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Nursing Ethics for the 21st Century

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A National Summit on Nursing Ethics: Literature Review

Ethics has been integral to the nursing profession from its earliest beginnings, when Florence Nightingale and other early pioneers articulated the ethical foundations of nursing practice. This foundation is vital for the future of nursing as the profession rises to the challenges of a rapidly evolving health care sector.

The need for a thorough understanding of current ethical issues facing nursing, as well as reflection on potential future challenges, prompted preparation of a review of the voluminous body of relevant recent literature in three key domains: clinical practice, nursing education, and nursing research. A separate review of the literature on ethics in nursing policy was not performed, in the belief that policy issues would emerge from consideration of the other three domains. Nor was a separate review of the philosophical and theoretical literature related to nursing ethics or the literature related to the ongoing education of practicing nurses included. Finally, the research ethics section does not include research about nursing ethics. All represent areas for future work.

The literature review was intended not only to uncover what we know about the ethical issues, practices, and topics, and the strength of that knowledge, but also to find out what we don’t know. Detailed reports on the literature reviews will be submitted for publication in appropriate journals at a later date.

what we need to know_ROL


Literature relevant to ethics in nursing practice, nursing education, and nursing research was divided among three groups of reviewers. The researchers used key words to search various databases, including PubMed, CINAHL, Ovid and Eric, for research published since 2004.  Summit organizers extend deep appreciation to Marion Broome, Lucia D. Wocial, C.C. Tang, Stacey Crane, Jeri Miller, Patricia Davidson, Melissa Kurtz, and Brian Wise for their contributions.

A separate review of the literature on ethics in nursing policy was not performed, in the belief that policy issues would emerge from consideration of the other three domains (clinical practice, education, and research).

The literature review was intended not only to uncover what we know about the ethical issues, practices, and topics, and the strength of that knowledge, but also to find out what we don’t know. Detailed reports on the literature reviews will be submitted for publication in appropriate journals and their availability reported here.

Clinical Practice

Reviewers of the Nursing Clinical Practice Literature:

Patricia M. Davidson, PhD, MEd, RN, FAAN
Professor and Dean, School of Nursing
Johns Hopkins University (JHU)

Melissa Kurtz RN, MSN
Doctoral Student
JHU School of Nursing
mkurtz4@jhu.eduBrian Wise, BSN
Student, 2014
JHU School of Nursing

Cynda Hylton Rushton PhD, RN, FAAN
Anne and George L. Bunting Professor of Clinical Ethics
JHU Berman Institute of Bioethics/School of Nursing
Professor of Nursing and Pediatrics

What is Known?

  • System, provider, and patient factors influence ethical issues in nursing clinical practice, and these issues are increasing in both diversity and complexity
  • There are both emerging and persistent ethical issues for patients from vulnerable groups and with specific diagnoses (e.g., mental disorders, physical disabilities, certain infectious diseases)
  • Population aging, globalization, technological innovation, advances in screening and genetic science create new and complex dilemmas for nurses
  • Increasing recognition of the social determinants of health as moderating health outcomes creates new challenges in access and acceptability of health care interventions
  • Many ethical issues occur among critically ill patients at the two extremes of the age spectrum – the very young and the very old
  • Nurses may experience role conflict and ambiguity in practice settings
  • Electronic medical records and the analysis of massive patient data sets raise concerns about privacy, confidentiality, and data sharing
  • Nurses play a key role in patient advocacy and monitoring health outcomes and are leading empirical work in addressing ethical challenges and providing a voice for patients and their families
  • Moral distress appears widespread among nurses and is present in nearly every work environment, while sources of resilience and problem-solving skills can lead to moral courage


What knowledge needs to be developed?

  • Negotiation of ethical principles and values in an increasingly diverse and pluralistic society and articulation of how these relate to nursing practice in the digital age
  • Reconcile ethical values and principles that undergird nursing practice with legal, social, religious/spiritual, cultural, and other frameworks
  • A more robust model of moral agency in nursing, including the knowledge, skills, and internal capacities that are needed to create self-awareness, self-respect, and effective advocacy
  • Methods to recognize moral distress, identify root causes, and develop a wide variety of interventions to help prevent and mitigate it
  • Advancement of nursing science to increase the number of interventions that are tailored and targeted to specific populations and ethical issues
  • Consideration of ethical issues for nursing within a context of system, clinician, and patient factors
  • Global factors, such as climate change and increasing pandemics, require a coordinated and integrated response, including nurses as part of the dialogue and decision-making

Selected Resources on Ethics in Nursing Practice

Nursing Education

Reviewers of the Nursing Education Literature:

Chia-Chun (CC) Tang, RN, OCN, MSN
PhD student, Indiana University
Lucia D. Wocial, PhD, RN
Nurse Ethicist, IU Health
Adjunct Assistant Professor, Indiana University

What is Known?

Teaching in the classroom: curricular content, teaching strategies, instructor preparation and class evaluation:

  • Studies have identified what should be included in the nursing ethics curriculum: basic concepts of ethics, codes of ethics for nurses, ethical principles and moral conflicts, and ethical problems in health care
  • Nursing ethics classes place more emphasis on general concepts and rules and special ethical issues occurring in health systems and less attention to wider social contexts
  • Culture influences the moral conflicts or ethical problems discussed in classrooms
  • Both students and instructors perceive that ethics education is important and relevant to clinical practice
  • While most programs do not require educators to complete formal ethics training, both educators and students rate educators’ knowledge of professional codes as adequate

Learning in the classroom: students’ ethical behavior manifests in the classroom:

  • Some unethical behavior, such as dishonesty, appears to predict future unethical behavior
  • Both educators and students believe academic dishonesty is a common problem, and the rate of academic dishonesty for nursing undergraduate students is similar to that of other undergraduates
  • Incivility is a bidirectional problem perpetrated by both student and faculty

Learning as a student in the clinical environment:

  • Ethical problems encountered when practicing as a student nurse included concerns about using patients as teaching material, making ethical decisions in practice settings, students’ observation of ethical problems, and concerns regarding using social media and relationships with pharmaceutical reps
  • Students in the clinical setting are unprepared to address ethical issues and tend to defer to staff nurse recommendations when making ethical decision in clinical settings, even if the advice contradicts best-practice standards
  • Student nurses’ limited clinical skills, lower status, and reticence lead to frustration, feelings of powerlessness, and silence


What is yet to be discovered?

  • The adequacy of current ethical education content for advanced nursing students (e.g., nurse practitioner, clinical nurse specialist, and doctoral students) is unknown
  • More studies are needed to explore emerging topics such as the impact on students of educators’ ethical behavior in the classroom and problems with social media
  • While some researchers advocate inter-disciplinary ethics education, more evidence regarding similarity of need, as well as class design, outcome, and feasibility is needed
  • Best practices for ongoing professional development and maintenance of ethics knowledge within the active nurse workforce
  • Research is needed to understand the adequacy and content of ongoing education for practicing nurses

Selected Resources on Ethics in Nursing Education

Nursing Research

Reviewers of the Nursing Research Literature:

Stacey Crane, MSN, RN, CCRP, CPON
PhD student, Indiana University
Marion E. Broome, PhD, RN, FAAN
Dean, Duke University School of Nursing

What is known?

  • The principles of the Belmont report (respect for persons, beneficence, and justice) endure as guiding principles for ethical research practices
  • Future approaches to address gaps in ethical regulations need to consider the research process and context, the target population, and the researcher-participant relationship, as well as societal requirements
  • Recurring themes in nursing research ethics are conflicting values (particularly between theoretical ethical standards, nursing practice, and nursing research), ambiguity in decision-making processes, scientific merit and integrity, and the protection of human subjects
  • Skills recognized as necessary in the ethical researcher include moral sensitivity, moral reasoning, moral commitment, and moral perseverance
  • Nurse researchers must be prepared with an ethical framework for identifying and handling dilemmas before they enter the field to conduct research
  • Informed consent is a process that must be participant-centered and that starts far sooner than the encounter where the actual consent document is signed; it unfolds as information about the proposed research is framed, communicated, and processed
  • Nurses have the ability to improve the informed consent process by incorporating strategies and measures to ensure patient comprehension
  • Incentives can serve as a sign of appreciation for the contributions of research participants and to facilitate clinical and behavioral research, but they are inappropriate when offered to participants who cannot freely make an informed choice
  • Gate-keeping occurs when healthcare providers or family members prevent access to eligible patients for research recruitment. Health care provider gatekeeping violates the ethical principles of autonomy, beneficence, and justice
  • Challenges to the researcher-participant relationship include potential for coercion and unintentional fostering of a therapeutic misconception
  • Ethical challenges for nurses involved with clinical trials include ensuring informed consent, maintaining confidentiality, and balancing dual roles of caring for the participant and performing research
  • Participatory research increases the relevance and legitimacy of the research to the affected community and participants, defines what is ethically acceptable, improves the informed consent process and the protections afforded participants, and ensures they receive research results
  • There is a need to balance protection of those deemed vulnerable with the risks created by limiting their involvement in research that could generate knowledge of potential benefit to them and otherwise impossible to obtain
  • Long-term care research presents specific challenges related to privacy and confidentiality, particularly during videography and interviewing
  • Researchers allow the principle of beneficence to supplant respecting autonomy when conducting research involving children. Intention support is critical to ensure children’s understanding, willingness to participate, and lack of parental or caregiver coercion
  • Nurses can serve as advocates for neonates in research and as safety monitors
  • Researchers studying people in vulnerable populations (e.g., children, prisoners, women experiencing violence, people with mental illnesses) must engage in reflective practice to ensure ethical research
  • Ethical threats when conducting research among people with dementia include their capacity to consent and the potential for disclosure of a diagnosis previously unknown to the participant
  • Heightened sensitivity to burden of data collection and vigilance about changing medical condition is critically important for researchers involved in end-of-life studies, suggesting a strong need for supervisory models in this population


What is yet to be discovered?

  • What are new models of informed consent that can guide research in developing countries when Western bioethical principles fail to acknowledge relevant cultural factors?
  • What are the adequate evaluation criteria that will maintain the rigor of the methodology and results during participatory action research with a vulnerable population?
  • What approaches can be used to address ethical regulations, while at the time consider research process and context ,the unique needs of vulnerable populations, and the researcher-participant relationship?
  • How do we measure and ensure researchers employ moral sensitivity, moral reasoning, moral commitment, and moral perseverance when working with individuals in the research context?
  • Does reflective practice, when engaged in by researchers working with vulnerable population in research, improve their ability to identify, anticipate and plan for resolving ethical dilemmas which inevitably arise?

Selected Resources on Ethics in Nursing Research

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