Nurses’ moral lives are growing in complexity given rapid changes that are the result of scientific advances, a growing business ethos, and technological processes aimed at standardizing patient care. At times, nurses believe that they cannot respond adequately to the ethical issues that they encounter because of their enormity and nurses’ responsibility to continue to care for patients despite the obstacles. For decades, nurse scholars have identified and explored how the context of healthcare can constrain nurses’ moral responses, leading to moral distress. More attention, such as the work of Musto, Rodney, and Vanderheide (2015), is now given to how nurses can take action to address the issues that cause this distress. Large scale change to overcome these constraints is possible through collective action in social groups, such as nursing organizations (Peter, 2011), but action at a micro level is also possible, particularly if nurses can avoid underestimating their potential power.
In his description of microethics in medicine, Komesaroff (1995) describes how “ethics is what happens in every interaction between every doctor and every patient” (p. 68). Ethics is not just constituted by those issues that garner public attention (i.e., euthanasia). Likewise, Walker (1998) describes morality as essentially interpersonal, existing in the real time and social space of our social roles and practices. Referring to interactions between patients and physicians, Komesaroff (1995) argues that no matter how minute, these are of continual ethical significance and can have a powerful and lasting impact on patients. In a similar way, all interactions nurses have with others also have the potential to be powerful. In other words, how nurses respond in everyday interactions with patients and other healthcare providers can have considerable impact.
Moral agency, the capacity to identify, deliberate, and act on moral phenomena (Peter, 2011), can be expressed in many ways that might not be initially obvious. For example, how nurses advocate for patients, even in small ways, can have impact. Requesting or connecting patients to additional resources could improve both the quantity and quality of their lives, and standing up for patients during team meetings when they are stereotyped or misunderstood can result in behavior change. Moreover, nurses who offer support to team members when they are struggling with ethical issues can create a ‘moral space’ so that reflection and shared decision-making about moral issues occurs (Walker, 2003). Diverse skills, such as those related to advocacy, speaking up, providing support, and communication, are all necessary for moral competence within the social space of nursing work and are learned and reproduced within these interpersonal contexts (Peter, Simmonds, & Mohammed, 2015; Walker, 1998). This development of competency typically goes beyond what is can be learned in classrooms, but can be learned in clinical practice particularly with good mentorship and support.
The authors of this OJIN: The Online Journal of Issues in Nursing topic identify multiple aspects of nurses’ moral agency that allow nurses to respond to the ethical concerns in their work. In the first article, “Ethical Awareness: What It Is and Why It Matters” Aimee Milliken, like Komesaroff (1995), describes how ethical awareness entails the recognition that all nursing actions, including routine ones, can have an impact on patients. She emphasizes that nurses must have awareness that any action in conflict with the nursing goals or in violation of the principles of bioethics (i.e., respect for autonomy, beneficence, non-maleficence, and justice) places nurses at risk for acting unethically. The importance of ethical awareness as a component of ethical competence is then illustrated by the analysis of three scenarios, revealing that everyday nursing actions can have a significant impact on patients.
The importance of the interpersonal context for nurses’ moral agency is highlighted in Wocial’s article, “In Search of a Moral Community.” She describes a moral community as a place where members are supported in reflecting and deliberating about practice. These communities are respectful even when there is conflict, are accepting of honest mistakes, and are open to learning (i.e., these communities provide a moral space for their members). Wocial provides several exercises that the reader can use to engage in self-reflection and lists resources to support moral communities. Most noteworthy, this article emphasizes the necessity of self-care and compassion to maintain the well-being, and ultimately the moral agency, of members of a moral community.
Ethics education is an essential element in the development and sustenance of nurses’ moral agency. Hoskins, Grady, and Ulrich, in their article entitled “Ethics Education in Nursing: Instruction for Future Generations of Nurses,” review the literature examining the presence, nature, and impact of nursing ethics education. A number of American studies have identified significant inconsistencies and gaps in the amount and type of nursing education provided and a lack of agreement on core objectives and educational standards. These authors provide a number of recommendations to foster further dialogue and underscore the centrality of nursing-specific perspectives in nursing education as ways to support nurses in responding to the everyday, microethical concerns in their work.
Grace continues the conversation of the value of nursing ethics education in her article, “Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation.” She argues that Doctor of Nursing Practice (DNP) programs, given their preparation of nurses who become experts in clinical leadership, can provide the opportunity for nurse leaders to become highly skilled and knowledgeable with respect to the ethics of everyday nursing. In particular, these DNPs can acquire the necessary personal characteristics and virtues, knowledge of ethical concepts, along with skills, such as mediation and collaboration to be leaders in ethics. In the end, this education not only has the potential to develop the moral agency of DNPs, but also, in time, that of those whom the DNPs lead.
Further challenges to nurses’ moral agency, can be the result of new technologies. In their article, “Identifying and Addressing Ethical Issues with Use of Electronic Health Records,” McBride, Tietze, Robichaux, Stokes, and Weber contend that the use of EHRs can result in untended consequences that can lead to patient safety concerns and moral distress when they involve clinical decision support (CDS). The formulaic alerts of CDS can be in conflict with the judgment of clinical teams, requiring nurses and others to override these alerts. Using Rest’s (1986) Four Component Model, which describes the elements of ethical sensitivity, judgment, motivation and action, these authors astutely describe how this concern can be addressed in an ethical manner.
In the final article by Kelly and Porr, “Ethical Nursing Care Versus Cost Containment: Considerations to Enhance RN Practice,” the ethical implications of working in the restructured Canadian healthcare system are examined. They argue that the business model that has been adopted in healthcare silences nurses from voicing their concerns and expressing what they think is the ethical way to care for patients, which can create stress and conflict among nurses. Much like McBride and colleagues, they maintain that standardized clinical pathways along with organizational and medical dominance can constrain nurses’ ethical judgment and action. They conclude by recommending that nurses, in partnership with nurse scholars, learn to use their voice effectively.
In summary, the authors for this topic of OJIN offer multiple perspectives regarding ways in which nurses can act in response to moral concerns in their work. In doing so, they highlight the technological, interpersonal, and social context of healthcare that influences, and can be influenced by, nurses. Recognizing the power nurses have to identify, deliberate, and act in their professional moral lives acknowledges the significant place of nurses in maintaining the ethical nature of healthcare provision. The journal editors invite you to share your response to this OJIN topic addressing Ethics in Healthcare either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Elizabeth Peter, PhD, RN
Komesaroff, P.A. (1995). Troubled bodies: Critical perspectives on postmodernism, medical ethics, and the body. Durham, NC: Duke University Press.
Musto, L.C., Rodney, P.A., & Vanderheide, R. (2015). Toward interventions to address moral distress: Navigating structure and agency. Nursing Ethics, 22(1), 91-102. doi:10.1177/0969733014534879
Peter, E. (2011). Fostering social justice: The possibility of a socially connected model of moral agency. Canadian Journal of Nursing Research, 43(2), 11-17.
Peter, E., Mohammed, S., & Simmonds, A. (2015). Sustaining hope as a moral competency in the context of aggressive care. Nursing Ethics, 22(7), 743-753. doi:10.1177/0969733014549884
Rest, J. R. (1986). Moral development: Advances in research and theory. New York: Praiger. Retrieved from http://catalog.hathitrust.org/Record/000441705
Walker, M.U. (1998). Moral understandings: A feminist study in ethics. New York: Routledge.
Walker, M.U. (2003). Moral contexts. Oxford: Rowman & Littlefield Publishers.