Common Ethical Issues in Nursing Practice
Registered Nurses (RNs) in every specialty will be challenged by an ethical issue or dilemma at some point. An ethical issue in nursing is a situation in which the nurse must make a choice between two “correct” but conflicting values: the values held by the nurse and the values of the other parties (the patient, the patient’s family, other healthcare staff, or some combination). A dilemma is then created because the decision ultimately doesn’t align with someone’s values.
RNs need to be able to identify these ethical issues and resolve them by utilizing the appropriate resources and maintaining a professional practice. At the same time, however, nurses should support the best outcome for the patient by being an advocate for their rights and respecting their cultural and individual needs. Navigating and subsequently achieving a satisfactory resolution in these ethical dilemmas can certainly pose a challenge, but are essential and core patient care skills for RNs.
The Code of Ethics in Nursing
The American Nurses Association (ANA) initially developed the Code of Ethics in Nursing in the 1950s. Over time, it has evolved to acknowledge and address the ever-broadening scope of nursing specialty areas, modern technological advances, revisions in general clinical and nursing policy, and the socioeconomic changes driven by an increasingly diversified national population. Its goal is to provide a structured, explicit set of ethical standards that clearly describe and define the nurse’s professional commitments, foundational values, expectations of duty, and boundaries of responsibility. The four core principles of nursing ethics as described by the ANA are autonomy, beneficence, non-maleficence, and justice.
Autonomy
Patients should receive and have access to all clinical information pertaining to their health status, including risks and potential complications, to make an informed and educated medical decision for themselves based on their personal values and beliefs. Frequently, this autonomy may conflict directly with established care guidelines or best practices; however, the patient has the right to refuse any treatment, including medication or even surgery, regardless of its potential health benefit. Nurses must honor those decisions with respect to the patient’s autonomy.
Beneficence
Beneficence can be defined as the promotion of goodness by acting on the intrinsic sense of love and compassion we have for our fellow human beings. Nurses demonstrate this beneficence by the thoughtfulness and kindness they show to patients, as well as in the respect they give to patients’ decisions and desires.
Non-Maleficence
All patients have a right to no harm. Non-maleficence is likely the most well-known nursing ethical principle, but it is also the most challenging to uphold. Nurses are bound by this principle to choose medical interventions that achieve the best outcomes while causing the least harm to patients– but are put in an ethical dilemma when, for example, a patient exercises their right to autonomy and refuses to take life-saving medication or undergo a treatment regimen.
Justice
RNs are required to provide the same level of care for every patient, regardless of their ethnicity or race, cultural background, gender, sexual orientation, religion, or financial situation. This type of ethical dilemma can often occur during patient triage scenarios, where nurses are required to decide which patient receives immediate medical attention over others.
Common Ethical Dilemma Situations
Ethical dilemmas present themselves frequently via patient interaction, but can sometimes occur through the nurse’s relationship with coworkers and other healthcare professionals. The most common ethical issues in nursing will involve:
Refusal of Medication or Life-Sustaining Treatment
Many patients who observe certain religions or ideologies will refuse a particular medical intervention or life-saving treatment. In this scenario, the RN should concentrate on educating patients to ensure a good understanding of the consequences of either rejecting or accepting treatment, while allowing them to practice self-care on their own terms, without judgment. Nurses can also advocate for their patients by encouraging the healthcare team to explore alternative treatment options that align with a patient’s beliefs.
Surrogate Decision-Making
Patients should be able to rely on RNs as healthcare professionals to help answer questions and guide them on what to expect during treatment courses. Patients must be empowered to be able to make their own educated healthcare decisions. However, if the patient is unable to make an informed decision regarding the course of their treatment, a surrogate is required to use their personal knowledge of the patient’s values and perspectives to determine the decision they would have made. Medical teams often look to the next-of-kin or other legally defined person as the surrogate to make medical decisions for the patient. Interpersonal relationships and conflicts in families can complicate the recognition and role of a surrogate decision-maker.
Advance Directive Planning and Do Not Resuscitate (DNR) Orders
Patient autonomy may challenge any medical directives, regardless of need or urgency. In fact, patients have a right to refuse any and all medical care. Thus, it is crucial for RNs to have a broad understanding of cultural differences, with insight into the particular patient’s situation, in order to effectively educate the patient on any medical necessity or course of treatment. Often, these scenarios involve having difficult conversations about advance directives, end-of-life options, and DNR status. Palliative care may frequently be presented as an option, but ultimately the patient, family, or surrogate must finalize the decision. Similar to surrogacy decision-making, end-of-life directives may be created by a patient, but healthcare providers must also work with the family of the patient. Sometimes what the patient wants and what the family wants are very different. When the patient isn’t able to speak for themselves, nurses can help navigate the best way forward.
Patient Privacy
RNs are obligated to treat the patient with the goal of achieving the best health outcome, which includes keeping patient medical and personal information private. While family members and others may be dutifully concerned and inquire about their loved ones, nurses should not release or disclose that information to unauthorized parties in the interest of protecting patient privacy.
Professional Nurse-Patient Boundaries
While warmth, friendliness, and empathy can positively impact the experience an RN can provide to a patient, a patient may try to cross the professional working boundary with their nurse. Patients must not depend on nurses beyond the scope of their professional capacity: anything more than a professional relationship creates ethical issues that can be very challenging to resolve tactfully. In these situations, a nurse manager should intervene when this boundary is crossed. Furthermore, RNs can benefit from establishing care routines that enable an appropriate and professional nurse-patient boundary early in their career paths.
Inadequate Staffing, Education, or Resources
Sometimes, RNs may be asked to take a patient or complete a task that they do not have the appropriate education, training, or resources to properly complete. RNs must speak up in these situations, especially nurses who are new to healthcare. Team leaders should also organize and provide training sessions for their staff to reduce inappropriate or unsafe nursing assignments.
Some facilities or units may face staffing shortages or have outdated equipment, which can impact the quality of patient care. Nurses who are asked to work in unsafe environments face an ethical dilemma of caring for their patients to the best of their ability or refusing to work in an unsafe manner. Nurse managers are encouraged to include staff in the shift planning and unit budgeting processes to empower nurses to suggest changes and understand demands.
Resolution Tips
All nurses will encounter ethical issues. Therefore it is vital for them to be able to identify the onset of an ethical issue, understand their personal perspective, explore professional policies and resources, and then resolve it appropriately. Nurses should draw on medical, legal, professional, and hospital guidelines when faced with an ethical dilemma. Ethical dilemmas can be intricate and complex. Only real-life situations with patients and nurse mentors will give nurses the experience it takes to properly address these issues as soon as possible. Unresolved issues often lead to stress, burnout, and professional or legal ramifications such as loss of nursing license or patient harm or death.
RNs should seek out nurses experienced in resolving ethical dilemmas, in addition to nurse leaders, for guidance. Those leaders should foster a culture and environment of unbiased learning, ongoing team training, open communication, and honesty without fear of reprisal. Many institutions also offer an ethical committee or team that can consult on complex ethical situations involving patients.
Additional Resources for Professional RNs
