Unity of knowing and action- exploring moral courage in nursing practice

Ethics is a core value of nursing, and hospital nurses will try, as much as possible, to be "good" in terms of established nursing ethics and values. Nurses learn the value of providing "patient centered care" in school and try to establish relationships of trust with their patients in clinical settings. However, the realities of working in the hospital teaches nurses that actual situations are complex to the point of inducing "ethical dilemmas" and "moral distress" because of the many factors that affect medical decisions regarding individual patients. If nurses could follow their conscience in managing difficult ethical situations with moral courage, they would promote the value of "good nurse" which is innate in both nurses and society. This article defines the parameters of conscience and moral courage, the conditions such should exhibit, strategies nurses should consider, and appropriate nursing training methods. The authors hope to help foster the development of moral courage and create positive practice environments for nursing staff.     

Informed consent and the elderly. An ethical challenge for critical care nursing

Nursing ethics was long reticent about ethical challenges that elderly patients pose for critical care nursing. One of these, the legal doctrine of informed consent, has important implications for critical care nursing ethics. Deriving from the principle of respect for persons and intended to preserve their autonomy, informed consent represents both a duty and an ideal for care givers to implement in the process of ethical decision making. All too often the ideal is lost, however, and the doctrine reduced to a sterile and bureaucratic procedure. When elderly patients are unable to give an adequately informed consent, advance directives can enable them to express their wishes by prior choosing. If they become cognitively impaired, however, it is much more difficult to determine what, if any, preferences such a patient might express if able to do so. Medical empowerment of the elderly, a laudable social goal, can be as contradictory as informed consent itself and many elderly patients may opt out of their own decision making. The resultant moral distress of such a complex process is still another ethical challenge that faces the critical care nurse. Because nursing holds a position of moral centrality among the health care professions, critical care nurses cannot avoid the prospect that issues like those identified in this article will continue to challenge and confront them in the coming decade. By turning to colleagues in nursing as well as other professions, nurses can best strengthen and consolidate their vital role as mediators of meaning and morality in life-and-death situations.     

Recovering ethics after 'technics': developing critical text on technology

Much modern science and ethics debate is on high-profile problems such as animal organ transplantation, genetic engineering and fetal tissue research, in discourse that assumes technical tones. Other work, such as narrative ethics, expresses the failed promise of technology in the vivid detail of human experience. However, the essential nature of contemporary technology remains largely opaque to our present ethical lens on health care and on society. The limited controversies of modern science and ethics perpetuate 'technics', a technical, problem-solving mindset that fails to grapple successfully with the complexity of technology. A critical dialectic between practice and scholarship widens the ethical conversation in nursing to consider technology as an ongoing set of daily and fundamental moral choices on how we live. Critical text on technology recovers ethics from the limits of technics, and assists nurses to develop an inherent knowledge of technology that is needed to provide ethical care in a technological world. There are overlooked ethical challenges in the mundane, everyday routine activities of professional practice, and these have gone largely unexamined. Ethical behavior is not the display of one's moral rectitude in times of crisis. It is the day-to-day expression of one's commitment to other persons and the ways in which human beings relate to one another in their daily interactions.     

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.     

Ethical dilemmas and moral distress in oncology nursing practice

Although ethical values and principles guide oncology nursing practice, nurses often are challenged to fulfill every professional core duty and responsibility in their everyday practice. Nurses commonly encounter clinical situations that have ethical conflicts, and they often have difficulty recognizing and articulating them. Unresolved conflicts can cause feelings of frustration and powerlessness, which can lead to compromises in patient care, job dissatisfaction, disagreements among those in the healthcare team, and burnout. This article reviews the ethical principles and values individual nurses bring to their practice as well as those basic to the profession of nursing. This article also discusses ethical conflicts in oncology practice and describes how nurses, especially students and novice nurses, may react to such situations with moral uncertainty or distress. In addition, a process for analyzing and resolving ethical problems in clinical situations is outlined. Increasing awareness and dialogue about ethical issues is an important first step in the process. Additional resources in the clinical setting may encourage nurses to actively participate in ethical decision making and take deliberate action as moral agents.     

Professional competence and palliative care: an ethical perspective

The aim of this article is to explore an ethical view of professional competence by examining the professional competence of physicians in the context of palliative care. A discussion of the four dimensions of professional competence--knowledge, technical skills, relationships, and affective and moral attitude--leads us to the conclusion that "habits of mind" are important in every aspect of professional competence. This observation is then considered in the context of virtue ethics and ethics of care. Virtue ethics focuses on personal qualities and moral attitudes, while the ethics of care concentrates on the way these qualities are lived out in specific care relationships. Our conclusion points up the importance of education in ethics in the development of professional competence, and argues that because palliative care involves intense human interactions, integrating palliative care into the medical curriculum may improve the ethical culture of health care as a whole.     

Relational and embodied knowing: nursing ethics within the interprofessional team

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as 'unique' within the context of an interprofessional team will be explored. We suggest that nursing's distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care.     

Value analysis: a method for teaching nursing ethics and promoting the moral development of students

In an investigation of junior-level baccalaureate nursing students, the value analysis teaching strategy was used to teach content related to nursing ethics. It was hypothesized that such a strategy, which emphasized the need for careful evaluation and weighing of facts preparatory to drawing conclusions, would impact on the student's level of cognitive moral development. Cognitive moral development was defined in accord with Kohlberg's theory of moral development. Control and experimental populations were derived from two groups of students sequentially enrolled in the same course. Pre- and post-testing using scores on Rest's Defining Issues Test (DIT) showed significant differences in gain between control and experimental subjects. There was a strong association between DIT score gains and self-report of peer discussion of ethical issues. The major implication of this study is that instructional intervention produces measurable change in some students' level of moral judgment.     

In the spirit of creativity: the learning and teaching of ethics in nursing

AIM: This paper discusses the development of a pedagogy that nurtures not only the caring and the critical, but also the creative spirit of nursing. To explore the idea of creative pedagogy the learning/teaching of ethics in nursing is considered. BACKGROUND: Based on the understanding of ethics as a deeply personal process that is lived in the complexity and ambiguity of everyday nursing work I describe a pedagogy that seeks to support students to 'become' moral agents -- to see ethics as something they are, not merely as something they follow, and 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 example of one student's experience is used to illustrate how a pedagogy of creativity can promote the development of students' creative capacity in their everyday ethical practice.     

New developments in international nursing ethics

This article has described numerous activities in nursing ethics at international levels. It acknowledges the larger context within which nurses practice by focusing on selected issues involved in resource allocation and death and dying, cross-culturally. The questions raised about universally shared moral principles reflects the larger questions of cultural and ethical relativism. The discussions of new developments in international nursing ethics focuses on international conferences, the teaching of nursing ethics, national nursing associations, and other professional groups that are actively involved in health care or nursing ethics. Finally, the development of international nursing ethics research studies is providing new knowledge about the scope of ethics within nursing and the nature of nursing care worldwide. Nurses are involved in some aspects of these new developments in nursing ethics in all countries. As they examine and reflect on ethical principles, virtues, and on an ethics of caring, they bring a new dimension to their work as nurses. This new dimension stands as one of the oldest and most central foundations in professional nursing.     

Ethical challenges in the care of older people and risk of being burned out among male nurses

Aim. The aim of this study was to illuminate the meaning of being in ethically difficult situations when caring for older people, as experienced by male nurses. Background. Nurses and physicians are frequently faced with ethical issues and challenges in their work with older people in hospitals. Male nurses are a minority group in the nursing profession, thus it is important to listen to their lived experiences of the ethical challenges they are faced with in their work. Method. The study is part of a comprehensive investigation into the narratives of female and male physicians and nurses, concerning their experiences of being in ethically difficult care situations in the care of older people. Five male nurses working at gerontology wards at a university hospital in Norway participated in the study. A phenomenological hermeneutical method was applied. Results. The narratives revealed that the nurses were focusing on good nursing, emphasizing what meeting the patient entails. They highlighted what they perceived as barriers to good nursing. A third theme was ethical challenges, which lead to emotional and moral strain and a fear of becoming burned out. Conclusions. Continuous stress, little degree of autonomy and high expectations of oneself are causing the male nurses much moral strain. These factors place them at risk of being burned out. The nurses emphasized that burn out can be counteracted by clinical supervision. Relevance to clinical practice. It is suggested that the male nurses feeling of doing an important and rewarding job may be essential for protection against becoming burned out and why they can endure being in ethically difficult care situations. Other institutional support structures like ethics education and ethics rounds are suggested to reduce the level of moral strain.     

Caring about--caring for: moral obligations and work responsibilities in intensive care nursing

The aim of this study was to analyse experiences of moral concerns in intensive care nursing. The theoretical perspective of the study is based on relational ethics, also referred to as ethics of care. The participants were 36 intensive care nurses from 10 general, neonatal and thoracic intensive care units. The structural characteristics of the units were similar: a high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses. The data consisted of the participants' examples of ethical situations they had experienced in their intensive care unit. A qualitative content analysis identified five themes: believing in a good death; knowing the course of events; feelings of distress; reasoning about physicians' 'doings' and tensions in expressing moral awareness. A main theme was formulated as caring about--caring for: moral obligations and work responsibilities. Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses. In conclusion there is a need to support nurses in difficult intensive care situations, for example, by mentoring, as a step towards developing moral action knowledge in the context of intensive care nursing.     

An overview of nursing ethics for nurse educators.

Nursing ethics is a topic included in most health care institutions as a requirement for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This article provides an overview of nursing ethics in a format that allows the reader to understand the basic principles while applying the information to daily work situations in a format for use in a classroom environment. The issue of dilemma recognition is addressed as well as mechanisms that may be used to facilitate dilemma resolution. Information is also provided for use in the development of skills in ethical decision-making.     

Ethical Dilemma and Moral Distress: Proposed New NANDA Diagnoses

PURPOSE: To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. SOURCES USED: Journal articles, books, and focus group research findings. DATA SYNTHESIS: Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. CONCLUSION: The two proposed NANDA diagnoses fill a void in current standardized terminology. PRACTICE IMPLICATIONS: It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.     

The ethics of nursing care and 'the ethic of care'

Recent discussions concerning the ethics of nursing care have gained added impetus from articulations of die so-called 'ethic of carersquo; in moral philosophy. This paper addresses the question of recognizing and elaborating the ethics of nursing care by exploring the problems and the possibilities of diese intersecting discourses. In the first part of the paper it is argued that appropriation of 'the ethic of care' by nursing theorists as the central value of nursing, in contradistinction to other moral values such as beneficence or justice, runs the risk of reinforcing the conventional approaches to ethics that 'the ethic of care' seeks to overturn. Central to 'the ethic of care' is the recognition that caring entails a focus on the particularities and context of the relationships in which it is expressed. Accordingly die application of a unitary concept of care to the context of nursing relations may seriously distort dieir diverse and complex-specific ediical possibilities. The dynamic complexity of nursing ethics may be more adequately understood by working through an array of specific examples of nursing practice highlighting the differences and similarities between them and other ethical practices of care. Experience of a set of examples in this way will draw attention to the multiplicity, ambiguity, and particularity of the ethics of nursing while facilitating the ability to recognize how other practices may or may not be understood as examples of ediical nursing care. In the second part of the paper a beginning is made on this project by addressing the work of several different theorists of care who have examined different practices of nursing from the overlapping perspectives of nurses, patients and the socio-historical construction of their relationships.     

Exploring ethics in practice: creating moral community in healthcare one place at a time

Examining everyday ethical situations in clinical practice is a vital but often overlooked activity for nursing leaders and practitioners, as well as most other healthcare professionals. In this paper, we share how a series of practitioner-led Ethics in Practice sessions (EIPs), which originated within a busy urban teaching hospital, were adapted and translated, first into home care and more recently, into an EIP session for public health nurses. The success of EIP sessions rests with their focus on issues that are selected by practitioners. The aims of EIPs are to foster ethical leadership within communities of practice, create safe places to share concerns, use relevant research evidence and other literature to support informed discussion, and generate stories that deepen our understanding of the ethical situations we encounter in our work. We hope our experience inspires nursing leaders, nursing colleagues and fellow healthcare professionals to consider using the EIP approach to build moral community and the idea of moral imagination with their clinical colleagues, one place at a time.     

Is there a distinctive care ethics?

Is it true that an ethics of care offers something distinct from other approaches to ethical problems in nursing, especially principlism? In this article an attempt is made to clarify an ethics of care and then to argue that there need be no substantial difference between principlism and an ethics of care when the latter is considered in the context of nursing. The article begins by considering the question of how one could in fact differentiate moral theories. As is explained, this cannot be done merely in light of the moral judgements they defend, nor their ontological commitments (e.g. their view of the nature of persons). Following these methodological beginnings, care-based ethics is described and critically discussed. It is shown that ontological commitments embraced within care ethics do not themselves show that care ethics is distinct from other approaches. The idea of 'psychological care' is also discussed, which stems from the work of Margaret Little. Her claim that the 'gestalts' of justice and care cannot be combined is rejected in favour of an approach that does just that and which has been developed by Joan Tronto. It is then claimed that the moral commitments of principlism are certainly not incompatible with those of an ethics of care in the nursing context. A challenge to the idea that principlism and ethics of care might be compatible is anticipated in the work of Eva Feder Kittay. This challenge is responded to and it is concluded that care considered as a moral orientation and the moral values embedded in principlism are best combined in the nursing context. Care provides a moral orientation over which the obligations referred to in principlism can be laid.     

Compassion: a concept analysis

Compassion is a quality deemed sine qua non for nursing and claimed to underpin the profession in its larger-than-life scope. Yet the meaning of the concept "compassion" (or "compassionate care") is neither clearly defined in nursing scholarship nor widely promoted in the context of contemporaneous everyday nursing practice. The term in its moral dimension has, at best, been downgraded as an optional practice in everyday nursing care and, at worst, dismissed as lofty ideals connected to other disciplines, such as religion and ethics. A concept analysis using Walker and Avant's strategic method as well as Rodgers's evolutionary paradigm was undertaken to clarify the meaning of the concept "compassion" and examine its relevance in the context of everyday nursing practice.     

Culpability and pain management/control in peripheral vascular disease using the ethics of principles and care

The purposes of this article were to provide insight into the process of ethics and ethical inquiry and to explore the ethical issues of culpability and pain management/control. Critical care nurses who currently care for vascular patients identified these issues as occurring frequently in their practice. Authors in critical care nursing generally have limited the process of ethical inquiry to a theoretical framework built around an ethic of principles. The message many critical care nurses heard was that this one type of theoretical ethical framework was the totality of ethics. The application of these principles was ethical inquiry. For some nurses, the ethic of principles is sufficient. For others, an ethic of principles is either incomplete or foreign. This second group of nurses may believe that they have no moral voice if the language of ethics is only the language of principles. The language of principles, however, is not the only theoretical framework available. There is also the ethic of care, and ethical inquiry can include the application of that framework. Indeed, the language of the ethic of care may give a voice to nurses who previously felt morally mute. In fact, these two theoretical frameworks are not the only frameworks available to nurses. There is also virtue ethics, a framework not discussed in this article. A multiplicity of ethical frameworks is available for nurses to use in analyzing their professional and personal dilemmas. Recognizing that multiplicity, nurses can analyze their ethical dilemmas more comprehensively and effectively. Applying differing ethical frameworks can result in the same conclusions. This was the case for the issue of culpability.(ABSTRACT TRUNCATED AT 250 WORDS)