Efforts to Improve Ethics Education for Nurses
In 2015, members of the American Nurses Association (ANA) Ethics Advisory Board examined the state of the science in ethics education in nursing. Those efforts are now coming to fruition. “Our healthcare system is increasingly complex and challenging. Nurses must be actively engaged in recognizing, intervening in, and preventing ethical issues — from the everyday to significant conflicts,” says Catherine Robichaux, PhD, RN, one of the committee members and an adjunct assistant professor at the University of Texas Health Science Center.
Board members noted nurses’ moral distress (related to an inability to do what they believed was ethically right for a patient), inadequate ethics preparation, and lack of direction on what ethics material to teach — and who should teach it. “These same issues have been identified across healthcare professions, including medicine and dentistry,” Robichaux observes.
Board members also noted requirements for nursing ethics education were going to be eliminated or “integrated” in academic accreditation documents. To push back against this, an ethics education subcommittee designed a framework for the development of academic curricula to serve as a guide for those providing ethics education to nurses.1
“The use of multimodal approaches that involve different cognitive and affective components may ensure that ethics knowledge and skills translate to ethical action,” Robichaux says.
When facing difficult cases, nurses often turn to the ANA Code of Ethics for guidance. “We wanted to see if the ANA Code of Ethics was still relevant during a novel situation like a pandemic,” says Cheryl Dellasega, CRNP, PhD, professor of medicine and humanities at Penn State College of Medicine and consultant at Penn State Health Nursing Research.
Dellasega and colleagues held focus groups with 23 nurses. They learned the ANA Code of Ethics was useful as a tool to frame discussion of ethical challenges.2 “While nurses didn’t necessarily remember the provisions of the code, they did readily identify the most relevant concepts to their practice during the pandemic,” Dellasega reports.
However, the nurses reported the code did not address distress caused by two challenges: the guilt nurses felt over isolating patients from their support systems and the guilt some nurses felt because they were not on the “front lines” of COVID-19 care.
For ethicists, Dellasega says the main message is “sometimes we have to think outside the box and recognize that new approaches are needed.” In teaching ethics to nursing and medical students, Dellasega has found “it’s easy to rely on the standards passed down through the profession.”
From their ethics education, nurses learn general knowledge of principles, such as the obligation to “do no harm.” In reality, nurses need practical implications of how those standards apply to what they are seeing in their day-to-day practice.
Mary Lou Kanaskie, PhD, RN, sees nurses struggle with ethical challenges “when there is conflict between two opposing factors.” Some situations that prompt nurses to seek outside help include these ethical dilemmas:
- Families might oppose telling an elderly patient their prognosis. Therefore, the patient lacks information to make an informed decision. “This dilemma is a common one, and may present itself in different forms,” says Kanaskie, director of the Office of Nursing Research and Innovation at Penn State Health Milton S. Hershey Medical Center.
- Nurses are asked to provide support for patients who could not survive without a ventilator, and obligations to the patient and the family conflict. “This raises questions about patient autonomy. Do we know what the patient’s wishes would be? It also raises questions on futility of the treatment,” Kanaskie says.
- Nurses are caring for low birth weight infants with a poor prognosis, raising questions about beneficence and nonmaleficence.
In each situation, nurses are providing critical care for patients with less-than-optimal futures. For nurses, “this can feel like they are prolonging suffering rather than saving lives,” Dellasega laments.
To raise awareness of how nurses should respond to those kinds of ethical questions, Kanaskie gathered nursing colleagues who all expressed a strong interest in healthcare ethics. “Together, we created a Nursing Ethics Interest Group for any nurses across the organization to join,” Kanaskie reports.
The group invited other clinical team members to participate, including nutrition care specialists, respiratory care therapists, social workers, and chaplains. The 30-member group meets the first month of each quarter for planning, and the next two months they attend ethics education sessions.
“Our primary goal is to make sure that the discussions occur on the unit level where clinical nurses can participate,” Kanaskie explains.
Elizabeth Lanphier, PhD, MS, supports nursing ethics education in collaboration with the Center for Professional Excellence/Education at Cincinnati Children’s Hospital Medical Center.
“What I see among nurses already in practice, or moving through a nurse residency program, is that there is strong interest in and awareness of ethics. But there is not always specific training in ethics,” says Lanphier, assistant professor in the Ethics Center at Cincinnati Children’s Hospital Medical Center.
Nurses probably have heard of the ethical principles of autonomy, beneficence, nonmaleficence, and justice. “But based on what nurses share with me, these principles are not always explicitly discussed in terms of how they apply to nursing practice and patient care,” Lanphier says.
Applying ethical principles to nursing care is “far from straightforward,” Lanphier adds. “There is quite a bit of nuance to the ANA code of ethics. There are important questions to consider about how it reflects the specificity of the nursing role.”
The best approach Lanphier has found is discussion of actual cases during ethics rounds. “Ethical concepts can be abstract. This makes them concrete and relevant, and builds up ethical knowledge among individuals and teams,” she observes.
For ethicists, it can be eye-opening to find out from nurses themselves what they need help with. “I look to my nursing colleagues to help me understand where they need support,” Lanphier shares.
From there, ethicists can identify the ethical questions embedded in the concerns nurses raise, and formulate a response to them. In conversation with nurses, one question that continually arises involves the nurse’s role as an advocate for patients. The ANA Code of Ethics states the nurse’s primary commitment is “to the patient, whether an individual, family group, community, or population.”3 Sometimes, nurses struggle to figure out what it means in the context of clinical care. “Advocating for the patient amidst a network of individuals and groups can be incredibly challenging, as their obligations sometimes appear to conflict,” Lanphier notes.
For example, there are cases in which the best clinical recommendation for a child puts a serious burden on a family. Parents might need to take time off work, or it might require home health support that insurance does not cover. In cases like that, ethicists can help nurses understand their obligations to patients, families, and the community. This is a good topic for nursing grand rounds or educational in-services, which ethicists could design and offer.
“Ethicists can support nurses to think about these various obligations proactively, how to define these terms, and how to weigh or balance them,” Lanphier says.
REFERENCES
- Robichaux C, Grace P, Bartlett J, et al. Ethics education for nurses: Foundations for an integrated curriculum. J Nurs Educ 2022;61:123-130.
- Dellasega C, Kanaskie ML. Nursing ethics in an era of pandemic. Appl Nurs Res 2021;62:151508.
- American Nurses Association. Code of ethics for nurses with interpretive statements. 2015.
Nurses probably have heard of the ethical principles of autonomy, beneficence, nonmaleficence, and justice. However, these principles might not be discussed in terms of how they apply to nursing practice and patient care.
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