuring that healthcare benefits and burdens are distributed fairly throughout the population. The uneven distribution of healthcare resources is related to societal inequities and personal prejudices. An example is patient triage: when a nurse must decide which of several needy patients requires immediate attention. That decision may depend on where the nurse can do the most good, or where the need is greatest, depending on the nurse’s determination of the most just course of action.

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Technology has impacted healthcare as much as any field, and like other industries, healthcare must address new technologies in ways that don’t threaten patients’ rights and the safety and confidentiality of patient data. These are among the most common ethical dilemmas that nurses face.

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The concept of self-determination is deeply ingrained in healthcare: As long as patients have sufficient decision-making capacity, they have the right to accept or decline the treatment that their healthcare providers prescribe. As the Journal of Medical Ethics points out, some time must pass between the moment the physician or other healthcare professional determines that some course of action should be taken and the moment the patient is competent enough to decide whether to follow the physician’s advice. Temporizing is the practice of waiting until a patient has sufficient decision-making capacity before advising on the matter.

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Nurses make decisions based on the information available to them in the current situation. The more relevant information they have, the more likely their decision will have a positive outcome. When a nurse’s decision leads to a negative outcome, the question becomes: What critical pieces of information were lacking at the time of the decision? Nurses must take responsibility for their decisions and strive to understand why some decisions have negative outcomes.

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Early palliative care has been shown to improve the dying experience for patients at the end of their lives as well as for their families. The AMA Journal of Ethics points out the variation in end-of-life care and an underappreciation of the social, political, and cultural issues that underlie decisions about the dying process. The researchers call for a more systemic implementation of communication guidelines for advanced care planning and competent patient-focused end-of-life care.

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The American Nurses Association’s nursing code of ethics serves as a guide for nurses to practice with competence and integrity. People’s own set of ethics and morals influence their actions and decision-making, as well as how they perceive the consequences of those actions. In healthcare, ethics allow nurses and other professionals to identify moral dilemmas and apply good judgment to their decisions.

ANA’s nursing code of ethics also ensures that nurses abide by all regulations and policies that apply to their profession and their employment. The code’s nine provisions guide nurses to act ethically in their daily duties and responsibilities. The provisions are based on the four main principles of nursing ethics — nonmaleficence, beneficence, autonomy, and justice — as explained in the book Nursing Ethical Considerations.

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ANA describes the nursing code of ethics as “non-negotiable in any setting.” The code serves as the foundation for “nursing theory, practice, and praxis” in expressing the “values, virtues, and obligations that shape, guide, and inform nursing as a profession.”

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Nurses recognize the dignity, worth, and uniqueness of all people. They understand that the right to healthcare applies to everyone, and they respect at all times their patients, co-workers, and everyone else they interact with.

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Nurses’ primary commitment is to their patients. They have a duty to recognize and address potential conflicts of interest that may jeopardize their commitment to their patients. This commitment extends to individuals, families, groups, and communities.

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Nurses promote and protect patients’ rights, health, and safety by understanding privacy guidelines, consent, and the need for full disclosure and honesty when dealing with patients. Misconduct or other threats to patients’ well-being must be reported in a timely manner.

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Nurses are accountable for the care they provide their patients. They must ensure that their care aligns with professional guidelines, ethical concerns, and patients’ rights.

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Nurses must apply the same care standards their patients receive to self-care. Their responsibility to promote health and safety extends beyond the workplace to their homes and other settings. They have a duty to improve and adapt to maintain competence and grow in their profession.

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Nurses have a duty to maintain a safe work environment that promotes quality care to all patients. Institutions are responsible for outlining safety standards and enforcing ethical obligations of care to ensure optimal patient outcomes.

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In all the roles they play, nurses are charged with advancing the profession through research, development of professional standards, and creation of nursing and health policy. They must ensure that professional practice standards evolve as new healthcare approaches are developed.

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In collaboration with other healthcare professionals, nurses protect human rights, foster health diplomacy, and address healthcare inequities. As part of this process, nurses are obliged to commit to constant learning and preparation to respond appropriately to novel and unusual situations.

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Social justice principles must be integrated into a nurse’s practice and advocacy for equitable healthcare policies. By taking part in organizations and committees that acknowledge and address ethics issues, nurses strengthen their voices in calling for social justice.

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ANA describes the nursing code of ethics as “self-reflective, enduring, and distinctive.”

• It restates the nursing profession’s fundamental values and commitments.
• It identifies the boundaries of duties and loyalty.
• It explains how nurses’ roles extend beyond individual patient interactions.
• It addresses the many relationships nurses have with other healthcare professionals, patients’ families, and the public.
• It makes nurses more aware of the sociopolitical, economic, and environmental context of their profession.

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The fourth, fifth, and sixth principles in the nursing code of ethics address the boundaries that nurses must identify in their work.

• Limits are applied in their personal relationships with patients and co-workers.
• The boundaries can be difficult to maintain because nurses become involved in their patients’ lives at very stressful times.
• Nurses have a duty to ask co-workers and supervisors for help when unsure how to respond to situations that threaten professional boundaries.

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Advocacy for patients and for healthcare equity extends nurses’ roles into politics and policy. The COVID-19 pandemic has illustrated the often-heroic effort nurses put forth for patients. Michigan Medicine describes how nurses have adapted to new roles and have had their lives turned upside down by the coronavirus.

• Nurses have put together care packages and organized meals for their colleagues to boost morale.
• Reader’s Digest describes how school nurses are creating masks for students and teachers, while other nurses have traveled hundreds or thousands of miles to assist where the need is greatest.
• Home care nurses are finding their roles expand as they comfort their patients, many of whom are older people, as they struggle with isolation during COVID-19 lockdowns, as Fox 13 (KSTU-TV) reports.

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Until the middle of the 20th century, healthcare ethics received little attention. However, the importance of ethics in nursing came to the fore following World War II, as Medscape explains. The horrors of medical experiments that German doctors conducted during the war led to the Nuremberg Code and the birth of modern medical ethics, as the United States Holocaust Memorial Museum describes.

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The need for ethical guidance for healthcare providers was one factor that led to ANA being created in the late 1880s. The first version of the code was adopted in 1950, and the most recent update was published in 2015. The code is continually updated to address changes in the art, science, and practice of nursing and as awareness grows of the link between global health and social, political, and cultural equality.

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Medical ethics involve issues that may arise in treating individuals based on values, facts, and logic, as Medscape describes. Doctors in particular face ethical issues that relate to legal and economic issues, such as whether to withhold treatment because of cost, whether to cover up a mistake, or whether to practice defensively to avoid potential malpractice suits.

By contrast, nursing ethics focus on patients’ rights and well-being, the healthcare environment’s safety and quality, and the community’s public health needs. Ultimately the arbiter of what’s ethical in any healthcare situation is the caregiver, in consultation with the patient. Ethical decisions are as integral to patient care as clinical and technical ones.

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Even the most extensive code of ethics can’t account for all the potential dilemmas that nurses may encounter in their work. That’s the reason that one of the duties stated in the nursing code of ethics is to seek the advice and counsel of others whenever a nurse is uncertain about a medical decision’s ethical aspects.

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Nurses must obtain a patient’s informed consent before any medical procedure. As Medical Records Info explains, in addition to explaining all of a procedure’s risks and benefits, nurses must ensure that the patient is sufficiently competent to grant informed consent. Even being medicated can impair a patient’s ability to understand a medical decision’s consequences, which usually means the patient’s family or caretaker will decide on the patient’s behalf.

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Sometimes the advocacy role nurses perform becomes second nature. However, this can cause problems if nurses are overworked or unprepared, despite their best intentions. Advocacy extends to the duty of healthcare administrators to ensure that nurses are working in an environment that allows them to provide patients with the quality care they deserve.

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Often a nurse may inadvertently breach patient confidentiality by misunderstanding an action’s consequences. Nurses have a duty to protect sensitive health information, such as medical history, and in the course of dealing with family members, co-workers, and law enforcement officials, they must preserve patient autonomy and avoid oversharing personal information.

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In recent years, much more attention has been paid to the need for nurses to understand the cultural implications of their interactions with patients. Nurse Advisor highlights the many benefits nurses realize by improving their cultural competence.

• They pay closer attention to the verbal and nonverbal messages that patients and their families send.
• The more contact nurses have with people from different cultures and socioeconomic backgrounds, the higher quality care they can provide as they come to understand new social norms and belief systems.
• By communicating more clearly with patients from diverse backgrounds, nurses engender a sense of trust that allows patients to feel more confident in opening up to healthcare providers.
• As the pace of societal change increases, nurses are better equipped to adapt and modify the care they provide to meet the ever-changing needs of their patients.

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• American Nurses Association, Diversity Awareness — Expands on ANA’s social policy statement to address diverse populations’ needs.
• National Association of School Nurses, Cultural Competency Resources — Provides links to sites offering information on becoming culturally sensitive and aware.
• S. National Library of Medicine, “Resources for Ethical Decision Making” — Includes resources on ethics in clinical settings, in home settings, and in perioperative nursing practice.

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The ethical issues that nurses face can increase work-related stress. For example, at Nurse.com, one intensive care unit nurse describes the “moral distress” doctors and nurses feel when a patient’s requests or refusal of treatment are inconsistent with best medical practice and against the patient’s best interest. That nurse sees ethics expressed in the goal of finding the solution that brings about the optimal patient outcome. The solution must also be in line with the patient’s wishes.

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Understaffing and other issues beyond a nurse’s control can threaten the responsibility to ensure patient safety. Plos One reports on a study that connected a hospital’s financial performance with its performance in quality and safety analyses. The researchers found that hospitals with the highest financial performance scores had the lowest rates of 30-day readmissions and 30-day mortality, among other quality and safety benefits.

Nurses and other healthcare professionals have little control over their employers’ financial management; yet the responsibility to provide ethical care and treatment as equitably as possible becomes more important when treating disadvantaged populations and those with limited access to healthcare resources.

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Nurses must be aware of the breadth of their responsibilities, and they must determine their readiness to accept those responsibilities. Collegian presents a framework of nurses’ responsibilities where seven domains are intended to promote safety and quality in healthcare.

• Promotion of safety
• Evidence-based practice
• Medical/technical competency
• Person-centered care
• Positive interpersonal behaviors
• Clinical leadership and governance
• Patient perceptions of quality

To validate the domains, researchers solicited nurses’ descriptions of their responsibilities for safe and high-quality care to ensure that nurses’ perceptions match the expectations of their organization and profession.

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A nurse’s duty to serve as an advocate for patients is stated in the nursing code of ethics’ third provision, as well as in provisions 9.3 and 9.4, which extend patient advocacy outside the workplace to promote social justice in nursing and health policy. Nurse.com explains that advocating for patients includes raising alarms about the climate crisis, food safety, and violence prevention.

ANA encourages nurses to participate in community groups, join neighborhood organizations, or support candidates for local political office. Often it seems progress on matters related to community health comes slowly or not at all, but nurses are trusted and well-respected members of their communities, and their advocacy efforts can be fruitful in many ways.

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The nursing code of ethics closely resembles the American Medical Association’s Code of Medical Ethics, which covers patient-doctor relationships, consent and medical decision-making, privacy, genetics, end-of-life care, and many other issues. A burgeoning area of ethical concern is bioethics, which attempts to promote knowledge and awareness of connections between human life, science, and technology.

Bioethics combines philosophy, theology, history, and law with medical science, emphasizing the application of ethical principles in nursing and health policy. The Center for Practical Bioethics focuses on four domains:

• Aging and end of life
• Clinical and organizational ethics
• Life sciences
• Disparities of health and healthcare

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The earlier nurses begin thinking about nursing ethics, the more aware they become of the importance of integrating ethics into all aspects of the nursing profession. However, a recent study reported in BMC Nursing found that many nursing students minimize the importance of specific ethical values in nursing, such as discussing public policy decisions affecting healthcare funding, and participating in peer reviews.

Just as nurses have many ethical duties to their patients, co-workers, and communities, nurse educators and nurse leaders have a duty to prioritize training nursing students on the importance of ethics in all aspects of nursing practice.