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Ethics Education in Nursing: Instruction for Future Generations of Nurses

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Katelin Hoskins, MSN, MBE, CRNP
Christine Grady, PhD, RN
Connie M. Ulrich, PhD, MSN, RN, FAAN


Ethics education in nursing provides a critical foundation for addressing ethical questions that arise in the patient-provider relationship. These questions are many and often include central concerns surrounding truth-telling, informed consent, and protecting the rights and welfare of patients and families in decision making. The lack of ethics preparation at both the undergraduate and graduate level hampers nurses’ ability to work collaboratively with other team members and share their voices when ethical issues confront clinicians and their patients and families. The purpose of this article is to discuss the importance of ethics education in nursing, identifying gaps in ethics education in nursing curricula, and review specific content issues within ethics curricula and future directions. We highlight the research and clinical opportunities that support ethics education, and offer innovative methods for ethics pedagogy. We also examine what we may learn from medicine. The article ends with recommendations and a conclusion to address ways to incorporate ethics inquiry in nursing curricula for educating future generations of nurses.

Citation: Hoskins, K., Grady, C., Ulrich, C.M., (January 31, 2018) "Ethics Education in Nursing: Instruction for Future Generations of Nurses" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 3.

DOI: 10.3912/OJIN.Vol23No01Man03

Key Words: ethics, education, nursing, nursing practice, pedagogy, curriculum development

Knowledge generation from breakthroughs... tests the ability of nurses to keep pace with ethical issues... Nurses often share in intimate struggles and complexities of life and death decisions with patients and families within any given clinical unit, practice setting, or designated role. Knowledge generation from breakthroughs in genetics, genomics, precision medicine, and other scientific areas test nurses' ability to keep pace with the ethical issues often associated with these technological developments in both clinical care and research. Ethical issues also arise in everyday nursing practice. These issues may be concerns affecting the nurse-patient relationship, including but not limited to, misunderstandings associated with informed consent; conflict about treatment goals; power differentials between and among healthcare clinicians, patients, families, and others; lack of supportive resources and policies to guide practice decisions; truth-telling; and disparities in access to care.

In 1946, Lucie Petry, Director of Nurse Education for the Unites States Public Health Service, wrote the following:

As one of the vital health professions, nursing today has a special significance as well as new responsibilities and outstanding opportunities. Spectacular advances in all fields of science are being translated into everyday living. Since the practice of nursing is the operation of principles of the social, biologic, and physical sciences, our profession will play an important part in helping to apply new knowledge, to create new patterns of life, and to guarantee that the means of attaining optimum health are available to everyone (p. iii).

Although much has changed since 1946, nursing remains committed to health advocacy on behalf of the public good and the beneficent care of the sick. Today, nurses represent the largest professional group of healthcare clinicians in the United States, and their responsibilities are indeed great. The nursing workforce has experienced rapid growth in the past decade, with a doubling of annual output of United States nursing programs from 2002 to 2012, contributing to a registered nurse workforce estimated between 3.3 and 3.6 million as of 2017 (Auerbach, Buerhaus, & Staiger, 2014; Kaiser Family Foundation, 2017; McMeanamin, 2016).

Demand for nurses may continue to grow with expanded care under the Affordable Care Act, projected physician shortages, and population growth with an aging society (Auerbach et al., 2014). As more individuals become interested in a nursing career, preparing them for the realities of clinical practice assumes increasing importance in light of the changing societal sociodemographic and everyday ethical challenges in patient care delivery.

...despite growth of nursing scholarship and pressing societal, research, and clinical ethical concerns, there is little consensus about the importance of ethics education in nursing... Nursing as a scholarly discipline has grown too. Advances in educational pedagogy have shaped nursing roles as expert bedside clinicians, advanced practitioners, and innovative researchers. Yet, despite growth of nursing scholarship and pressing societal, research, and clinical ethical concerns, there is little consensus about the importance of ethics education in nursing, the role of ethics education in the nursing curricula, and outcomes that can be achieved from ethics education. The purpose of this article is to discuss the importance of ethics education in nursing, highlight the research and clinical opportunities that support it, and address ways to incorporate ethics inquiry in nursing curricula for educating future generations of nurses. We review innovative models for ethics pedagogy, discuss how our interdisciplinary colleagues developed a framework in medicine for ethics education, and provide specific recommendations for further action.

Ethics Education and Nursing Practice

Nursing practice is inextricably entwined with moral complexity. Nursing practice is inextricably entwined with moral complexity. From the moment a newly graduated nurse enters the clinical environment, he or she must be ready to deliver quality patient care while navigating complex relationships with patients, families, physicians, nurses, and other members of the healthcare team. In navigating these relationships, ethical conflict commonly occurs. Forty years ago, Mila Aroskar highlighted the importance of ethics education in nursing because of the types of decisions that occur in clinical practice – “dependent, independent, and interdependent” – that engender ethical conflicts (1977, p. 260). These conflicts, especially when not addressed, can lead to a frustrated workforce and a loss of qualified nurses who are physically and emotionally worn out.

Pavlish, Brown-Saltzman, Jakel, and Fine (2014) noted that ethical conflicts in clinical practice are on the rise with an aging society, changes in the financial healthcare landscape, technological advances, finite resources, populations who are culturally and religiously diverse, and changing public expectations of the healthcare system. Nurses need a solid knowledge base that supports the recognition of emerging ethical problems, as well as the skills to deliberate judiciously and take moral action when required in any clinical or research situation. Nurses across the continuum of educational level, from entry-level to doctorally-prepared, must be equipped to confidently manage the ethical components of clinical and research practice, especially those that come with caring for patients and families.

...high-quality ethics pedagogy should be an essential component of nursing education. The nursing profession has an obligation to prepare nurses for the ethical morass of clinical practice; and high-quality ethics pedagogy should be an essential component of nursing education. Didactic immersion is a first step in cultivating professional identity, steeping student nurses in the values of the profession (e.g., social justice, advocacy, beneficent care), while challenging them to reflectively examine their assumptions, values, and beliefs. In 2016, the Presidential Commission for the Study of Bioethical Issues under President Obama recommended bioethics education for all professional groups as a means to engage in morally relevant issues at both the micro and macro levels. The Commission further noted that: “[T]o fulfill our professional obligations, we must resolve dilemmas, understand the obligations of our professions, and attend to the broader social impacts of our work. In each of these roles, the ability to recognize, articulate, and resolve ethical challenges is absolutely essential” (Presidential Commission, 2016, p. 7).

Gaps in Ethics Education in Nursing Curricula

Despite the importance of ethics education for student nurses and for those already in clinical practice, many gaps remain. Despite the importance of ethics education for student nurses and for those already in clinical practice, many gaps remain. More than 25 years ago, Thompson and Thompson (1989) asked the following salient questions related to ethics education: “What ethics content is needed in nursing?”; “When should it be taught?”; “How should it be taught?”; “Who should teach it?”; and, “How can it be evaluated?” Unfortunately, there remains an absence of sufficient empirical data on the value of ethics education in nursing curricula and its associated impact. Grady et al. (2008) found that approximately 22.7% of nurses in their study reported no ethics education and only slightly more than half (51.2%) had ethics course work in their basic and/or advanced professional program. Moreover, nurses with ethics education were more likely to take moral action and have higher levels of confidence than those without education. Grady et al. (2008) called for more attention to the content of ethics education and ways to support nurses when they confront ethical issues in their practice.

Multiple articles have described limited progress toward consensus in ethics education... Burkemper, DuBois, Lavin, Meyer, and McSweeney (2007) conducted a national survey of graduate programs (Master of Science, MSN) accredited by either the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC) to determine what ethics education they offered, updating Stone’s 1989 report on ethics education in graduate nursing programs (Stone, 1989). Burkemper and colleagues (2007) found notable variation across MSN programs in terms of ethics instruction, content, and faculty education. The authors noted a lack of core objectives and significant gaps in clinical ethics topics. In addition, they highlighted the absence of consensus on ethics education and a need for ethics education standards.

Multiple articles have described limited progress toward consensus in ethics education, recognizing ongoing variations in knowledge dissemination across the educational continuum (Grady et al., 2008; Vynckier, Gastmans, Cannaerts, & de Casterle, 2015; Laabs, 2012). Krautscheid and Brown (2014) conducted a qualitative study of undergraduate senior-level Bachelor of Science (BSN) students to understand student experiences making microethical clinical decisions in practice settings. The authors defined microethics as “the everyday ethical decisions that practicing nurses make in the context of common or routine clinical situations” (Krautscheid & Brown, 2014, p. S19). When faced with a microethical issue, specifically decision-making around safe medication administration, in a simulated environment, participants struggled to recall and deliberately apply ethics principles. The authors identified a mismatch between faculty perception of content delivery via the curriculum and students’ lived experiences, arguing that decontextualized ethics education does not fully support knowledge transfer from the classroom into practice (Krautscheid & Brown, 2014). Though Krautscheid and Brown (2014) reported thematic saturation for their qualitative data, the small sample size of seven participants should be noted and interpreted with caution.

When faced with a microethical issue, specifically decision-making around safe medication administration, in a simulated environment, participants struggled to recall and deliberately apply ethics principles. Laabs (2012) surveyed advanced practice registered nurses (APRNs) to assess their preparation to manage ethical challenges, post-graduate education in advanced clinical practice. The survey sample consisted of graduates from one university college nursing graduate program who completed Masters of Science in Nursing (MSN) or a postmaster’s certificate between 1992 and 2007 (n=172, with respondents practicing in 18 states). Laabs (2012) adapted an instrument developed for medical residents to measure APRNs’ perceived confidence and ethics knowledge. APRN respondents were asked about the degree of confidence in their ability to: 1) recognize a genuine ethical problem; 2) reach a sound decision when facing a clinical ethics problem; 3) determine if consent is truly informed; 4) understand and manage ethical aspects of cost containment; and five other key issues. Ethics knowledge topics included issues related to managed care, determination of incompetence, moral hierarchy of surrogate decision-makers, and the meaning of “fiduciary” in the APRN/patient relationship.

Laabs (2012) found fairly high levels of confidence in APRNs’ perceived ability to manage ethical problems, but overall low levels of ethics knowledge. Despite a majority of respondents reporting ethics course completion during their APRN education (94%), ethics knowledge scores varied widely, with an average test score of 55%. The discrepancy between reports of ethics education course completion and knowledge scores indicates a need to reassess relevant ethics content and teaching strategies, as well as to examine the validity of outcome measures as they pertain to APRNs (Laabs, 2012).

The discrepancy between reports of ethics education course completion and knowledge scores indicates a need to reassess relevant ethics content and teaching strategies... Understanding the educational gaps between academia and practice requires a more detailed analysis and evaluation of ethics content delivery. With a continued focus on APRNs, Laabs (2015) argued that “clear curriculum guidelines are needed so that nurses at the highest level of practice are well-prepared and capable of not only managing ethical challenges confidently, but also handling them knowledgably and appropriately” (p. 249). In another study, Laabs (2015) used a conventional Delphi technique to survey self-identified ethics experts to develop consensus about essential ethics content, teaching strategies, and teacher preferred qualifications for APRNs prepared at the doctor of nursing practice (DNP) level. She recruited experts from a national professional organization of bioethicists who identified themselves as holding a doctoral degree and having an interest in nursing ethics (n=8), and from the American Association of Colleges of Nursing (AACN) directory of schools offering doctoral programs of nursing that confer a DNP degree (n=21).

Experts reached consensus about only a few items that represent foundational knowledge, such as the American Nurses Association (ANA, 2015) Code of Ethics for Nurses with Interpretive Statements and certain ethics terminology. These experts also agreed that an ethics course should be required. Laabs (2015) argued that while codified rules and terminology may be appropriate for entry-level clinicians, APRNs require more sophisticated knowledge to manage the increasing complexities of care delivery. Of note, a key limitation of her survey was the limited response rate. Twenty-nine participants completed the first survey and 13 participants completed the third survey; the 70% per round response required for Delphi rigor was not met (Laabs, 2015). It is also not clear whether those who identified as bioethics experts with an interest in nursing ethics had received specific instruction in bioethics or had ever taught a course in nursing ethics.

Nurses graduating from undergraduate, graduate, and doctoral programs do not necessarily share an ethics vocabulary... With limited empirical data and no expert guidance as to “best practice” for any level of nursing education, each individual nursing program determines its own specific curricular content (Iacobucci, Daly, Lindell, & Griffin, 2012; Laabs, 2015). Nurses graduating from undergraduate, graduate, and doctoral programs do not necessarily share an ethics vocabulary nor a sufficient ethics-related knowledge base, potentially contributing to difficulty addressing ethical challenges in practice. With no uniform expectations for ethics education, it is difficult to identify relevant outcomes or competencies to measure knowledge transmission and implementation.

Much more research is needed to examine the critical role that ethics education plays with respect to quality of patient care, health equity issues, interdisciplinary collaboration, as well as the overall satisfaction and health of the workforce. We do not really know whether or what kind of ethics education (e.g., formal didactic, online, continuing education) mitigates clinicians’ ethics stress and moral distress, and whether ethics education influences patient-related outcomes (Ulrich, 2015; Ulrich, Zhou, Hanlon, Danis & Grady, 2016).

Specific Content Issues Within Ethics Curricula

No systemic evaluation has been done to determine the type of ethics education programs or methods that best prepare nurses for managing ethical dilemmas, conflicts, and morally distressing situations in clinical practice (Grady et al., 2008). Controversy remains regarding inclusion of theory versus skill-based approaches, which specific topics to teach, and the importance of education in interdisciplinary ethics. The study by Benner and colleagues (2009), known as the Carnegie Foundation National Study of Nursing Education, reported that bioethics was typically taught as a version of “dilemma ethics” with an emphasis on Beauchamp and Childress’ principle-based model (i.e., autonomy, beneficence, justice, and nonmaleficence) along with other salient topics (e.g., truth-telling, just allocation of scarce resources, withdrawal of treatment, and fairness) (Beauchamp & Childress, 2012; Benner, Sutphen, Leonard & Day, 2009; Benner, Sutphen, Leonard-Kahn, & Day, 2008).

...principlism alone is an insufficient framework for the nursing profession... Benner and colleagues (2008) claimed that bioethics is critically necessary for the nursing profession, particularly because bioethics offers an external stance and disciplined thinking regarding patient rights and provider obligations. However, the authors argued that principlism alone is an insufficient framework for the nursing profession, as decontextualized standards and principles do not provide a robust positive framework for “everyday ethical comportment” (Benner et al., 2008). These authors emphasized the importance of specifying principles and learning good practices internal to the discipline (Benner et al., 2008). This might include practices related to how nurses support patient decision-making, provide comfort to those who are suffering, fairly allocate time and resources among patients, and appropriately advocate for patients and their families (Benner et al., 2008).

Other authors have more explicitly criticized principle-based approaches to ethics education, emphasizing the limited translation of abstract concepts into practice, as well as potential insensitivities to power relationships within the healthcare system (Pariseau-Legault & Lallier, 2016). Pariseau-Legault and Lallier (2016) stressed that principle-based approaches may devalue advanced practice nurses’ clinical judgment and do not alone strengthen moral agency. Empirical research would be helpful to address this critique.

...knowledge of both bioethics and nursing ethics are indispensable for nursing practice. Grace and Milliken (2016) echoed concerns regarding the potential loss of a nursing-specific disciplinary perspective when dilemma- and principle-based approaches are primary teaching modalities. The authors argued that knowledge of both bioethics and nursing ethics are indispensable for nursing practice (Grace & Milliken, 2016). They described “distinct foci” for each field, further defining nursing ethics as “an applied professional ethics that determines the scope and boundaries of nursing practice, its practice goals, and how nurses should act” (Grace & Milliken, 2016, p. S13). The authors called for further support and development of nursing ethics. Grady (2016) argued that nursing ethics underscores commitment to the patient, but also acknowledges a broader social responsibility to act collaboratively with others to meet public health needs. Moreover, nursing, with its relational emphasis, infuses practice insight back into theory (Grady, 2016).

Ten years ago, Burkemper’s (2007) original survey of ethics education in MSN programs revealed that the topic of health law was found more frequently than any ethical issue related to direct patient care. Today, legal issues remain relevant and are often intertwined with ethical issues. Nursing scholars, however, have increasingly shifted their attention from law and traditional bioethics topics to the day-to-day ethical concerns of nursing practice, as described below. For example, in their study of the type, frequency, and level of stress experienced by nurses in everyday practice, Ulrich et al. (2010) found that nurses faced daily ethical challenges while providing patient care. The most stressful and frequently encountered issues were protecting patient rights, autonomy and informed consent to treatment, staffing patterns, advanced care planning, and surrogate decision-making (Ulrich et al., 2010).

Microethics often involves nuanced, contextualized decision-making... Krautscheid and Brown (2014) expanded on use of the term “microethics” to describe ethical concerns in everyday practice. Microethics often involves nuanced, contextualized decision-making, and the resolution of these microethical issues requires moral sensitivity (i.e., recognizing the presence of an ethical issue); moral reckoning (i.e., critical consideration of options, actions, and consequences); and intentional application of ethical theories (Krautscheid & Brown, 2014). Milliken and Grace (2017) stated that while much attention has focused on the role of nurses in recognizing ethical dilemmas, less attention has been paid to whether nurses understand the ethical nature of everyday practice. They asserted that that all nursing actions, from routine to complex, have ethical components. Recognition of the ethical nature of practice “is a necessary antecedent to ethical sensitivity and subsequent moral agency and moral action” (Milliken & Grace, 2017, p. 523). Further research may determine what educational methods best cultivate nurses’ understanding of everyday ethics.

The Carnegie Study on Nursing Education (Benner et al., 2008; Benner et al., 2009) found six key ethical themes from interviews on formative learning experiences by nursing students:

  1. Meeting the patient as a person
  2. Preserving the dignity and personhood of patients
  3. Learning how to respond to substandard practice
  4. Advocating for patients
  5. Engaging in learning to do “good” in nursing practice (both students and faculty)
  6. Learning how to be present with patient and family suffering

Benner and colleagues (2009) called for a major redesign of ethics curricula to focus not only on critical and ethical dilemmas, but also issues related to “everyday ethical comportment,” as it pertains to relational or care ethics. Ideally, academic curricula redesign for nursing education would incorporate foundational instruction in theoretical underpinnings of bioethics, methods for deliberative decision-making, clinical cultivation of moral agency, and an actionable philosophical, empirical, and conceptual skill set to navigate stressors across clinical unit, organizational, and policy domains.

The national shortage of nursing faculty has been a barrier to ethics education content development and delivery. The national shortage of nursing faculty has been a barrier to ethics education content development and delivery. Data from the AACN (2017) indicate a national nurse faculty vacancy rate of 7.9%, with most of the vacancies (92.8%) being positions that prefer or require a doctoral degree. Ethics experts and educators lack agreement on the required credentials for ethics faculty within nursing programs (Laabs, 2015).

Medical schools face similar shortages of suitably trained faculty in ethics. Doukas et al. (2015) asserted that, “Educational programs in ethics and the humanities need to be taught by experts comparable to those faculty teaching more traditional disciplines, lest these important topics suffer not because of content but because of poor execution” (p. 740). Furthermore, the Presidential Commission on the Study of Bioethical Issues (2016) explicitly recommended the development of teacher instruction in bioethics education. Ethics faculty qualifications, meaningful faculty development, nursing program resources, and cross-discipline instructional opportunities should be further examined as content discussions continue.

Innovative Methods for Ethics Pedagogy

Undergraduate Level Methods
Despite limited consensus regarding optimal ethics education content, several nursing scholars have piloted innovative methods for ethics education within academic and clinical milieus. Hickman and Wocial (2013) referenced the expectations for ethical comportment outlined in the Carnegie Study and emphasized the need for strong moral competence in everyday nursing practice. They used an active learner approach with the integration of team-based learning concepts in an undergraduate applied ethics course. Students work through case-based exercises with diverse teams. Unannounced team and individual readiness assessment tests hold students accountable to course reading content. Students may clarify reading concepts before tests and receive immediate feedback. They also complete a midterm and final exam, case analysis paper, and peer reviews. The authors reported growth of moral perception, judgment, and behavior through mastery of course concepts, increasingly nuanced team discussions, reflective analysis, and transparent, actionable voting on ethical decisions (Hickman & Wocial, 2013).

...high fidelity simulation provides a valid representation of patient care scenarios and facilitates student rehearsal of ethical knowledge and conflict communication. Krautscheid (2017) expanded on her prior work by implementing ethics education via microethical dilemmas embedded in high-fidelity simulation scenarios in an undergraduate senior level medical-surgical course. In this context, high fidelity simulation provides a valid representation of patient care scenarios and facilitates student rehearsal of ethical knowledge and conflict communication. Examples of microethical dilemmas include substandard infection control practices, unsafe medication administration procedures, and confidentiality breaches (Krautscheid, 2017). Goals of the simulation involve questioning of unsafe and unethical activities; advocacy for ethical, evidence-based care; demonstration of ethically informed and evidence-based patient-centered care; and discussion of professional ethical standards in group debriefing (Krautscheid, 2017). Students gained confidence, preparation, and advocacy skills, fueling this author’s recommendation that further studies examine the transfer of embedded microethical dilemmas from academia into clinical practice.

Ethics Education for APRNs
While Hickman, Wocial, and Krautscheid focused on ethics education for undergraduate nursing students, Pariseau-Legault and Lallier (2016) concentrated on APRNs. The authors created an ethical program of instruction that translates ethical concepts into a six-step decision-making framework for APRNs. This approach stresses the consolidation of moral integrity and procurement of deliberative competencies (Pariseau-Legault & Lallier, 2016). Pariseau-Lagault and Lallier (2016) emphasized that APRNs must “acknowledge their moral accountability when facing an ethical challenge and to find creative solutions to solve complex clinical situations rather than imposing a dualistic decision making process” (p. 401). Steps include the development of ethical sensitivity and reflective competence, factual evaluation of the situation, identification of applicable principles, development of deliberative competencies, and evaluation of outcomes of the process. Pariseau-Legault and Lallier’s (2016) model stands out in its emphasis on the deliberative process and the need to discuss complex subjects in nondiscriminatory, inclusive ways.

Education in Clinical Settings
Leaders in nursing ethics have also launched trailblazing programs in clinical settings. To address moral distress, retain nursing staff, and ultimately improve patient care, the team involving Grace, Robinson, Jurchak, Zollfrank, and Lee (2014) obtained funding from the Health Resources and Services Administration (HRSA) to develop a Clinical Ethics Residency for Nurses (CERN) program within two academic medical centers. The educational program had two main goals: 1) to increase nurse confidence in ethical decision making and subsequent action, thus decreasing moral distress; and 2) to prepare nurse ethics leaders who can act as resources at the unit or institutional level (Grace et al., 2014).

A preparatory needs assessment, which included ratings of nurses’ self-perceived competency in ethics, informed the curriculum design. These findings plus CERN faculty expertise, current literature, and the American Association for Bioethics and Humanities (ASBH) document Guidelines for Improving Competencies in Clinical Ethics Consultation: An Education Guide led to curriculum development for the fellowship. Faculty utilized a variety of pedagogical approaches based on James Rest’s four-component model of cognitive processes underlying moral reasoning (Robinson et al., 2014). The curriculum included didactics, simulation practice, and a mentored clinical practicum (Grace et al., 2014). Participants applied to the 10-month, 96-hour program and completed an online preparatory course prior to program initiation to enhance foundational knowledge. Simulation sessions with de-identified clinical ethics cases targeted nurses’ abilities to facilitate ethics rounds and conduct ethics consultation or act as a resource to the care team (Grace et al., 2014).

CERN participant evaluations indicated increased ethics knowledge, decreased moral distress, and more effective moral agency in clinical practice (Robinson et al., 2014). CERN demonstrated initial evidence of effectiveness in achieving goals of improved knowledge, attitudes, and practice (Robinson et al., 2014). The program merits replication across other institutions in light of these positive outcomes, plus the opportunity to collect additional data in efforts to establish best practices for ethics education in clinical milieus.

What Can We Learn From Medicine?

Medical students, residents, fellows, and practicing physicians share similar ethical issues, ethical dilemmas, and morally distressing events in clinical practice... Medical students, residents, fellows, and practicing physicians share similar ethical issues, ethical dilemmas, and morally distressing events in clinical practice as their nursing counterparts. They, too, are in need of ethical guidance and support in reasoning through concerns related to informed consent, end-of-life decision-making, communicating diagnoses and prognoses, and balancing risks and benefits of treatments for their patients. Medical educators face similar challenges as nurse educators because of a lack of consensus about specific goals of medical ethics education, critical knowledge for future clinicians, best methods for instruction, and ideal assessment strategies, in addition to variation in the extent and quality of ethics education across training programs (Carrese et al., 2015).

Members of the Project to Rebalance and Integrate Medical Education (PRIME), a national working group focused on ethics and humanities education in relation to professionalism education in medical school and residency, produced the Romanell Report in 2015. The Romanell Report (Carrese, 2015) spoke to ethics education goals, teaching methods, and assessment strategies, all of which may support constructive discourse within the nursing profession, given the limited consensus at this level regarding ethics content, the role of ethics education in curricula, teacher training, and short- and long-term assessment monitoring.

The Romanell Report expanded on the earlier 1985 DeCamp Report, which advocated for required medical ethics education in medical schools (Carrese, 2015; Culver et al., 1985). The Romanell authors aimed to help ethics educators meet accrediting organization expectations by addressing medical ethics education goals and objectives, teaching methods, and assessment strategies. The report (Carrese et al., 2015) proposed the following goals and objectives for physicians to meet upon completion of medical school or residency:

  1. Demonstrate an understanding of the concept of physician as fiduciary and the historical development of medicine as a profession
  2. Recognize ethical issues that may arise in the course of care
  3. Understand relevant ethics statements from professional associations
  4. Think critically and systematically through ethical problems using bioethical principles and other ethical analysis tools
  5. Provide a reasoned account of management of ethical problems and act accordingly
  6. Articulate ethical reasons to others coherently and respectfully

Carrese et al. (2015) discussed the timing and structure of ethics education within curricula and advantages and disadvantages of integrated versus separate ethics content. The report proposed content domains, discussed the utility of different pedagogical approaches, and emphasized a multidisciplinary approach, which includes contributors from the arts and humanities. In terms of assessment, the authors suggested linking objectives to outcomes when reasonable and feasible, and recommended developing assessment methods to connect medical ethics and professionalism education with patient outcomes (Carrese et al., 2015). The Romanell Report concluded with key research questions to further establish a conceptual and empirical scholarship agenda.

Clear conceptual intersections exist between medical and nursing ethics. Clear conceptual intersections exist between medical and nursing ethics. In this era of team-based care, there is inherent value in cultivating a shared, interdisciplinary knowledge base geared toward delivery of high quality patient care. Nurses and physicians may create constructive partnerships to identify core components of ethics education, as well as methods to identify the impact of ethics instruction on patient outcomes.

Future Directions

The Josiah Macy Jr. Foundation is dedicated to improving the public’s health by advancing the education of health professionals. It emphasizes interdisciplinary collaboration and innovative strategies for clinical education. The Macy Foundation asserted that education in the health professions is fragmented, time-bound, and often disconnected from optimal pedagogies (Josiah Macy Jr. Foundation, 2017). In response to the challenges of information explosion, student debt burden, and inadequate preparation for transition to practice, some health professions educators have shifted away from a traditional time-based educational system toward a time-variable, competency-based system, in which advancement is based upon concept and skill mastery. In June 2017, the Macy Foundation hosted educators in medicine, nursing, and pharmacy, plus experts in educational theory, medical residents, and program accreditors, to review the current state of competency-based, time variable health professional education. The group made the following recommendations (Josiah Macy Jr. Foundation, 2017):

  1. Systematic redesign for curricula, learning environments, and faculty development to achieve a successful competency-based, time-variable health professions education system
  2. Create a continuum of education, training, and practice
  3. Implement a robust program of assessment
  4. Enable technologies in the implementation of competency-based, time variable-education throughout the education continuum
  5. Evaluate outcomes

These recommendations highlight competency-driven and criterion-based assessments, longitudinally-oriented competency acquisition through the learner’s career, and outcomes linked to improved patient care and clinician satisfaction (Josiah Macy Jr. Foundation, 2017). Although the recommendations do not specifically address ethics education, they provide a helpful framework for thinking through the challenges in ethics education, particularly as educators seek new models of interdisciplinary instruction focused on knowledge transmission from the classroom to clinical practice. Further research on the development and potential role of competency-driven, time-variable strategies for ethics education may be valuable.

Recommendations and Conclusion

In conclusion, we recommend the following ideas to promote further dialogue on the value of ethics education in nursing and to develop ethics content for the future:

  1. Offer ethics education within academic settings, as well as clinical settings. Collaborations with accrediting bodies may aid the implementation of developed ethics content within academic milieus.
  2. Re-survey BSN and MSN programs to document changes in ethics education over the past decade since the Burkemper (2007) study and Carnegie Study on Nursing Education (Benner et al., 2009). Conduct a survey of doctoral programs (both PhD and DNP). Such surveys on the current state of ethics education would help identify gaps and develop appropriate programming.
  3. Establish a working group of bioethicists and nurse leaders to initiate research on the most effective pedagogical strategies and key content areas, then subsequently develop best practice guidelines for nursing ethics education.
  4. Pilot innovative curricula models for undergraduate and graduate levels of nursing ethics education and link didactic goals with measurable outcomes. Tracking cohorts of students who train in innovative ethics programs will provide longitudinal data through the transition to practice.
  5. Invest in a new generation of nursing ethics faculty to strengthen nursing ethics scholarship; develop innovative curricula; and steward students through the transition to clinical practice through academic-professional partnerships within clinical practice settings.
  6. Identify opportunities for partnerships between ethics content experts and professional organizations (e.g., the ANA) that represent key stakeholders to increase access to standardized ethics education content. For nurses who have transitioned out of academia exclusively to clinical milieus, online access to core content is an invaluable resource, especially when onsite ethics resources are limited.
  7. Develop ongoing relationships with professional organizations (e.g., The Josiah Macy Jr. Foundation) to support interdisciplinary ethics education programs, faculty instruction, and research initiatives.
  8. Develop partnerships for interdisciplinary education on bioethics with physicians and other healthcare professionals.

The approach of nursing “that encompasses both care and cure, intimate concern for the lived body and scientific treatment of the observed body” (Gadow, 1980, p. 98) assumes increased salience as technological advances in clinical care and research generate new knowledge. Nurses face ethical issues and choices in daily practice, and they commonly encounter ethical conflict. Leaders in the nursing profession have an obligation to prepare nurses for the ethical challenges of clinical practice, equipping them with the ability to recognize morally relevant issues as well as with an actionable, philosophical, empirical, and conceptual skill set to address ethical concerns and navigate stressors across the healthcare system.

By recommitting to ethics education as a vital priority, the nursing profession demonstrates an investment in the well-being of both nurses and patients... With a growing workforce at risk for moral distress, members of the nursing profession must reflect inward and create moral spaces to teach and to care for one another. Established gaps in knowledge transmission from the classroom to clinical practice highlight the critical need to evaluate current curricula content systematically and to develop impactful, high quality ethics education. By recommitting to ethics education as a vital priority, the nursing profession demonstrates an investment in the well-being of both nurses and patients, while honoring the adaptability and ingenuity that define its history.


Katelin Hoskins, MSN, MBE, CRNP

Katelin Hoskins is a doctoral student at the University of Pennsylvania and a Robert Wood Johnson Foundation Future of Nursing Scholar. Ms. Hoskins completed the Master of Bioethics program at the University of Pennsylvania, and she is a board-certified Family Psychiatric-Mental Health Nurse Practitioner. Her clinical practice focuses on adolescents.

Christine Grady, PhD, RN

Christine Grady is a nurse-bioethicist who currently serves as the Chief of the Department of Bioethics at the National Institutes of Health Clinical Center. Her research contributions are both conceptual and empirical and are primarily in the ethics of clinical research, including informed consent, vulnerability, study design, recruitment, and international research ethics, as well as ethical issues faced by nurses and other healthcare providers.

Connie M. Ulrich, PhD, MSN, RN, FAAN

Connie M. Ulrich is the Lillian S. Brunner Endowed Chair and Professor of Bioethics and Nursing at the University of Pennsylvania School of Nursing. She is a nurse-bioethicist whose program of research has focused on ethical issues in clinical practice and research.Her empirical and conceptual work has focused on ethics stress, ethics education, informed consent, recruitment and retention in clinical trials, and understanding the unique ethical issues that clinicians, patients, and their family caregivers face in everyday clinical care.


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© 2018 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2018

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