Factors that Influence Ethical Decision Making in Nursing

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Abstract

Modern nursing demands that todays nursing professional include a few universal characteristics that have become expected among fellow nurses across the country. Today nursing is expected to have an accreditation process for education, an impartial system for licensure and certification, but most importantly, a code of ethics that is implemented as the foundation of the nursing profession. This paper is set out to review various factors that influence ethical decision making in nursing and consider actions that may improve ethical decision making by professional nurses.

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Ethical considerations in Nursing

The Merriam-Webster Dictionary defines ethics as; “the discipline dealing with what is good and bad and with moral duty and obligation”. A lay explanation of ethics would be how we should treat each other, how we should act, what actions we should or should not take, and why. Our laws and policies are driven primarily by the candle light of ethics, but in nursing there are countless decisions that do not fall directly upon an established law or regulations.

As science and technology progress at a pace that often exceeds policy making, the professional nurse is expected to continue making the correct ethical decision.

Research/Articles

For researching this topic, the sources of information that were primarily used are The American Journal of Nursing website and The Journal of Nursing Education and Practice International Peer-reviewed and Open Access Journal for the Nursing Specialists website to search peer reviewed nursing articles. One such article that was reviewed was titled Adopt Zero Tolerance for Hospital Staff Bullying Nursing Students by John Burkley.

Burkley is bringing awareness to the practice of current working practicing RN’s bullying nursing students. He says by impart his concern is overall staff incivility and uses examples such as staff members being exclusionary, hostile or rude, or dismissive toward students. Burkley provided a personal story with him as an instructor about the interaction between him as a clinical instructor nurse, a working registered nurse at a clinical site and a student nurse. The eventual conclusion was that because of a negative interaction of one practicing RN, one of the students concluded nursing wasn’t for them while the other declared they would never work at that hospital. This article set the pace for negative stress in nursing starting in the educational stages of a nurse’s career before he/she is even a nurse!

Burkley proposes that certain behaviors of nurses toward student nurses disregards the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements. He believes that this code is ethics is violated anytime a practicing nurse fails to create an ethical environment and culture of civility and kindness, treating colleagues, co-workers, employees, students, and others with dignity and respect. I agree with his thoughts wholly. All nurses initial practical view as a practicing professional nurse comes from their first act of practice. This act is always under the guidance of established practicing nurses. What message are we as nurses sending if we don’t abide by ethical standards with impressionable future nurse?

Another such article was The influence of Ethics Education on Awareness of Nursing Students with no Clinical Experience Regarding the Code of Ethics: A Case Study by Se-Won Kang. In this article the author explored the uses of situational awareness as it applies to ethical issues in nursing. As Kang explains, correct situational awareness lends itself to solving ethical dilemmas. This is done by creating a framework for assessment, application, and reflection for nurses at all levels within any organizations.

Kang notes the loss of situational awareness often exacerbates ethical dilemmas. Because ethical dilemmas are often open for interpretation, when a problem arises that require an ethical decision to be made, the nurse usually falls back on his/her personal values. By being situationally aware the author proposes the nurse will have more data and information at his/her disposal which will aid in making the proper ethical decision when the time comes.

Kang also points out the purpose of consistent situational awareness is that the nurse can’t predict when he/she will be called upon to make an ethical decision, so it is important to be aware of his/her environmental situation to have the maximum amount of data needed whenever the situation may arise.

To put this theory through the test, ethics education was given to 48 sophomore nursing students with no clinical experience. After the ethics education was given it was found that the nursing students’ awareness regarding the code of ethics was raised. Awareness of the code of ethics is essential to maintain moral standards of professional behaviors required for professional nurses. Therefore, it would do well for future generations that ethics education be implemented. Ethics education aids in building a desirable ethical value system among future nurses and enables them to ethically practice by improving their moral judgment and sensitivity, through education of situational awareness.

Another article that touches on this subject is; Understanding how student nurses experience morally distressing situations: Caring for patients with different values and beliefs in the clinical environment by Mary Jo C Stanley, and Nancy J. Matchett. In this article concepts surrounding morality in the context of stressful situations and ethical decision-making are discussed. Stanley, and Matchett set out to understand how student nurses experience morally distressing situations during clinical rotations by caring for clients with different values and beliefs than their own. The article relied on the stories of eight student nurses. Findings of the article suggest there is a unspoken form of moral distress that often goes unreported in the modern nursing culture and that stress differs from the classic definition of distress. While moral as we traditionally know it still exist, Stanley, and Matchett suggest personal conflict as a result of differing value systems between the nursing student and client may result in a moral challenge within nursing students as each of those students work with culturally diverse patients.

Stanley, and Matchett agreed with my earlier article that ethics education is needed in nursing school. The suggestion is that ethics education would reduce moral distress in the clinical environment when differing value systems between the nursing student and client exist. Just as new nurses develop their clinical skills, nurses should also practice developing their moral reasoning skills. To do this nurses need strong ethical nurse educators to guide them through this journey. Another reason why my first article was so egregious.

Following up on that article from 2014 I read Mary Jo Stanley wrote a later article titled Understanding how patient’s personal value systems challenge nurses’ views when providing care. This article was solely written by Mary Jo Stanley without co-author and was somewhat of a follow up article from her prior 2014 article of similar content. This article by Stanley was written in 2018 with four years of retrospective thought process behind it. In this article Stanley presupposes that differences in value systems can and often do become a moral challenge for nurses when caring for clients with different cultures and beliefs than their own. This conflict often results in distress. In my opinion she rightly assumes that it is inevitable that there will be differences in values systems between the nurse and client and that these moral conflicts could be distressing. This article presupposes this sentiment and set out to explore why this conflict challenges our ethical decision making.

The Moustakas phenomenological approach was used to uncover the meaning from ten nurse’s stories about morally challenging situations. Only two of the ten nurses wrote about their experiences; one worked in a busy emergency department and the other nurse worked in a rural community setting.

Stanley identifies four themes: differences, moral code, weight of the transgression, and internal resolution. When nurses shared their stories of caring for patients with different values and beliefs other than their own, they commonly reported the feeling of a value system conflict.

Stanley believes that nurses may be challenged to care for patients who have different cultural practices than themselves and when this situation arises then value system conflicts may cause strife for nurses who have different beliefs than the patients they care for. To plan for this inevitable conflict, Stanley suggest that future teaching institutes include this differentiating value/belief system conflict in a teaching simulation. The suggestion is that the use of training simulations can assist nurses to work through these morally challenging situations. This to many is a wonderful idea as many nursing students report that simulations vastly improve their confidence in clinical settings. Adding this element would be a great layer to already learning rich simulations. But what do working nurses today say are causing them moral distress?

In an article titled; Registered nurses’ perceptions of moral distress and ethical climate.Nursing Ethics Moral distress is a phenomenon of increasing concern in nursing practice, education and research by Bernadette Pauly, Colleen Varcoe, Janet Storch and Lorelei Newton, these three authors set out to review a study where a randomly selected sample of registered nurses were surveyed using Corley's Moral Distress Scale and Olson's Hospital Ethical Climate Survey. The registered nurses that responded to the survey (374 in total) reported moderate levels of moral distress intensity.

Researchers found that moral distress frequency was positively correlated with moral distress intensity and a poor ethical climate. The same researchers found that ethical climate was found to be a predictor of moral distress intensity for perspective nurses.

Thirty-eight points of nursing interest were surveyed including actions such as “give medication intravenously during a Code with no compressions or intubation and ‘ask the patient’s family about donating organs when the patient’s death is inevitable” On the scale of 0–6, with 0 being no stress 6 being the highest stress, the mean moral distress intensity was 3.88. The item with the highest score was ‘work with levels of registered nurse staffing that I consider unsafe’ (intensity 4.63). Levels of staffing and competency of self and other health care providers had the highest scores associated with moral distress based on this survey.

This study was primarily informational and didn’t have an ultimate conclusion outside of raw data that was received but is an important article none the less and should contribute greatly to the ever-important study of moral distress with nurses because examining the study and eventual resolution of moral distress in relation to the ethical climate has potential benefits for both nurses and patients.

The impact on patients regarding ethical and moral dilemmas are at the foremost of all nursing actions. We aren’t working on diseases, or even patients, we are caring for and serving people. We are serving mothers, daughters, fathers, sons. And all clinical decisions should be made through the lens of ethical decision making.

I work at Cox health and their Compliance & Ethics department mission is “to be there for those that need us by teaching how to make better decisions and report concerns, guiding you by being a resource to answer your questions, and protecting those we service by staying informed, auditing our business practices and ensuring compliance with state and federal regulations and CoxHealth policies” This statement supports the philosophy of the authors in each of theses articles, which is to breed a climate of support for ethical decision making. Ultimately this generation of nurses should concern themselves with helping the next generation of nurses improve their ethical decision making and that generation of nurses should repeat.