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Journal of Nursing Law, Volume 13, Number 3, 2009
68 • Copyright © 2009 Springer Publishing Company DOI: 10.1891/1073-7472.13.3.68
Ethical Issues in Nursing Practice
Mihyun Park, MSN, RN
Nurses play a role as advocates to assist patients and families struggling with complex information and difficult decisions. In particular, the fact that nurses encounter clinical situations that require ethical judgment highlights the need for nursing staff to gain knowledge and expertise in deliver- ing care in an ethical manner. In this study, through reviewing empirical studies of hospital-based nurses’ experiences, the author identified the ethical issues that nurses frequently face and the approaches that they have taken to solving them. The findings can serve to intensify the awareness of the ethical issues in both clinical and educational areas.
Keywords: ethical issues; nursing practice; education; hospitals
Advances in medical technology allow for bet-ter recovery for critically ill patients and dramatically extend the human life span. However, while advances bring benefits to patients and families, they simultaneously raise moral and ethical issues regarding respect for patient integrity and autonomy, soaring medical costs, quality care, and end-of-life decision making (Scanlon & Fleming, 1990; Wright, Cohen, & Caroselli, 1997). As the largest group of health care providers, nurses are frequently placed in unique positions to assist patients and families struggling with complex information and dif- ficult decisions (Briggs & Colvin, 2002). The fact that nurses encounter clinical situations that require ethi- cal judgment highlights the need for nursing staff to gain knowledge and expertise in delivering care in an ethical manner.
Reporting the lack of ethical confidence among newly graduated nurses, nursing ethics researchers have emphasizes the importance of having well- educated and well-qualified nurses who know how to find feasible solutions to ethical problems (Bunch, 2001; Woods, 2005). Although nursing schools have become more concerned with the ethical development of their students, researchers point out that education has not reflected reality and does not prepare newly qualifying nurses to deal effectively with a variety of ethical situations in the health care setting ( Woods, 2005). The traditional ethics education has tended to emphasize the acquisition of philosophical and
theoretical knowledge and has created a gap between theory and practice ( Woods, 2005). New approaches are needed for teaching nursing ethics pragmatically.
The nursing ethic as a dynamic standard for nurses’ professional moral behavior should address ethical issues confronted by nurses (Omery, Henneman, Bil- let, Luna-Raines, & Brown-Saltzman, 1995). Therefore, knowledge about specific nursing ethical issues found in the health care setting and understanding the impact of these issues on practice will be essential, pragmatic parts of nursing ethics education. That is, the ethical issues are subjects that should be dealt with in ethics education for nursing students before entering in nurs- ing practice. Thus, identifying what issues should be dealt with in classes is needed.
Researchers have tried to identify ethical issues that nurses confront in the clinical area since Vaughan’s (1935) study. The earliest study of ethical issues in nursing practice (Vaughan, 1935) identified 2,265 ethical issues based on the diaries of 95 nurses that recorded ethical issues. Since this study, many other studies have been focused on ethical issues that affect the profession of nursing and the everyday practice of individual nurses using qualitative methodolo- gies. In a review study, Christensen (2002) identified the ethical and legal issues that oncology nurses in hospitals face: (a) advance directives, ( b) do-not- resuscitate orders, (c) documentation and patient privacy, (d) informed consent, (e) medication errors, and (f ) pain management. A systematic analysis
Park • Ethical Issues in Nursing Practice • 69
study of nurses’ ethical conflicts identified each main ethical issue in a particular role or setting (Redman & Fry, 2000). Examples were (a) harm/good of life- prolonging aggressive therapies (intensive care unit); ( b) inadequacy of resources for care (administration); (c) undertreatment, consent, and refusal of treatment (oncology); (d) disagreement with quality of medical care (diabetes educators); and (e) protection of child’s rights (pediatric nurse practitioner). However, a sys- tematic review of ethical issues encountered by nurses in current practice is rarely found.
The purpose of this study is to review the empiri- cal studies of hospital-based nurses’ experiences with ethical issues to identify (a) the ethical issues nurses face and ( b) the approaches they have taken to solving them.
METHODS
This article reviewed quantitative studies of hospital- based nurses’ experiences with ethical issues. To be included in this review, a publication was to have reported the findings from a research project studying nurses’ experiences. The integrative review included the reports of primary research studies that were pub- lished in the English language from 1990 and 2007. This study began with a search of multiple library databases, including PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health (CINAHL), and ISI Web of Knowledge, to identify research related to ethical issues that nurses face. Key words used in the search process were “nursing ethics” and “issue” and/or “problem.” Additional literature was identified by reviewing the reference lists of journal articles identified during the literature review.
Examination of the published abstracts and studies resulted in a decrease of the number of studies included in the first sampling because studies that did not match the project criteria were excluded ( n = 25). This study was limited to hospital-based research and settings in the United States. Most studies in special clinic areas dealt with a more specific ethical issue or conflict situa- tion. Therefore, these articles were excluded. However, this review included the studies done in operating room areas and collected data from registered nurses in a local area because the studies dealt with more general ethical issues encountered by perioperative nurses or registered nurses with a large sample size. One article that collected data from directors of nursing in hos- pitals was included because the directors explained ethical issues not that they faced but that were faced by staff nurses. Therefore, through the second review, the
researcher excluded the articles that did not match the purpose of this project.
This review classified the ethical issues reported by each study into three categories of the Ethical Issues Scale (EIS): end-of-life treatment decisions, patient care issues, and human rights issues. Fry and Damrosch (1994) developed the EIS in a study of Maryland nurses. The EIS was validated with a sample of New England registered nurses currently in practice (Fry & Duffy, 2001). The scale described the full range of ethical issues experienced by nurses in current practice. The 32-item scale represented three conceptual categories of ethical issues: end-of-life treatments, patient care, and human rights (Fry & Duffy, 2001) (see Table 1). The end-of-life treatment category was defined as issues about death or the dying process and included 13 issues. The patient care category addressed issues about how patients receive or do not receive quality nursing or health care (14 items). The human rights category was defined as issues concerning the rights of nurse, patients, and family members (five items). The EIS pro- vides information about the full range of ethical issues of registered nurses in active practice experience. The reliability and validity of the EIS have been validated through a study with a large RN sample ( n = 2,090) and nurses with expertise in bioethics (Fry & Duffy, 2001).
RESULTS
Twenty-five studies were identified through the first review process, and 11 studies met the inclusion crite- ria. All studies used a descriptive research method with survey instruments. Articles reviewed were classified into two settings: hospital and operating room. One article collected data from registered nurses in Mary- land; this article was integrated to hospital setting data. The ethical issues reported in reviewed studies were divided into three categories (end-of-life treatment decisions, patient care issues, and human rights issues) in the EIS. This review described disturbing ethical issues that were encountered by nurses separated from the frequent ethical issues. This study identified the top five frequent ethical issues and disturbing ethical issues reported in each article and then integrated and analyzed these issues. Furthermore, this study identi- fied the approaches that nurses have taken to solve the ethical issues and the resources that nurses frequently used to get help and information.
Ethical Issues
As shown in Table 2, the most of frequent ethical issues faced by nurses related to patient care issues and human
70 • Journal of Nursing Law • Vol. 13, No. 3
TABLE 1. The Ethical Issues Scale
Component 1: End-of-life treatment decisions
Prolong dying process with inappropriate measures Treatment or nontreatment despite patient or family wishes Use or removal of life support including nutrition and hydration To resuscitate or not to resuscitate Treatment or nontreatment of very disabled infant, child, adult Not considering quality of patient’s life Acting against your own personal or religious views Acting against patient’s personal or religious values Determining when death occurs Organ transplantation, or organ or tissue procurement Over- or underuse of pain management Ordering too many or too few procedures, tests, etc. Participation or refusal to participate in euthanasia or assisted suicide
Component 2: Patient care issues
Staffing patterns that limit patient access to nursing care Child or spousal or elderly or patient abuse or neglect Allocation of resources (human, financial, equipment) Implementing managed care policies threatening quality of care Breaches of patient confidentiality or privacy (e.g., HIV status) Irresponsible or unethical or incompetent or impaired colleague Ignoring patient or family autonomy Patients or families uninformed or misinformed about treatment, prognosis, medical alternatives Rights of minors versus parental rights Discriminatory treatment of patients Unsafe equipment or environmental hazards Conflict in nurse or doctor relationship (or other professional relationship) Reporting unethical or illegal practice of health professional or health agency Implementing managed care policies threatening availability of care
Component 3: Human rights issues
Use or nonuse of physical or chemical restraints Issues involving advance directives Protecting patient rights and human dignity Informed consent to treatment Providing care with possible risk to RNs’ health (e.g., TB, HIV, violence)
Note. From “The development and the psychometric evaluation of the Ethical Issues Scale,” by Fry and Duffy, 2001, Journal of Nursing Scholarship, 33(3), p. 276.
rights issues rather than end-of life issues. The most frequent issues were founded in patient care issue cat- egory. Of patient care issues that nurses encountered, staffing patterns that limit patient access to nursing care ( n = 6) was the most frequent ethical issue. In addition, nurses frequently encountered patient care issues such as conflict in nurse or doctor relationship ( n = 4), alloca- tion of resources (human, financial, equipment) ( n = 4), patient confidentiality or privacy ( n = 4), and incom- petent or impaired colleague ( n = 4). In human rights issue category, the following three items were identi- fied as the most frequent ethical issues: (a) protecting patient rights and human dignity ( n = 5), (b) providing
care with possible risk to RNs’ health ( n = 5), and (c) informed consent to treatment ( n = 4).
When this review separated the setting into a gen- eral hospital versus operating room area, studies done in a general hospital setting identified other frequent ethical issues: dealing with an irresponsible or unethi- cal or incompetent or impaired colleague (Berger, Sev- erson, & Chvatal, 1991; Cook, Hoas, & Joyner, 2000), end-of-life care (Killen, 2002; Scanlon, 1990, 1994), and pain management (Omery et al., 1995; Scanlon, 1994). Nurses in hospitals reported that they experienced fre- quent ethical problems related to patient confidential- ity or privacy issues as well as staffing patterns issues.
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