The Top Ethical Challenges for Nurses

Ethical dilemmas can place nurses in situations where they feel moral distress because they feel they cannot do "the right thing." While some have the courage to speak up or take action, others do not.

“There is such a moral burden to witnessing the suffering of patients and trying to balance the suffering vs. the benefit and the complexity of decisions that can be made in the acute-care setting,” said Mary K. Walton MSN, MBE, RN, nurse ethicist at the Hospital of the University of Pennsylvania. “The basic questions are ‘What is the right thing to do?’ and ‘What makes it so?’”

One of the best parts of nursing is relieving the suffering of patients, but complex interventions often cause patients to suffer while restoring them to health.

“Being part of the implementation is a heavy weight when you are at the bedside,” Walton said.

Carol Pavlish, RN, PhD, FAAN, associate professor at the UCLA School of Nursing in Los Angeles, has studied ethical issues facing nursing RNs and has developed helpful strategies for helping them.

Ethical Dilemmas in Nursing Can Take Many Forms 

“Ethical dilemmas primarily had to do with watching patients suffer, which nurses find is unnecessary suffering,” Pavlish agreed. Nursing interventions may increase the patients’ suffering without necessarily improving an outcome.

Pavlish found nurses were concerned that patients and families were not fully informed about treatment options, their clinical prognosis and whether the patient voice was being represented. For instance, advance directives were not being followed because families wanted something else.

Nurses often come to Walton with concerns about informed consent, pain and going beyond a common goal, but dilemmas in nursing ethics are not limited to end-of-life care.

“The issue of moral distress is when they feel they know the correct action but cannot carry it out because of the organizational environment they are in,” said Connie M. Ulrich, PhD, RN, FAAN, associate professor of bioethics and nursing at the University of Pennsylvania School of Nursing in Philadelphia and author of Nursing Ethics in Everyday Practice. “It could be [from] a multitude of situations.”

Ulrich indicated that end-of-life issues arise as concerns, but ethical dilemmas also extend to the day-to-day issues of caring for patients.

The American Nurses Association (ANA) responds to members who write in about ethical issues in nursing and then tallies the queries to learn the most common ethical concerns in nursing. Martha Turner, PhD, RN-BC, assistant director of ANA’s Center for Ethics and Human Rights, reported that the work environment, integrating genomics and genetics into practice, and end-of-life issues and palliative care round out the top three ethical dilemmas.

ANA’s position statements on ethics and human rights can guide nurses and aid in their dealing with the ethical dilemmas they face in practice.

Nursing Ethics: The Work Environment  

Nurses report communication difficulties and workplace bullying and violence as serious work environment ethical dilemmas, Turner said.

“The hierarchy or work structure do not encourage conversations,” Pavlish added. She is developing models and tools to allow such discussions to take place so that everyone can feel comfortable speaking up.

“We are looking for ways that it becomes a community obligation to the patient, with collaboration in answering questions and talking about issues,” Pavlish said. “The work of ethics is dialogue.”

Patient Safety and Staffing

Patient safety and staffing issues also fall into the work environment category. Pavlish found nurses reporting they do not have the time to do what they intended for patients—helping them recover or adapt, or address patients’ emotional needs.

“They felt compromised and that some of their moral obligations were not being recognized by the system,” Pavlish said.

“They just don’t have the time,” Ulrich added. “How you prioritize those needs can be very stressful.”

As a result, nurses often come away from these situations feeling they failed hose patients who did not receive optimal care.

“You cannot change the tragedy,” Walton said. “I try to get them to refocus: ‘Did you fulfill your obligation? Did the patient or family feel cared for? Did you learn something?’”

Walton recommended nurses reflect on how they manage competing obligations and suggested nurses call on their team members, for example, to help them balance tasks and talking with patients who are upset. Priorities may change as new patients arrive or coworkers require assistance. As nurses develop and gain experience, they become better at managing these responsibilities.

Turner added that nurses “can be advocates for staffing in a way that is appropriate for the patient population and resolve issues when there is inadequate staffing.”

Social Media and Personal Boundaries

Social media and personal boundaries are part of the work environment nursing ethics. Technology keeps evolving and blurring traditional values about privacy and boundaries.

“Social media and the use of technology is a far more difficult problem for nurses, including what they post and the types of relationships they can have with patients,” Turner said.

Genomics and genetics

“The [genetic testing] technology should be available to everyone and not performed at random, but the workforce is not up to speed on those topics,” Turner said. “Many nurses and physicians graduated before these things were common.”

Yet, patients may have learned about their genetic profile through an online service, putting the clinician in an awkward position.

“Education about what is available and how it can be used appropriately, and without causing distress to patients, can help practitioners with this ethical issue,” Turner indicated.

Other Nursing Ethics Concerns 

“Cultural diversity, caring for people with different values and traditions, and accepting their rituals can present challenges in the practice setting,” Turner explained. Education can help address this type of scenario.

Access to affordable and equitable care presents ethical dilemmas for nurses as they work to make it a reality in their communities.

Nurses working in non-acute care settings, such as schools and prisons, have concerns related to bedside nurses but they can differ, Turner explained. For instance, some school nurses are now dealing with the fallout from legal actions in their states that now allow untrained laypeople to administer insulin and other medications to students.

“That becomes an ethical issue for nurses,” Turner said.

Additionally, parents opting to not vaccinate pose a challenge for school nurses.

How to Deal with Ethical Issues in Nursing 

Where can nurses find help for their ethical dilemmas? One place is The Hastings Center, a research institution

dedicated to bioethics that offers several helpful resources. In addition, universities often post beneficial information about nursing ethics topics that nurses can access. Topics in the ANA’s Online Journal of Issues in Nursing often cover ethical concerns.

“Ongoing education in ethics is encouraged,” Turner said. She explained that ethical concerns may change as the nurse matures in their role.

Ulrich discussed the importance of education in nursing programs to prepare undergraduate and graduate students for clinical practice.

“The Joint Commission requires nursing ethics resources be available to nurses-—be it a committee, an individual or a community organization,” Turner said. Additionally, the ANCC Magnet program requires ethics resources.

“Every hospital should have an ethics committee, and nurses need to have a voice in the decisions that are being made,” Ulrich said. “They can access an ethics committee to voice their concerns and get help.”

Ulrich also suggested providing unit-based ethics mentors who could help nurses think through the ethical dilemmas when facing them. She advocated for more creative solutions.

At Penn, nurses generate between one-third and one-half of the ethics consults.

“We help people refocus on the good they have done and how they fulfilled their moral obligation to the family,” said Walton, who added, “Being present and letting someone share their pain is a therapeutic intervention.”

Start a Conversation about Ethics in Nursing

“Communication is key for helping nurses work through ethical issues in nursing. In fact, having conversations with the healthcare team and holding family conferences can help ease the ethical conflict,” Pavlish reported.

“A lot of the distress people feel, even if they don’t agree with the advice they receive, is diminished if they have had an opportunity to communicate their view,” Pavlish added.

Walton made the argument for moral advocacy, speaking up and discussing options early.

“How do we talk about the hard stuff and share and invite our team members?” Walton said. “That is what mitigates moral distress.”