Ethical awareness involves recognizing the ethical implications of all nursing actions, and is the first step in moral action. Given the complexity of contemporary healthcare environments, it is vital that nurses are able to recognize and address ethical issues as they arise. Ethical awareness involves recognizing the ethical implications of all nursing actions, and is the first step in moral action (Milliken & Grace, 2015). This means that nurses must first recognize the potential ethical repercussions of their actions in order to effectively resolve problems and address patient needs. The aim of this article is to provide an overview of ethical awareness and its important role in ethical nursing care. Three everyday scenarios highlight the importance of ethical awareness in everyday nursing practice. Finally, strategies for heightening ethical awareness in the clinical setting are suggested.

Background

...nurses do not often recognize daily activities... as having ethical implications. Many scholars have addressed the ethical nature of nursing practice (Austin, 2007; Erlen, 1997; Milliken & Grace, 2015; Truog et al., 2015; Ulrich et al., 2010). Though nursing ethics education often focuses on dilemmas and challenging situations (Truog et al., 2015; Zizzo, Bell, & Racine, 2016), ethical awareness involves recognizing that every nursing action has the potential to impact the patient, even routine daily actions (Grace & Milliken, 2016; Milliken, 2016; Milliken, 2017a; Milliken & Grace, 2015). Recent work suggests that this awareness may be lacking, and that nurses do not often recognize daily activities (e.g., taking vital signs, administering medications, or starting an intravenous line) as having ethical implications (Krautscheid, 2015; Milliken, 2017a; Truog et al., 2015). This trend is problematic, and may put patients at risk for harm.

Nursing goals encompass the “the protection, promotion, and restoration of health and well-being; the prevention of illness and injury; and the alleviation of suffering, in the care of individuals, families, groups, communities, and populations” (American Nurses Association [ANA], 2015, p. vii). For a nursing action to be considered ethical, it should be aimed at promoting the goals of nursing  in conjunction with the patient’s wishes. Using the language of ethics, the goals of nursing can be broadly categorized into actions aimed at promoting the four major ethical principles. These principles are autonomy (the right to self-determination); beneficence (promotion of good); maleficence (avoidance/minimization of harm); and justice (fairness/equal distribution of benefits and burdens) (ANA, 2015; Beauchamp & Childress, 2009).

Awareness ideally leads the nurse to take action to practice in the most ethically acceptable way. If an action is in conflict with a nursing goal or one of these principles, or if it ignores a patient’s preferences, the nurse risks acting unethically. Ethical awareness involves recognizing the risk that nursing actions could fail to adhere to the goals of nursing, thereby violating an ethical principle. Awareness ideally leads the nurse to take action to practice in the most ethically acceptable way (Milliken, 2016; Milliken, 2017a; Milliken & Grace, 2015).

Research has suggested that nurses often feel unprepared to manage ethical challenges they face in practice (Austin, 2016; Rodney, 2017; Woods, 2005), resulting in possible moral distress and burnout. Ensuring that nurses have the tools to manage difficult situations is one way to mitigate this concern (Jurchak et al., 2017). Ethical awareness is important for nurses to develop as part of the larger skill set of ethical competence (Grace & Milliken, 2016; Kulju, Stolt, Suhonen, & Leino-Kilpi, 2016; Lechasseur, Legault, & Caux, 2016). The following everyday scenarios highlight the importance of ethical awareness, and focus on the role it plays in day-to-day nursing care. In the interest of confidentiality, these cases are not actual occurrences, but constructed scenarios that represent common challenges.

Ethical Awareness: Everyday Scenarios

Even everyday clinical situations require careful consideration of ethical risk.Even everyday clinical situations require careful consideration of ethical risk. Though the risk may seem low at the outset, the following scenarios highlight the way that even routine situations can have profound ethical implications for patients. While there are many ways to conduct an ethical analysis, the focus here will be on the four primary ethical principles foundational to nursing practice (defined above) and how they relate to the scenarios. For the purpose of illustration and discussion, these scenarios assume nurses who could benefit from a higher level of ethical awareness, to include potential everyday challenges, as opposed to higher profile cases more commonly discussed in the literature (e.g., initiation of feedings/ventilation).

Scenario One
Mr. M is an 85-year-old man admitted to the neurological intensive care unit (ICU) after developing a subdural hematoma due to a recent fall. Mrs. M (his wife) asks to spend the night in her husband’s room, as she is concerned he may become distressed if she leaves. The rules in the ICU prohibit family members from staying overnight, unless the patient is actively dying. Citing this rule, John, the ICU nurse, sends Mrs. M home. Overnight, Mr. M becomes acutely agitated, requiring wrist restraints and repeated doses of intravenous sedatives.

This case suggests several possible ethical concerns. First, it appears as though John, the nurse, has acted based on routine. In this sense, we may be concerned that John has not fully considered Mr. M’s possible unique interests in this case. This relates to John’s ethical obligation to promote Mr. M’s autonomy, and involves considering the question: what would be best for Mr. M, given his clinical situation and what we know about his goals and values? A second ethics-related concern has to do with John’s obligation to promote good (beneficence) and to prevent harm (non-maleficence). The harm, in this case, would be Mr. M’s increase in agitation and the possible need for restraints and sedation.

Ethical awareness would have helped John to recognize the range of potential ethical implications of his decisions as they relate to the possible concerns. Ethical awareness would have helped John to recognize the range of potential ethical implications of his decisions as they relate to the aforementioned concerns. In other words, ethical awareness would enable John to have a more holistic view of Mr. M’s predicament and may allow him to develop a plan of care more in line with this view. In a patient such as Mr. M, with a neurological injury, minimizing the need for sedation and restraints is preferable, both ethically and clinically, as any change in neurologic status may be cause for concern.

In viewing the situation with this lens, John may have decided to let Mrs. M stay, despite the unit routine, thus promoting Mr. M’s autonomy. This decision also aligns with John’s obligations related to beneficence and non-maleficence. Allowing Mrs. M to stay on the unit may minimize the risk of agitation if her presence helped soothe her husband. This action may have successfully prevented use of more restrictive measures (i.e., restraints and sedation), thereby promoting a better outcome (beneficence) and mitigating potential harm.

Scenario Two
Mr. L is a 50-year-old man admitted for gastrointestinal (GI) bleeding. After a couple of days his hematocrit is still low and his physician tells him that he is not ready to be discharged today. Mr. L becomes angry and tells the team he wants to leave against medical advice (AMA). His nurse, Susan, and his physician outline the risks of leaving, including the risk of rebleeding, but he insists and leaves the hospital. That night, Mr. L ends up back in the Emergency Room with profuse GI bleeding.

...the provider’s obligation to promote the patient’s best interests may outweigh the patient’s desire to act autonomously. While leaving AMA is often viewed as a patient right based on the principle of autonomy, it is also necessary to consider whether the patient is putting himself at undue risk for harm. When the risks of a situation outweigh the possible benefits, the provider’s obligation to promote the patient’s best interests may outweigh the patient’s desire to act autonomously (Grace, 2014). Thus, the ethics worry in this case relates to the potential conflict between Susan’s ethical obligation to promote good (beneficence) and Mr. L’s right to autonomy.

To promote Mr. L’s ability to act autonomously in the future, it is necessary to minimize the potential harm to which he exposes himself in the present. To promote Mr. L’s ability to act autonomously in the future, it is necessary to minimize the potential harm to which he exposes himself in the present. Ethical awareness would help Susan recognize this responsibility. To address this obligation, Susan could try to talk through the situation in greater depth with Mr. L in an effort to uncover the reasoning behind his desire to leave. There may be additional factors of which Susan is unaware that are contributing to Mr. L’s anger. If these reasons are explicated, perhaps they can arrive at a compromise to appease Mr. L, while keeping him medically safe.

Additionally, Mr. L’s clinical picture includes a low hematocrit. This factor may be negatively impacting his decision-making abilities. Susan may wonder whether Mr. L is truly making an autonomous decision, which would require that he fully understands and is able to use reason to determine the potential long-term outcomes of leaving the hospital. Susan could further explore these concerns to ensure that Mr. L’s decision to leave is actually fully informed. Should she reach an impasse, she may consider seeking additional resources to keep Mr. L safe, including involving psychiatry and possibly an ethics consult.

Scenario Three
Emily is a new nurse on a medical-surgical unit. She has a busy assignment, and is behind on documentation. She has her patients’ vital signs on a piece of paper in her pocket but has not written them in the chart. However she is happy to see her hypertensive patient, Mrs. O, is now normotensive.

The medical team rounds on Mrs. O without Emily, and sees that the most recent blood pressure (BP) documented in the chart is still elevated. They order an increase in Mrs. O’s antihypertensive medications, not realizing her BP is has now normalized (since Emily has not yet charted it). In an effort to help Emily catch up, a nurse colleague gives Mrs. O the new dose of medication. An hour later Mrs. O becomes diaphoretic and dizzy. When Emily rushes in to re-check her blood pressure, she is hypotensive.

Because Emily was behind, the plan of care was changed based on old data, putting Mrs. O in a dangerous situation. Though Emily had good intentions, her patient was given an improper dose of medication. Using ethics-language, Emily was unable to provide beneficent (good) care, and her patient suffered a potential harm. Nurses often fall behind during the course of a shift; this is a reality of practice. However, this scenario demonstrates that even something as simple and routine as charting vital signs has potential ethical implications. Falling behind, and being unable to perform necessary duties, can result in potential harm.

An additional ethics worry is that Emily was so busy that she missed rounds with the medical team. This means Emily did not have the ability to fully update the team about Mrs. O’s progress and to raise any potential concerns or considerations for the plan of care. This represents a lost opportunity to advocate for her patient. Advocacy is an important component of the duty to promote autonomy, particularly when patients are in a position where they cannot make their own needs or wishes known, or when patients may not have all the necessary information to make informed decisions.

... [Emily] has an ethical obligation address the situation that is leading to her busyness. Ethical awareness would have helped Emily recognize that, based on her duty to promote good (beneficence), to advocate for her patient (autonomy), and to prevent harm (non-maleficence), she has an ethical obligation address the situation that is leading to her busyness. The inability to meet her patient’s needs may result in possible harm, as Mrs. O experienced. This is not only a clinical problem or a possible bad outcome; this is fundamentally ethical in nature. This recognition may help Emily feel more confident in asking for help. Ethical awareness also may prompt Emily to evaluate the root cause of this issue, so that she (and possibly others) could avoid similar circumstances in the future.

Discussion

...increasing nurses’ ethical awareness to include the implications of everyday decisions is important to maximize safe, ethical patient care. These three scenarios highlight the importance of recognizing that even routine and seemingly mundane nursing actions can have major implications for patients. As noted, nurses have professional goals and related ethical obligations that should guide nursing practice. However, routine practice actions may not always be viewed through this lens. This lack of recognition is in no way malicious or intentional; it stems from lack of awareness. Consequently, it becomes clear that increasing nurses’ ethical awareness to include the implications of everyday decisions is important to maximize safe, ethical patient care.

An awareness of the ethical components of a situation ideally should prompt nurses to take action (Milliken, 2016; Milliken & Grace, 2015). The scenarios above demonstrate how heightened ethical awareness may have helped clarify the way that these nurses thought about the implications of their decisions. This perspective may have helped them view the scenarios more completely, and be sensitive the possible range of actions they might have taken (Rest, 1982). In other words, had the nurses in these cases recognized that their patients were at risk, they may have been more likely to intervene or take proactive measures.

...ethical awareness is an important first step in sustainable, optimal ethical practice. Such a proactive measure, or intervention, is called “moral agency.” The nurse recognizes a potential ethical issue, and acts to resolve it. In addition to willingness and ability to take action, moral agency requires that nurses embody this perspective in practice, recognizing that as a profession, we have an obligation to act as agents on behalf of patients (Liaschenko & Peter, 2016; Musto & Rodney, 2016). Embracing one’s role as a moral agent in this way can facilitate resilience, or an individual nurse’s ability to learn and grow from challenging clinical situations that may cause distress (Rushton, 2016b). Consequently, ethical awareness is an important first step in sustainable, optimal ethical practice.

The important role of ethical awareness in patient care suggests that individual nurses, as well as nurse leaders and healthcare organizations, hold the responsibility to develop this important skill. Strategies to heighten ethical awareness in the clinical setting have been discussed in depth elsewhere (Milliken, 2017b). Briefly, these include interventions targeted at the individual, unit, and organizational level. For example, individual nurses can improve ethical awareness by developing ethical competence, or overall ethical understanding and skill-set (Kulju et al., 2016; Lechasseur et al., 2016). Participating in ethics-related discussions, utilizing available ethics resources (Milliken, 2017b), and becoming familiar with the ANA Code of Ethics for Nurses with Interpretive Statements (Code of Ethics) are several ways of developing ethical competence.

The ANA Code of Ethics (2015) establishes the “ethical standard for the profession” (p. vii) and serves as the profession’s “non-negotiable ethical standard” (p. viii). The nine provisions outline the expectations to which nurses, as professionals, must adhere. The Code of Ethics emphasizes that the scope of ethical nursing practice extends far beyond the nurse’s role in challenging dilemmas. Recent work suggests that many nurses may be unfamiliar with the Code of Ethics document (Heymans, Arend, & Gastmans, 2007; Milliken, 2017a). Nevertheless, familiarity with this document has been identified as an essential part of preparation for ethical practice and should serve as a foundational step to develop ethical awareness (Grace & Milliken, 2016).

At the unit and organizational-level, nurse leaders can create opportunities for individual nurses to develop moral agency and resilience (Milliken, 2017b). These opportunities may include unit-based ethics rounds; in-services; formal and informal ethics training; and participation in interprofessional education (Hamric & Wocial, 2016; Milliken, 2017b; Rushton, 2016b). Nurse leaders can also model and contribute to shifting values toward an organizational culture that supports ethical awareness and ethical practice (Hamric & Epstein, 2017; Liaschenko & Peter, 2016). This requires attention to unit-specific issues (e.g., complex patient populations and staffing issues) and creation of platforms for nurses and other healthcare providers to participate in regular discussions about ethics and ethical issues (Hamric & Wocial, 2016; Liaschenko & Peter, 2016; Milliken, 2017b).

Interventions such as these can foster individual and collective ethical awareness. Keeping ethics at the forefront of conversation, in this way, can help to better ensure that patient needs are met. It may also help nurses facing everyday, yet challenging situations, like those in the case scenarios, to feel more confident in decision making and in their ability to access ethics-related resources at the moment of concern.

Conclusion

Developing and fostering ethical awareness fundamentally requires recognition that ethics is in everything that we, as nurses, do. Developing and fostering ethical awareness fundamentally requires recognition that ethics is in everything that we, as nurses, do (Austin, 2007; Milliken & Grace, 2015; Truog et al., 2015; Ulrich et al., 2010). While dilemmas and challenging situations create the most obvious, dramatic risks to patients, routine actions have implications for patients as well. Consistent recognition of the ethical implications of nursing actions will, ideally result in care that more consistently supports patient goals and preferences, and is also aligned with the ethical obligations of the nursing profession (Milliken & Grace, 2015). Developing ethical awareness is one way to empower nurses to act as moral agents to provide patients with safe and ethical care.

Author

Aimee Milliken, PhD, RN
Email: abmilliken@gmail.com

Aimee Milliken is the Weise Postdoctoral Fellow in Clinical Bioethics at Brigham and Women’s Hospital in Boston, Massachusetts. She received a PhD from Boston College. Her dissertation work involved the development and psychometric evaluation of the Ethical Awareness Scale, an instrument to measure ethical awareness in critical care nurses.