Listening to nurses' moral voices: building a quality health care environment

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.     

临床护士道德困境的潜在剖面分析及其与道德敏感性的关系研究

目的 调查临床护士道德困境现况,分析临床护士道德困境的潜在剖面及其与道德敏感性的关系并探讨不同剖面的影响因素。方法 采取便利抽样法于2022年5月选取武汉市某三级甲等综合医院1 022名临床护士作为调查对象。采用一般资料调查表、护士道德敏感性量表、护士道德困境量表进行调查,以护士道德困境量表的4个外显指标进行潜在剖面分析,并用单因素分析、二分类Logistic回归分析进行统计分析。结果 1 022名临床护士的道德困境可分为“低道德困境型”（72.7%）和“高道德困境型”（27.3%）2个潜在剖面。道德困境的影响因素包括年龄、职称、道德力量与责任、道德负担感（P<0.05）。结论 临床护士道德困境水平处于轻度水平。护士道德困境可分为2个类别,护理管理者应根据不同剖面的人群特征制定针对性的干预方案,增强护士道德敏感性,降低其道德困境水平。针对“高道德困境型”护士,既要注意培养护士道德决策能力,也要充分营造良好的医院伦理氛围,合理授权,疏导其因道德困境产生的不良情绪;针对“低道德困境型”护士,要强化护士职业道德伦理再教育,提升护理道德修养,规范临床实践中的道德行为,从而改善护理质量。     

Is there a unique nursing ethic?

There is no agreement in the nursing literature as to the meaning of the term, nursing ethics. Proposed definitions refer to nurses' moral decision-making and behaviors, ethical conflicts, and analysis of ethical issues that arise within nurses' practice. Presumably, a distinct nursing ethic should address unique theories, standards, and inquiry into what comprises nurses' ethical behavior and study of how nurses actually behave and reason about ethical issues. The purpose of this column is to synthesize the dialogue regarding the potential existence of a unique nursing ethic, and to propose that such an ethic has yet to emerge.     

Does nursing need its own ethics?

In contrast to a medicine and medical ethics dominated by the physician, nurses claim more professional autonomy, domains of independent responsibility and recognition of their own moral judgment and ethical reflection. In my article I endorse these claims, but I object to the widespread opinion that their fulfillment requires a nursing ethics of its own, in the sense of a specific moral theory for nursing. Such a "special ethics" would be counterproductive to the concerns of nurses, and just as mistaken as a special medical or physicians ethics. Instead, a critique of medicine on the basis of a general ethics is required both for nurses and physicians. Part I presents arguments against mistaken conceptions of a special nursing ethics. Part II outlines elements of a general ethics for medicine and nursing. Part III explains my understanding of an ethical critique of medicine, which is founded upon the distinction of three conceptual dimensions of medicine: as science, institution and practice. This critique focuses the ethical attention on the life situation of the patient. Consequences for argumentative support and political fulfillment of the nurses' claims mentioned will thereby become evident.     

Expanding nurses' participation in ethics: an empirical examination of ethical activism and ethical assertiveness

This research project investigated the extent to which nurses engage in two important kinds of ethical behaviours: ethical activism (where they try to make hospitals more receptive to nurses' participation in ethics deliberations) and ethical assertiveness (where they participate in ethics deliberations even when not formally invited). This research probed not only the extent to which nurses engage in these ethical behaviours but also whether this is influenced by professional, training and organizational factors. A random sample of 165 nurses from three major hospitals in Los Angeles provided the data. Regression analyses indicate that both ethical activism and ethical assertiveness are strongly influenced by nurses' perceptions of the receptivity of hospitals to their inclusion in ethics deliberations. In addition, nurses' education in ethics is a significant predictor of ethical activism. The findings have important implications for the content of nurses' ethics training as well as for expanding the boundaries of nurses' participation in ethics deliberations. The authors define ethics deliberations as specific meetings of a number of people to discuss an ethical issue, such as one regarding the care of a patient.     

Exploring the heart of ethical nursing practice: implications for ethics education

The limitations of rational models of ethical decision making and the importance of nurses' human involvement as moral agents is increasingly being emphasized in the nursing literature. However, little is known about how nurses involve themselves in ethical decision making and action or about educational processes that support such practice. A recent study that examined the meaning and enactment of ethical nursing practice for three groups of nurses (nurses in direct care positions, student nurses, and nurses in advanced practice positions) highlighted that humanly involved ethical nursing practice is also simultaneously a personal process and a socially mediated one. Of particular significance was the way in which differing role expectations and contexts shaped the nurses' ethical practice. The study findings pointed to types of educative experiences that may help nurses to develop the knowledge and ability to live in and navigate their way through the complex, ambiguous and shifting terrain of ethical nursing practice.     

An ethical framework for nursing service administration

Nurses as administrators are responsible for creating an ethical work environment in which nurses' human welfare is promoted. Bureaucratic organizations can dehumanize people, wherein human welfare suffers in the midst of institutional constraints. Amid these conditions nurses' ethical competence cannot develop nor can nurses maintain a sense of personal integrity. Applying concepts from nursing and general ethics to administrative practice provides a basis for developing an ethical framework for management. The proposed framework involves ethical awareness, principled reasoning, moral commitment to the profession and to one another, and primary consideration for human welfare with strategies to promote it. Use of these components when making decisions in daily practice and on a policy level enhances the well-being of nurses working in organizations.     

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

Many studies have examined clinical and institutional moral problems in the practice of nurses that have led to the experience of moral distress. The causes and implications of moral distress in nurses, however, have not been understood in terms of their implications from the perspective of virtue ethics. This paper analyzes how nurses reach for the telos of their practice, within a context of moral distress. A qualitative case study was carried out in a private hospital in Brazil. Observation and semi‐semistructured interviews were conducted with 13 nurse participants. With the aid of ATLAS.ti software, the data were analyzed by using thematic content analysis using virtue ethics to theorize the findings. These nurses experienced a loss of their nursing identity as they encountered an ambiguous telos and the domination of institutional values. In their reach for the telos of their practice, nurses found an environment permeated by ethical challenges, which not only created moral distress but also created professional invisibility, a phenomenon referred to as ‘invisibility of the self’.     

Professional values and norms for nurses in Belgium

Because of their responsibilities for providing high-quality care, at times when they are continuously confronted with inherent professional and ethical challenges, nurses should meet high ethical standards of practice and conduct. Contrary to other countries, where codes of ethics for nurses are formulated to support those standards and to guide nurses' professional practice, Belgian nurses do not have a formal code of ethics. Nevertheless, professional ethics is recognized as an important aspect in legal and other professional documents. The aim of this article is to illustrate that codes of ethics are not the only professional documents reflecting nurses' values, norms and responsibilities. Other documents can also set out professional nursing ethics, and as such replace codes of ethics.     

A comparative study of Chinese,American and Japanese nurses' perceptions of ethical role responsibilities

This article reports a survey of nurses in different cultural settings to reveal their perceptions of ethical role responsibilities relevant to nursing practice. Drawing on the Confucian theory of ethics, the first section attempts to understand nursing ethics in the context of multiple role relationships. The second section reports the administration of the Role Responsibilities Questionnaire (RRQ) to a sample of nurses in China (n = 413), the USA (n = 163), and Japan (n = 667). Multidimensional preference analysis revealed the patterns of rankings given by the nurses to the statements they considered as important ethical responsibilities. The Chinese nurses were more virtue based in their perception of ethical responsibilities, the American nurses were more principle based, and the Japanese nurses were more care based. The findings indicate that the RRQ is a sensitive instrument for outlining the embedded sociocultural factors that influence nurses' perceptions of ethical responsibilities in the realities of nursing practice. This study could be important in the fostering of partnerships in international nursing ethics.     

Bridging Western ethics and Japanese local ethics by listening to nurses' concerns

Among Japanese nurses ethics is perceived as being distant and unrelated to their practice, although this is filled with ethical concerns and the making of ethical decisions. The reasons for this dissociation are the primacy of western values in modem Japanese health care systems and the suppression of Japanese nurses' indigenous ethical values because of domination by western ethics. A hermeneutic study was conducted to listen to the ethical voices of Japanese nurses. Seven ethical concerns were revealed. Although some of these concerns may seem to share similar values with western ethical principles, the basis for the concerns was unique and rooted in the Japanese cultural value system. The meanings of each concern are explicated in conjunction with related background meanings. Listening and trying to understand these nurses' voices in their own context suggests a way of bridging the gap between abstract and universal ethics and practical and local ethics.     

Articulating a policy resolution for sexual diversity research: nurses as moral agents.

This case study of community nurses in the Canadian province of Ontario explores the relevance of power relations to nursing ethical inquiry. Public health nurses critically reflected on their role in challenging social inequities as they generated evidence to inform practice. In the process, they developed a policy resolution articulating values and principles for ethical nursing research with diversely situated sexual minorities.The author uses a qualitative case study design and applies a feminist bioethics framework using critical literature to analyze this document and the practice context.The findings suggest that dynamics of power, including gender, influence nurses' ability to advocate for sexual minorities through research, prompting the development of a public statement on knowledge production. There are implications for undertaking nursing ethical inquiries that explore how dominant and counter-discourses and multiple dimensions of power shape nurses' moral agency in challenging the status quo.     

Nursing resistance as ethical action: literature review

BACKGROUND: Much has been written about nursing as a predominantly female profession whose members display passivity, submission, obedience and powerlessness. Alternatively, some authors have presented evidence of nurses' capacity to exercise power, revealing the possible relationship between powerlessness and ethical compromise. Thus, empowerment strategies for nurses can yield ethical action. AIM: The aim of this paper is to use analysis of the literature to demonstrate how the actions and responses of nurses to ethical concerns are examples of nurses exercising power. METHOD: Empirical studies published in the nursing literature between 1990 and 2003 have been analysed to illustrate how nurses' actions of resistance can ensure that moral values are realized in practice. Foucauldian notions of power relations and feminist ethics provide the theoretical framework. CONCLUSIONS: Nurses were found to resist in situations where they experienced moral conflicts in relation to the actions of health professionals; however, instances were cited where they did not. Consequently, strategies for nursing education and management are proposed to increase nurses' understanding of the potential acts of resistance that they could employ in situations of moral conflict or concern.     

护理人员照顾临终患者时的伦理困惑和应对方式

目的探讨临床护理人员照顾临终患者时所经历的伦理困惑和应对方式。方法运用现象学方法,对上海4个不同等级医院的25名护士进行深入访谈。结果护理人员遭遇的伦理困惑主要包括"减轻痛苦"与"延缓生命""生命价值"与"医疗资源不足""代理人行使知情同意权"与"医疗干预权"之间的不同立场和伦理决策取向。应对方式包括:耐心沟通并与患者家属达成共识;无力改变患者家属的决定,选择接受,自我调适;遵循规章制度,依赖团体决策等。结论本文对产生伦理困惑的原因进行了阐释和分析,对如何提高护理人员应对能力给出了建议,为临床护理伦理决策提供了参考和依据。     

Invisibility, moral knowledge and nursing work in the writings of Joan Liaschenko and Patricia Rodney

The ethical 'eye' of nursing, that is, the particular moral vision and values inherent in nursing work, is constrained by the preoccupations and practices of the superordinate biomedical structure in which nursing as a practice discipline is embedded. The intimate, situated knowledge of particular persons who construct and attach meaning to their health experience in the presence of and with the active participation of the nurse, is the knowledge that provides the evidence for nurses' ethical decision making. It is largely invisible to all but other nurses. Two nurse researchers, Joan Liaschenko of the University of Minnesota and Patricia Rodney of the University of Victoria, have investigated the ethical concerns of practising nurses and noted in their separate enquiries the invisible nature of critical aspects of nursing work. Noting the similarities in their respective observations, and with the feminist ethics of Margaret Urban Walker as a theoretical framework, this article examines the concept of 'invisibility' as it relates to nursing work and nursing ethics.     

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer.

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.     

Ethical practice in nursing: working the in-betweens

BACKGROUND: While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. PURPOSE: With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. DESIGN AND METHODS: Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. FINDINGS: The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. CONCLUSIONS: Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.     

Nurses' views on ethical codes: a focus group study

AIM: This paper reports a study exploring nurses' views on the 'potential' content and functions of an ethical code for nurses in Belgium. The term 'potential' is used, because Belgian nurses do not have experience with an ethical code. BACKGROUND: Ethical codes have been developed to guide nurses' practice and to improve their professional status. Little empirical research, however, has been undertaken to determine nurses' views on the content and functions of these codes. The available quantitative studies merely give some information on nurses' (lack of) knowledge and use of their ethical code. No nursing ethical code currently exists in Belgium. Qualitative research exploring nurses' views, therefore, was needed in order to find out which functions an ethical code could fulfil and what the code's content could be. METHOD: Eight focus groups were conducted with 50 nurses in different healthcare settings in Belgium. Data were generated during 2003. FINDINGS: According to participants, an ethical code could fulfil several functions, including supporting their professional nursing identity (external function) and giving guidelines for nursing practice (internal function). In addition, some aspects of content were mentioned, including nurses' responsibilities in a relational context: particular attention should be paid to the personality of the nurse and to the specificity of nursing as a relational activity. Most agreement was reached on the 'ethical' function of the code, namely guiding nurses' professional moral practice. Regarding disciplinary use and the need for legalization of the ethical code, on the contrary, opinions were divergent. CONCLUSIONS: It is of utmost importance to take into account nurses' views when developing an ethical code for their profession. This study gave a first picture of the views of nurses themselves. These initial findings should be completed with nurses' views on the formulation, dissemination and promotion of the ethical code. Such evidence-based development of an ethical code will probably give more guarantees that the code will meet nurses' expectations and will function optimally.