Effective Date: 2021
Status: Position Statement
Written by: ANA Center for Ethics and Human Rights
Adopted by: ANA Board of Directors
Nurses face increasingly complex ethical issues and challenges in today’s workplaces. They recognize the mutuality between environments that cultivate ethical practice and the provision of high-quality, patient-centered care. Creating, sustaining, and continuously improving all nursing practice environments is of strategic importance to the entire profession and the public it serves.
The purpose of this position statement is twofold:
- To underscore the nurse’s commitment to create, sustain, and continuously improve the ethical workplace environment in all practice settings.
- To support nurses by offering an array of tools and setting-related resources with which they can fulfill that commitment; the position statement’s robustness reflects that additional help.
Statement of ANA Position
ANA holds that nurses in all roles and settings must recognize their responsibility for ethical practice environments and therefore must have access to resources that facilitate assessment, reflection, and support for education to improve ethical practice. Nurses in all roles and all settings desire and deserve to work in an ethical environment that respects the inherent dignity of every patient and every nurse. An ethical professional practice environment facilitates nursing care that prioritizes ethical reflection and inquiry, allows for expression of varying viewpoints without fear of reprisal, and promotes professional and ethical values and trust.
ANA supports initiatives providing ongoing ethics and ethical practice education for the nursing workforce in all roles and all settings. This education should include but not be limited to the definitions and principles of ethics in general, and bioethics, nursing, and organizational ethics specifically. Ethics education should include ongoing access to ethics resources/materials such as the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a) (the Code) and opportunities for discussion of ethics topics and simulated situations without fear of retribution.
An ethical environment is one in which:
- Individuals are aware of the work they perform and understand how the work environment influences their ability to raise questions about ethical concerns
- Individuals are aware of what comprises an ethical culture
- Individuals have positive perceptions of the ethical climate
- Institutional policies and procedures address ethical principles
- Purposeful discussions of ethics take place
- Identifiable behavioral expectations are provided (Murray, 2007)
Ethical environment may also be called ethical climate, which comprises the perceptions of conditions and ways that ethical issues are dealt with and resolved. These include mechanisms like hospital ethics committees, ethics consultants, and ongoing ethics education. An organization’s ethical climate can be assessed by measuring employee perceptions of organizational practices that reflect (a) how problems having ethical content are solved, (b) the presence of organizational conditions that allow employees to engage in ethical reflection, or both (Brown, 1990, in Olson, 1998). Whether these conditions are referred to as ethical environment, ethical culture, moral community, or ethical climate, nurses must promote organizational conditions and practices that influence and support the ways in which ethical issues and concerns are identified, discussed, and decided.
ANA supports initiatives directed toward assessing the ethical environment of all work settings, including collaborating with partners and employing and/or supporting nurses. Since ethics occurs within the context of relationships, those with whom nurses interact in their work must be included as important partners in creating ethical practice environments. Once opportunities for improvement have been identified and assessed, organizations should take specific, measurable steps to improve the ethical environment as demonstrated by development of a plan, implementation of the plan, and evaluation of the outcomes to ensure that progress is being made toward optimizing the ethical environment.
Nurses must foster the organizational conditions, practices, and norms that identify and explore ethical issues. They must develop analytical and decision-making skills and actively participate in resolving ethical concerns. Ethical practice environments support nurses’ interactions with patients, families, colleagues, and others, including how decisions addressing ethical challenges are raised, discussed, and resolved. Positive perceptions of an ethical practice environment can reduce the moral distress associated with the inability to resolve difficult ethical issues.
Nurses’ personal reflections, informed by the Code, on what help is available to them to resolve the ethical questions inevitably encountered in their practice are also an important environmental assessment tool. Once nurses identify opportunities for improvement, they should hold their organizations accountable for taking specific, timely, measurable, evaluated steps to improve the ethical practice environment, an environment built on trust, advocacy, safety, sufficient compensation, safe staffing, and support for the nursing workforce in all roles and all settings.
As the largest organization and professional voice of the nation’s nearly four million nurses, ANA supports the following recommendations:
- Nurses in all settings should assess the presence or lack of the conditions that comprise ethical environments in their workplaces, possibly using one or more resources cited in this position statement or another tool. Results of this assessment should be shared with organizational leaders.
- Nurses at every level in every practice setting should familiarize themselves with the Code (2015a) and reflect on its applicability to their practice.
- Nurses must enhance their awareness of and sensitivity to the ethics content of challenges they face in their practice and take ownership of their own ethical competence to address these challenges.
- Organizational leaders must take the following actions:
- Provide ongoing education in ethics concepts and ethical practice for nurses in all roles and all settings.
- Strongly encourage use of the Code as an ethical framework for nursing.
- Demonstrate zero tolerance of lateral violence or other disregard for nurse safety and well-being.
- Create safe spaces for discussing ethics issues without fear of retaliation.
- Organizations must include individuals in ethical deliberations who have a stake in the outcome of those deliberations—e.g., clinicians, families, patients and their loved ones, chaplains, etc.
- Every nurse must learn about the existing resources in their practice setting for resolving situations involving ethical conflicts, learn how to use them, and collaborate with colleagues at all levels to institute approaches to such conflict resolution as needed. Approaches include:
- Establishment of an ethics consult service
- Creation of ethics committees
- Policy development, such as
- Just-culture policies
- End-of-life treatment policies, including those that minimize unwarranted, unwanted, or unnecessary medical treatment and patient suffering
- Required debriefing after critical incidents
- Moral distress consult service or committees
- Quality improvement initiatives that acknowledge the reliance of quality care on explicitly ethical practice
- Nurses should explore becoming ethics champions in their organization or practice setting, similar to those described by Fitzgerald, Knackstedt, and Trotochaud (2018, https://www.americannursetoday.com/novel-ethics-champion-programs/).
- Additional interventions may include seeking magnet status, with its emphasis on ethical practice, promoting shared governance, and including ethical environment resources as conditions of employment negotiated by contract in collective bargaining settings.
Code of Ethics for Nurses with Interpretive Statements
The Code of Ethics for Nurses with Interpretive Statements (2015a) is “the profession’s non-negotiable ethical standard.” It establishes the responsibility of nurses in all roles and settings to create and continually improve ethical practice environments, stressing the particular duty executive nurse leaders have to create them. “Nurse executives have a particular responsibility to ensure that employees are treated fairly and justly, and that nurses are involved in decisions related to their practice and working conditions” (Provision 6, Interpretive Statement [IS] 6.3). Furthermore, nurse executives should ensure that policies addressing conscientious objection are available (Provision 5, IS 5.4). Nurses should not be forced to violate their conscience. If conflicts occur, the nurse must never abandon a patient. Agency policy must provide a way to honor conscientious objection that adheres to the standard outlined in the Code.
The Code emphasizes the connection between ethical practice environments and quality care: “The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care” (Provision 6). It even cites the nurse’s
“duty to resign from healthcare facilities, agencies, or institutions where there are sustained patterns of violation of patient’s rights, where nurses are required to compromise standards of practice or personal integrity, or where the administration is unresponsive to nurses’ expressions of concern.… The needs of patients may never be used to obligate nurses to remain in persistently morally unacceptable work environments. By remaining in such an environment, even if from financial necessity, nurses risk becoming complicit in ethically unacceptable practices and may suffer adverse personal and professional consequences” (Provision 6, Interpretive Statement [IS] 6.3).
The Code points out that “authentic expression of one’s own moral point of view is a duty to self. Sound ethical decision-making requires the respectful and open exchange of views among all those with relevant interests. Nurses must work to foster a community of moral discourse. As moral agents, nurses are an important part of that community. They have a responsibility to express moral perspectives, especially when such perspectives are integral to the situation, whether or not those perspectives are shared by others and whether or not they might prevail” (Provision 5, IS 5.3). Ethical environments facilitate nurse well-being in addition to respectful moral discourse and duties to patients. “Nurses in all roles should seek this balance, and it is the responsibility of nurse leaders to foster this balance within their organization” (Provision 5, IS 5.2).
Position Statement on Human Rights
The ANA position statement The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings (ANA, 2016) on the nurse’s role in ethics and human rights “provides the foundation and context for all other position statements related to the practice of nursing.” The protection and promotion of human rights related to health and health care are fundamental functions of ANA. The statement describes the relationship between nurses’ ethical obligations, the concept of human rights, and professional nursing practice. The human rights of self, patients, colleagues, and all communities are a nursing concern, requiring nurses’ action to ensure they are protected and promoted.
Scope and Standards of Practice
ANA’s authoritative Scope and Standards documents for nursing practice and for several specialties of nursing describe each nurse’s obligation to lead collective and collaborative advocacy to promote environments that facilitate ethical practice. “Nursing occurs in any environment where there is a health care consumer in need of care, information, or advocacy” (ANA, 2021, p. 3). A basic tenet of nursing is that “The nurse needs an understanding of basic ethical nomenclature and principles to be able to discern ethical issues that arise within the course of nursing wherever and whenever nursing takes place.” (ANA, 2021, p. 14). This means that:
The nurse-patient relationship is fiduciary in nature, built on trust, and reflected in Provision 2 of the Code of Ethics for Nurses with Interpretive Statements: “The nurse’s primary commitment is to the patient, whether individual, family, group, community, or population.” Nurses may be challenged to focus on this priority in environments where the efficient, the economical, and the procedural may be more valued. As with the deontological duties, conflicts can arise between or among the ethical principles, resulting in ethical dilemmas (ANA, 2021, pp. 131-132).
Scope and Standards of Practice: Nursing Administration
Nurse administrators in all settings need a mutual understanding of the challenges and demands placed by external factors such as regulatory agencies and accrediting bodies (ANA, 2016). Nurse administrators must foster healthy work environments conducive to civility, patient inclusion in decision-making, and implantation science (ANA, 2016).
Nurse administrators therefore have heightened duties to promote ethical practice environments, regardless of setting. Their duties include integrating ethical provisions in all areas of practice and providing leadership in their organization toward that goal. ANA states that they must do the following:
- Assure a process exists to identify and address ethical issues within nursing and the organization.
- Incorporate the Code to guide practice.
- Create and maintain healthy work environments.
- Design innovations that change practice and outcomes.
- Participate on multidisciplinary and interdisciplinary teams that address ethical risks, benefits, and outcomes.
- Respect their nurses’ rights, autonomy, and responsibilities (ANA, 2016; ANA, 2015a).
To comply with Joint Commission requirements for a resolution process for ethics conflicts, many organizations and practice settings have formal ethics resources, but others do not. Ethics resources are “those individuals, teams, or committees, charged with addressing ethical problems and fostering ethical reflection at any level in an institution” (Hamric & Wocial, 2016, S22). The most common resources are ethics committees, ethics consult services, and individual ethicists. Services provided by chaplains and palliative care consultants are also resources. Hamric and Wocial (2016) note that “interprofessional team meetings, family meetings, institutional practices for managing error disclosure, Schwartz rounds, even shift huddles are potential reflective spaces where the moral responsibilities and accountabilities of team and patient/family can be clarified” (S23). Examined this way, resources to create ethical practice environments can extend to every practice setting while reflecting four important characteristics. Resources must be
- Sanctioned—i.e., supported by colleagues, managers, and administrators
Ethical Awareness and Competence
Nurses may not recognize situations with ethical content, be familiar with resources to resolve them, or be encouraged to access those resources that do exist. To create and engage in a moral community or ethical environment in any practice setting, a place that keeps “moral space open” (Walker, 1993, p. 33, as quoted in Liaschenko & Peter, 2016, p. S20) and in which members are encouraged to “reflect on their practice” (Wocial, 2018), nurses must first develop ethical awareness. Defined as recognition of the ethical implications of all nursing actions, ethical awareness begins with an understanding of the import and strength of nurses’ professional and ethical obligations as mandated in the Code (Milliken et al., 2018).
Ethical awareness is a precursor to ethical action and a component of ethical competence (Lechasseur et al., 2018; Robichaux, 2017), all of which should be recognized and fostered by faculty in academic settings and strengthened in all practice areas. Methods to enhance ethical skills include action-based or problem-based learning strategies, simulations, and discussions of relevant, real-world cases. Use of multi-modal methods that are repeated over time and incorporate reflective practice techniques may also raise awareness and enhance moral agency (Robinson et al., 2014; Milliken et al., 2018). While these approaches may be implemented in a formal setting, conversations that occur informally and promote ethical discourse in the workplace also help nurses develop ethical competence and a moral community and/or ethical environment (Milliken, 2018). Initiatives created by and for nurses, such as the ethics champion program (Fitzgerald et al., 2018) or ethics steward/nursing ethics council (Sauerland et al., 2015), provide a safe place where nurses can discuss issues and can support and learn from their peers, enhancing ethical competence. Such group reflection facilitates a “bottom up” rather than a “top down” approach, placing moral responsibility and ethical action in nurses’ hands (Rasoal et al., 2017).
Ethical leadership is essential to an ethical environment (Edmonson, 2015; Makaroff & Storch, 2019). Ethical leaders focus explicitly on ethical obligations and guidelines and hold others accountable to do the same. They encourage critical thinking and questioning regarding situations with ethical content. They stress transparency in an organization when establishing and sustaining ethical environments in practice settings. Several authors have proposed a framework that addresses the responsibilities and behaviors of nurse leaders at the macro, meso, and micro levels (Gallagher & Tschudin, 2010; Gaylord & Grace, 2018; Grace, 2018; Storch, 1994; Storch et al., 1994, 2013; Robichaux, 2017). The terms “macro,” “meso,” and “micro” reflect the environment of practice rather than the magnitude of influence of the ethical nurse leader.
The Department of Veterans Affairs National Center for Ethics in Healthcare has created a leadership assessment tool as part of its Integrated Ethics (IE) program (2018). This self-administered instrument assesses the behaviors and characteristics reflective of the four domains identified as integral to ethical leadership in the VA system:
- Demonstrate that ethics is a priority.
- Communicate clear expectations for ethical practice.
- Practice ethical decision-making.
- Support your local ethics program.
The ethical leadership tool can be adapted and/or used by other organizations, nurse leaders, and individual nurses (Chanko, 2017).
Recognizing that the nurse leader’s role is crucial to sustaining a healthy, ethical work environment that results in optimal patient outcomes, the American Organization for Nursing Leadership (AONL), formerly the American Organization of Nurse Executives (AONE), developed educational and certification programs to recognize and support the leadership role of nurse managers, directors, and executives (AONL, 2019). Several of the ethical leadership competencies identified by the AONL are consistent with Pavlish et al.’s (2015) recommendations:
- Engage in discussions with entity and system leaders that advance familiarity with ethical principles and incorporate values as guardrails for ethical decision-making.
- Facilitate standardized approaches to competency development in ethics and monitor regularly for all members of the system.
- Model principled, values-based, ethical thinking in the system.
- Effectively develop moral courage in expressions of clinical priorities, values, and perspectives at all system levels.
Assessing Ethical Climate
Nurses must assess the ethical environment of their practice settings. They can use assessment tools like the Hospital Ethical Climate Questionnaire (Olsen, 1998), the Moral Distress Thermometer (Wocial & Weaver, 2013), the Measure of Moral Distress in Healthcare Professionals (Epstein et al., 2019), and others. The Hospital Ethical Climate Questionnaire can be used to assess the ethical environment in acute care and other practice areas including long-term care and psychiatric settings (Koskenvuori, Numminen & Suhonen, 2019; Lützén et al. 2010; Suhonnen et al., 2015). The American Association of Critical Care Nurses (AACN) Healthy Work Environment Tool (AACN, 2018), based on the six evidence-based standards related to provision of safe, quality care, and maintenance of professional integrity, can also be employed. Recognizing that academic settings must be ethical environments that promote civility and collegiality, the National League for Nursing (NLN) has revised the Healthful Work Environment Toolkit (2018) to reflect recent research on contributing factors.
Incivility, Bullying, and Workplace Violence
Environments that are characterized by incivility, bullying, and lateral violence are inherently unethical and jeopardize both patient safety and professional integrity (ANA, 2015b; Clark, 2019a). Numerous strategies have been developed to strengthen respectful communication and conflict resolution skills among providers, including crucial conversations (Patterson, Grenny, McMillan & Switzler, 2012), elements of TeamSTEPPS (AHRQ, 2019), cognitive rehearsal (Griffin, 2004; Griffin & Clark, 2014), and cognitive rehearsal using evidence-based scripting (Clark, 2019b). Clark has conducted extensive research on incivility in academic and work environments and has developed a number of assessment tools, interventions, and programs that can be used to assess and strengthen civility from the personal to the organizational level (Clark, 2013; 2017; 2019a). Additional resources to enhance the ethical environment through the use of respectful dialogue and behavior are contained in the ANA position statement on incivility, bullying, and workplace violence (ANA, 2015b).
Across health care disciplines and practice areas, moral distress is often associated with suboptimal ethical environments and is a major contributor to burnout and leaving a profession (Austin, 2016; Epstein et al., 2019; Hamric & Epstein, 2017; Sauerland et al., 2014; Whitehead et al., 2015). Introduced by Corley in 2001, the Moral Distress Scale has been revised several times to reflect increased understanding of root causes. The current version, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), consists of 27 items representing those currently known components and can be used in acute care, outpatient, and long-term care settings. For those institutions or settings with limited resources, the MMD-HP may be used in high-risk areas to identify interventions for particular units, teams, and providers (Epstein, Whitehead, Prompahakul & Hamric, 2019).
The Moral Distress Thermometer (MDT) was created by Wocial and Weaver (2013) to address the “real time” presence of moral distress, to expedite the identification and delivery of effective interventions, and to track changes over time. The MDT has been used to evaluate an educational intervention to reduce the moral distress of physicians and nurses in a pediatric intensive care unit (Wocial et al., 2017) and, in conjunction with a moral dilemma survey, to assess the moral distress of school nurses (Powell, Engelke, & Swanson, 2018).
Moral Resilience and Courage
Moral resilience and moral courage may mitigate the effects of moral distress while helping nurses contribute to and maintain an ethical environment (Murray, 2010; Rushton, Schoonover-Shoffner & Kennedy, 2017; Turner, 2019). Recommendations to foster and support resilience at the individual and organizational levels include ethics education, cultivation of ethical competence, self-care, and implementation of evidence-based strategies (ANA, 2017; Rushton et al., 2017). To help nurse leaders be proactive about moral distress in clinical practice, Pavlish et al. (2016) developed the SUPPORT model. This model “provides strategies for nurse leaders to simultaneously develop nurses’ ethical skills and team-based dialogue while also creating policies shaped by standards of healthy work environments and the American Nurses Association Code of Ethics” (p. 319).
Recognizing that resilience is essential to nurse well-being and professional joy, Bernard (2019) incorporated elements of The Institute of Healthcare Improvement’s Framework for Improving Joy in Work (Perlo et al., 2017) and the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience (Brigham et al., 2018) to create a comprehensive toolkit for nurse leaders. Interventions to develop moral resilience are included in the toolkit in addition to strategies to address nurse fatigue and the necessity to decompress.
Individuals with moral courage have developed the skills of effective engagement and the “willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way” (Lachman, 2007, p. 131). Lachman (2007, 2010a, 2010b; Lachman et al., 2012) has written extensively about moral courage in nursing and links it to virtue ethics, which emphasizes the role of character in ethical situations. Moral courage in nursing practice has also been described as “risk taking actions, despite fear for self and others with the intent to ensure safe patient care,” and/or preserve provider integrity (Hawkins & Morse, 2014, p. 268). Nurses may develop moral courage by consistently practicing in an ethically courageous manner similar to the way they develop expertise in clinical skills through constant application. Many ethical situations are difficult, however, and, despite excellent motivation, may be emotionally and cognitively overwhelming. Lachman et al. (2007, 2012) have developed a simple mnemonic (CODE: courage to be moral, obligations to honor, dangers to manage, expression and action) that reminds nurses of their ethical obligations and actions as detailed in the Code of Ethics for Nurses (2015a). The CODE strategy helps recall these actions and includes ways to overcome fear and reluctance to speak up, including reflection, reframing, and assertiveness skills (Robichaux, 2017; Turner, 2019).
This position statement describes and facilitates each nurse’s duty to assert their moral voice, to assess the need for an ethical practice environment, and to integrate resources for ethical practice in all settings. Since ethics occurs within the context of relationships, those with whom nurses interact in their work environment must be included as important components of creating an ethical practice environment. The Code of Ethics for Nurses with Interpretive Statements (2015a) clearly outlines the nurse’s professional obligation to assure an ethical practice environment and to provide ethical leadership. The persistent lack of an ethical practice environment, despite repeated efforts by nurses to improve it, is detrimental to nurses and patients and may, as stated in the Code, be just cause for nurses to resign. Nurses foster the organizational conditions, practices, and norms that promote identification and discussion of ethical issues and develop analysis and decision-making skills to actively participate in resolving ethical concerns.
Liz Stokes, PhD, JD, RN
Liz Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including medical marijuana, assisted death, intellectual disabilities, and women's reproductive health. She is an international speaker on the Code of Ethics for Nurses is published in the Journal of Nursing Regulation and the Journal for Nurse Practitioners. Liz also serves as an Associate Editor for the Journal of Bioethical Inquiry. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing, ethics, law, and policy.
References, Bibliography, and Tools
Agency for Healthcare Research and Quality. (2019). TeamSTEPPS. AHRQ. https://www.ahrq.gov/teamstepps/index.html
American Association of Critical Care Nurses. (2018). Healthy Work Environments. Aliso Viejo, CA: AACN. https://www.aacn.org/nursing-excellence/healthy-work-environments?tab=Patient%20Care
American College of Healthcare Executives. (2019). Ethics toolkit. https://www.ache.org/about-ache/our-story/our-commitments/ethics/ache-code-of-ethics/creating-an-ethical-culture-within-the-healthcare-organization/ethics-toolkit
American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession (3rd ed.). Silver Spring, MD.
American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD. https://www.nursingworld.org/coe-view-only
American Nurses Association. (2015b). Incivility, bullying and workplace violence. Silver Spring, MD. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/
American Nurses Association. (2016). Nursing administration: Scope and standards of practice (3rd ed.). Silver Spring, MD.
American Nurses Association. (2017). Call to action: Exploring moral resilience: Toward a culture of ethical practice. Silver Spring, MD: ANA. https://www.nursingworld.org/~4907b6/globalassets/docs/ana/ana-call-to-action--exploring-moral-resilience-final.pdf
American Nurses Association. (2019). Healthy work environment. https://www.nursingworld.org/practice-policy/work-environment/
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). Silver Spring, MD.
American Organization for Nursing Leadership. (2019). AONL nurse leader competencies. Washington, D.C. https://www.aonl.org/resources/nurse-leader-competencies
Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30(1), 81–88. http://downloads.lww.com/wolterskluwer_vitalstream_com/journal_library/ans_01619268_2007_30_1_81.pdf
Austin, W. (2016). Contemporary healthcare practice and the risk of moral distress. Healthcare Management Forum, 29(3): 131-133.
Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11): 42-48. https://journals.lww.com/ajnonline/FullText/2017/11000/Creating_a_Fair_and_Just_Culture_in_Schools_of.28.aspx#pdf-link
Bernard, N. (2019). Resilience and professional joy: A toolkit for nurse leaders. Nurse Leader, 17(1): 43-48. https://www.nurseleader.com/article/S1541-4612(18)30283-0/fulltext
Bollig, G., Schmidt, G., Rosland, J. H., & Heller, A. (2015). Ethical challenges in nursing homes – staff’s opinions and experiences with systematic ethics meetings with participation of residents’ relatives. Scandinavian Journal of Caring Science, 29(4): 810-823.
Brigham, T., Barden, C., Dopp, A. L., et al. (2018). A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. NAM Perspectives, Discussion Paper. Washington, D.C.: National Academy of Science. https://nam.edu/wp-content/uploads/2018/01/Journey-to-Construct-Conceptual-Model.pdf
Cane, C. (2015). The 2014 scope and standards of practice for psychiatric mental health nursing: Key updates. OJIN: The Online Journal of Issues in Nursing, 22(1): Manuscript 1. https://ojin.nursingworld.org/table-of-contents/volume-20-2015/number-1-january-2015/2014-scope-and-standards-for-psychiatric-mental-health/
Chanko, B. (2017). Applying integrated ethics in nursing practice. In C. Robichaux (Ed.), Ethical competence in nursing practice: Competencies, skills, decision-making (pp. 277–302). Springer.
Clark, C. (2013). Clark workplace civility index, revised. Source: Creating and sustaining civility in nursing education. Indianapolis, IN: Sigma Theta Tau International Publishing.
Clark, C. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18-23. https://www.americannursetoday.com/wp-content/uploads/2015/11/ant11-CE-Civility-1023.pdf
Clark, C. (2016). Conflict negotiation, Parts 1&2. Reflections on Nursing Leadership, 42(1).
Clark, C. (2017). An evidence-based approach to integrate civility, professionalism, and ethical practice into nursing curricula. Nurse Educator, 42(3): 120-126. https://pdfs.semanticscholar.org/24be/f9a7c46c4c050352098b212cef6bf1e242a7.pdf
Clark, C. (2017). The path to organizational civility is marked PFOC. Reflections on Nursing Leadership, 43(1). https://www.reflectionsonnursingleadership.org/features/more-features/Vol43_1_the-path-to-organizational-civility-is-marked-pfoc
Clark, C. (2019a). Fostering a culture of civility and respect in nursing. Journal of Nursing Regulation, 10(1): 44-52.
Clark, C. (2019b). Combining cognitive rehearsal, simulation and evidence-based scripting to address incivility. Nurse Educator, 44(2): 64-68.
Corley, M., Elswick, Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing 33(2): 250–56.
Critical Access Hospital Ethics Resource Guide. (2012). https://www.ruralcenter.org/resource-library/critical-access-hospital-ethics-committee-resource-guide
Edmonson, C. (2015). Strengthening moral courage among nurse leaders. OJIN: The Online Journal of Issues in Nursing, Vol. 20 No. 2. https://ojin.nursingworld.org/table-of-contents/volume-20-2015/number-2-may-2015/articles-on-previously-published-topics/strengthening-moral-courage/
Edwards, M. P., McClement, S. E., & Read, L. R. (2013). Nurses’ responses to initial moral distress in long term care. Journal of Bioethical Inquiry, 10(3): 325-336. https://pubmed.ncbi.nlm.nih.
Emergency Nurses Association (ENA). (2019). Position statement: Healthy work environment in the emergency care setting.
Epstein, E., Whitehead, P., Prompahakul, C., Thacker, L., & Hamric, A. (2019). Enhancing understanding of moral distress: The measure of moral distress for healthcare professionals. AJOB: Empirical Bioethics, 10(2):113-124.
Fairbanks Center for Healthcare Ethics. (2015). Ethics consultation: When to call, what to expect (webinar). https://www.youtube.com/watch?
Fitzgerald, H., Knackstedt, A., & Trotochaud, K. (2018). Novel ethics champions program. American Nurse Today, 13(3). https://www.americannursetoday.com/novel-ethics-champion-programs/
Gallagher, A., & Tschudin, V. (2010). Educating for ethical leadership. Nurse Educator Today, 30(3), 224–227.
Gaylord, N., & Grace, P. (2018). Ethical leadership by advanced practice nurses. In P. Grace (ed.). (p. 153-170). Nursing Ethics and Professional Responsibility in Advanced Practice. Burlington, MA: Jones & Bartlett. http://samples.jblearning.com/9781284107333/Chapter_5.pdf?_ga=2.42012325.1087771735.1566410103-920114928.1566410103
Grace, P. (2018). Enhancing nurse moral agency: The leadership promise of Doctor of Nursing Practice preparation. OJIN: The Online Journal of Issues in Nursing, 23(1): Manuscript 4. https://ojin.nursingworld.org/table-of-contents/volume-23-2018/number-1-january-2018/enhancing-nurse-moral-agency/
Griffin M., & Clark, C. (2014). Revisiting cognitive rehearsal as an intervention against incivility and lateral violence in nursing: 10 years later. Journal of Continuing Education in Nursing, 45(12):535-54.
Haddad, L. M., and Toney-Butler, T. J. (2019). Nursing shortage. StatPearls. Treasure Island, FL: StatPearls Publishing. Cites WHO 2013 World Health Statistics Report. https://www.ncbi.nlm.nih.gov/books/NBK493175/
Hamric, A. B., & Epstein, E. (2017). A health system-wide moral distress consultation service: Development and evaluation. HEC Forum 29 (2):127–43. https//doi.org/10.1007/s10730-016-9315-y
Hamric, A. B., & Wocial, L.D. (2016). Institutional ethics resources: Creating moral spaces. Hastings Center Report, 46, S22–S27. https://doi.org/10.1002/hast.627
Hawkins, S., & Morse, J. (2014). The praxis of courage as a foundation for care. Journal of Nursing Scholarship, 46(4), 263–270.
Hem, M., Pederson, R., Norvoll, R., & Molewijk, V. (2015). Evaluating clinical ethics support in mental healthcare: A systematic literature review. Nursing Ethics, 24(4): 452-466.
Institute for Healthcare Improvement. (2019). IHI white papers: IHI framework for improving joy in work. http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx.
Jameton, A. (2017). What moral distress in nursing history can suggest about the future of healthcare. AMA Journal of Ethics, 19(6): 617-628. https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-04/mhst1-1706.pdf
Koskenvuori, J., Numminen, O., Suhonen, R. (2019). Ethical climate in nursing environment: A scoping review. Nursing Ethics, 26(2), 327-345. https://doi.org/10.1177/0969733017712081
Lachman, V. (2007). Moral courage in action: Case studies. MEDSURG Nursing, 16(4), 275–277.
Lachman, V. (2010a). Strategies necessary for moral courage. OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 3. http://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-and-Distress/Strategies-and-Moral-Courage.html
Lachman, V. (2010b). Do not resuscitate orders: Nurse’s role requires moral courage. MedSURG Nursing, 19(4), 249–251.
Lachman, V., Murray, J., Iseminger, K., & Ganske, K. (2012). Doing the right thing: Pathways to moral courage. American Nurse Today, 7(5), 24–29. https://www.americannursetoday.com/doing-the-right-thing-pathways-to-moral-courage/
Lechasseur K., Caux C., Dollé S., & Legault A. (2018). Ethical competence: An integrative review. Nursing Ethics, 25(6):694-706.
Liaschenko, J, & Peter, E. (2016). Fostering nurses’ moral agency and moral identity: The importance of moral community. Hastings Center Report 46(5): S18-S21. https://doi.org/10.1002/hast.626
Lützén, K., Blom, T., Ewalds-Kvist, B., Winch, S. (2010). Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nursing Ethics, 17(2):213-224.
Makaroff, K., & Storch, J. (2019). Guidance for ethical leadership in nursing codes of ethics: An integrative review. Nursing Leadership, 72(1): 60-79.
McDaniel, C., Roche, R., & Veledar, E. (2011). Ethics environment in LTC. Journal of Applied Gerontology, 30(1) 67-84.
Milliken, A. (2018). Ethical awareness: What it is and why it matters. OJIN: The Online Journal of Issues in Nursing, 23(1): Manuscript 1. https://ojin.nursingworld.org/table-of-contents/volume-23-2018/number-1-january-2018/ethical-awareness/
Milliken, A., Ludlow, L., DeSanto-Madeya, A., & Grace, P. (2018). The development and psychometric validation of the Ethical Awareness Scale. Journal of Advanced Nursing, 74(8): 205-216.
Murray, J. S., (Sept 30, 2010). Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk. OJIN: The Online Journal of Issues in Nursing, 15(3). https://ojin.nursingworld.org/table-of-contents/volume-15-2010/number-3-september-2010/moral-courage-and-risk/
National Center for Ethics in Healthcare. (2018). Ethical leadership: Fostering an ethical environment and culture. https://www.ethics.va.gov/integratedethics/ELC.asp
National League for Nursing. (2018). Healthful Work Environment Toolkit. Washington, DC: NLN. https://www.nln.org/docs/
Olson, L. L. (1998). Hospital nurses’ perceptions of the ethical climate of their work setting. Image: The Journal of Nursing Scholarship, 30(4), 345-349.
Patterson, K., Grenny, J., Mc Millan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when the stakes are high. New York, NY: McGraw-Hill.
Pavlish, C., Brown-Saltzman, K., So, L., Heers, A., & Iorillo, N. (2015b). Avenues of action in ethically complex situations: A critical incident study. The Journal of Nursing Administration, 45(6), 311–318.
Pavlish, C., Brown-Saltzman, K., So, L., & Wong, J. (2016). SUPPORT: An evidence-based model for leaders addressing moral distress. Journal of Nursing Administration, 46(3), 313–320.
Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., and Feeley, D. (2017). IHI Framework for Improving Joy in Work. (IHI White Paper.). Cambridge: MA. http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx
Powell, S., Engelke, M., Swanson, M. (2018). Moral distress among school nurses. The Journal of School Nursing, 34(5): 390-397.
Preshaw, D., Brazil, K., McLaughlin, D., & Frolic, A. (2016). Ethical issues experienced by healthcare workers in nursing homes: Literature review. Nursing Ethics, 23(5): 490-506.
Rasoal, D., Skovdahl, K., Gifford, M., & Kihlgren, A. (2017). Clinical ethics support for healthcare personnel: An integrative review. HEC Forum, 29 (313-336). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688194/
Reiley, K., & Jurchak, M. (2017). Developing professional practice and ethics engagement: A leadership model. Nursing Administration Quarterly, 41(4):376-383.
Robert Wood Johnson Foundation. (2015). Pacers: Civility toolkit webinars. https://www.youtube.com/channel/UCfambua1b0CnkdxMXtX36kA/feed
Robichaux, C. (2017). Applying ethics to the leadership role. In C. Robichaux (ed.), (p. 181-207). Ethical competence in nursing practice: Competencies, skills, decision-making. New York, N.Y.: Springer.
Robinson, E., Lee, S., Zollfrank, A., Jurchak, M., Frost, D., & Grace, P., (2014). Enhancing moral agency: Clinical ethics residency for nurses. Hastings Center Report, 44(5): 12-20.
Rushton, C., Schoonover-Shoffner, K., & Kennedy, S. (2017). Executive summary: Transforming moral distress into moral resilience in nursing. American Journal of Nursing, 117(2): 52-56. https://journals.lww.com/ajnonline/Fulltext/2017/02000/Executive_Summary__Transforming_Moral_Distress.27.aspx
Sasso, L., Delogu, B., Carrozzino, R., Aleo, G., & Bagnasco, A. (2018). Ethical issues of prison nursing: A qualitative study in Northern Italy. Nursing Ethics 25(3):393-409.
Sauerland, J., Marrotta, K., Peinemann, M., Berndt, A., & Robichaux, C. (2015). Assessing and addressing moral distress and ethical climate part II: Neonatal and pediatric perspectives. Dimensions in Critical Care Nursing, 34(1):33-46. https://journals.lww.com/dccnjournal/Fulltext/2015/01000/Assessing_and_Addressing_Moral_Distress_and.8.aspx#pdf-link
Savage, T. (2016). Ethical issues in school nursing. OJIN: The Online Journal of Issues in Nursing, 22(3): Manuscript 4. https://ojin.nursingworld.org/table-of-contents/volume-22-2017/number-3-september-2017/ethical-issues-in-school-nursing/
The Schwartz Center for Compassionate Healthcare. (2019). Supporting caregivers: Educational programs (webinar series). https://www.theschwartzcenter.org/supporting-caregivers/educational-programs/upcoming-compassion-action-webinars/
Storch, J. (1994). Ethical dimensions of nursing management. In: Hibberd, J. L. and Kyle, M. E. (eds.), (p. 142-158). Nursing management in Canada. Toronto, ON, Canada: WB Saunders Canada.
Storch, J., Makaroff, K., Pauly, B., & Newton, L. (2013). Take me to my leader: The importance of ethical leadership among formal nurse leaders. Nursing Ethics, 20(2),150–157.
Strauss, S. (2019). Sexual harassment in healthcare: Overview and summary. OJIN: Online Journal of Issues in Nursing, 24(1). https://ojin.nursingworld.org/table-of-contents/volume-24-2019/number-1-january-2019/os-sexual-harassment-in-healthcare/
Suhonnen, S., Stolt, M., Katajisto, J., Charalambous, A., & Olson, L. (2015). Validation of the Hospital Ethical Climate Survey for older people care. Nursing Ethics, 22(5):517-532.
The Society for Post-Acute and Long-Term Care Medicine (ethics resources). https://paltc.org/search/node/ethics
Turner, M. (2019). Moral courage: Knowing and doing the right thing. Nurse Insider, 2(4): https://indd.adobe.com/view/60b9569e-6e1b-4d23-90ec-9b65991f816d
United States Department of Veterans Affairs Center for Ethics in Healthcare. (2018). Ethical leadership: fostering an ethical environment and culture. Ethical leadership self-assessment tool. https://www.ethics.va.gov/integratedethics/ELC.asp
van der Dam, S., Molewijk, B., Widdershoven, G. A., & Abma, T.A. (2014). Ethics support in institutional elderly care. Journal of Medical Ethics, 40(9):625-6
Walker, M. (1993). Keeping moral space open: New images of ethics consulting. Hastings Center Report 23(2):33-
White, K., Jordens, F., & Kerridege, I. (2014). Contextualizing professional ethics: The impact of the prison context on the practices and norms of health care practitioners. Bioethical Inquiry, 11(3): 333-3
Whitehead, P., Herbertson, R., Hamric, A., Epstein, E., & Fisher, J. (2015). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2):117–25. https://doi.org/10.1111/jnu.12115
Wocial, L. (2018). In search of a moral community. OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 2. https://ojin.nursingworld.org/table-of-contents/volume-23-2018/number-1-january-2018/search-of-moral-community/
Wocial, L., Ackerman, V., Benneyworth, B., Patel, V., Tong, Y., & Nitu, M. (2017). Pediatric ethics and communication excellence (PEACE) rounds: Decreasing moral distress and patient length of stay in the PICU. HEC Forum, 21(9):75-91. https://scholarworks.iupui.edu/bitstream/handle/1805/13961/Wocial_2016_pediatric.pdf?sequence=1&isAllowe
Wocial, L., & Weaver, M. (2013). Development and psychometric testing of a new tool for detecting moral distress: The Moral Distress Thermometer. Journal of Advanced Nursing 69(1), 167–174.
Appendix A: Additional ANA Guidance and Authority Supporting the Need for Ethical Practice Environments
Many previous ANA position statements and related guidance demonstrate standards that nurses can use to influence decision makers who are critical to enhancing ethical practice environments. These include:
Nurses have the right to:
- Practice in a manner that fulfills their obligations to society and to those who receive nursing care.
- Practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice.
- Work in an environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses with Interpretive Statements (2015).
- Freely and openly advocate for themselves and their patients, without fear of retribution.
- Receive fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities.
The 2010 position statement (requires ANA membership to access) states:
The Just Culture model, which has been widely used in the aviation industry, seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues. … Traditionally, healthcare’s culture has held individuals accountable for all errors or mishaps that befall patients under their care. By contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A Just Culture also recognizes many individual or “active” errors represent predictable interactions between human operators and the systems in which they work. However, in contrast to a culture that touts “no blame” as its governing principle, a Just Culture does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record, performing professional duties while intoxicated).
Assuring patient safety: RN responsibility in all roles and settings to guard against working when fatigued (2014)
Registered nurses and employers in all care settings must collaborate to reduce the risks of nurse fatigue and sleepiness associated with shift work and long work hours.
Both registered nurses and employers have an ethical responsibility to carefully consider the need for adequate rest and sleep when deciding whether to offer or accept work assignments, including on-call, voluntary, or mandatory overtime.
Patient Safety: Rights of RN when considering a patient assignment (2009)
Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.
ANA believes that registered nurses—based on their professional judgment and ethical responsibilities—have the right to reject, accept, or object in writing to any patient assignment that potentially puts patients or themselves at serious risk for harm.
The Nurse’s Role in Addressing Discrimination: Protecting and Promoting Inclusive Strategies in Practice Settings, Policy, and Advocacy (2018)
ANA recognizes impartiality begins at the level of the individual nurse and should occur within every health care organization. All nurses must recognize the potential impact of unconscious bias and practices contributing to discrimination, and actively seek opportunities to promote inclusion of all people in the provision of quality health care while eradicating disparities.
The nursing profession is responsible for promoting an environment of inclusiveness where all receive safe, quality care and caregivers are intolerant of any discriminatory practice.
Incivility, Bullying, and Workplace Violence (2015)
This position statement has recommendations for primary, secondary, and tertiary preventions for bullying in the workplace; it states that the nursing profession will no longer tolerate violence of any kind from any source. All RNs and employers in all settings, including practice, academia, and research, must collaborate to create a culture of respect that is free of incivility, bullying, and workplace violence.
ANA Scope and Standards (2021)
ANA’s authoritative Scope and Standards documents for nursing practice and for several specialties of nursing describe each nurse’s obligation to lead collective and collaborative advocacy to promote environments that facilitate ethical practice. Examples of relevant standards include:
- Coordination of care: The RN coordinates care delivery (Standard 5A).
- Ethics: The RN practices ethically (Standard 7).
- Communication: The RN communicates effectively in all areas of professional practice (Standard 10).
- Leadership: The RN leads within the profession and practice setting (Standard 12).
- Quality of Practice: The RN contributes to quality nursing practice (Standard 15).
- Professional Practice Evaluation: The RN evaluates one’s own and others’ nursing practice (Standard 16).
- Environmental Health: The RN practices in a manner that advances environmental safety and health (Standard 18).
Examples of relevant competencies include:
- Identifies actual or potential risks to the health care consumer’s health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural, socioeconomic, or environmental circumstances (p. 77)
- Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care (p. 90).
- Promotes safe care of health care consumers, safe work environments, and sufficient resources (p. 91).
- Promotes safety in the care or practice environment by disclosing and reporting concerns related to potential or actual hazards or deviations from the standard of care (p. 95).
- Engages in creating an interprofessional environment that promotes respect, trust, and integrity (p. 97).
- Develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team (p. 80).
- Facilitates a work environment supportive of ongoing education of health care professionals and interprofessional colleagues (p. 99).
- Creates a safe and healthy workplace and professional practice environment (p. 106).
- Demonstrates a primary commitment to the recipients of nursing and health care services in all settings and situations. (Fidelity) (p. 89).
- Engages in self-care and self-reflection practices to support and preserve personal health, well-being, and integrity (p. 90).
- Advocates for the health care consumer and their preferences and choices when care processes and decisions do not appear to be in the best interest of the health care consumer (p. 95).
- Embraces practice innovations and role performance to achieve lifelong personal and professional goals (p. 97).
- Communicates to lead change, influence others, and resolve conflict (p. 97).
- Partners with the health care consumer and key stakeholders to advocate for and effect change, leading to positive outcomes and quality care (p. 96).
- Fosters a professional environment that does not tolerate abusive, destructive, and oppressive behaviors (p. 106).
- Promotes evidence-based practices to create a psychologically and physically safe environment (p. 106).
- Mentors nurses new to their roles for the purpose of ensuring successful enculturation, orientation, competence, and emotional support (p. 99).
- Incorporates technologies to promote safe practice environments (p. 107).
- Engages health care consumers in self-care to achieve preferred goals for quality of life (p. 84).