Which describes the role of the nurse in the resolution of ethical dilemmas?

If you are a nurse, chances are you have faced situations where you had to make decisions based on your belief of whether something is right or wrong, safe or unsafe. This type of decision is based upon a system of ethical behavior. It is essential that all nurses develop and implement ethical values into nursing practice. If this sounds familiar, you may be asking, "What are the common examples of ethical dilemmas in nursing?" There are many things that could be considered an ethical dilemma in nursing, and it is important for nurses to know how to address them when they occur. In this article, I will share the 20 most common examples of ethical dilemmas in nursing and offer some insight into handling them.

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What Is An Ethical Dilemma In Nursing?

5 Main Reasons Why Nurses Face With Ethical Dilemmas In Nursing

1. Patients or their loved ones must make life or death decisions
2. The patient refuses treatment
3. Nursing assignments may contradict cultural or religious beliefs
4. Nursing peers demonstrate incompetence
5. Inadequate staffing

How To Identify Ethical Dilemmas In Nursing?

WHAT ARE THE COMMON EXAMPLES OF ETHICAL DILEMMAS IN NURSING?

Example #1: Pro-Life vs. Pro-Choice

Scenario:

Ethical Dilemma:

How to Deal with this Ethical Dilemma:

Although Nurse Jennifer does not believe in abortion, she should not express her personal beliefs or opinions to the patient. Instead, the nurse should encourage the patient to talk with her significant other (if appropriate), family, spiritual advisor, or others she feels she can confide in and seek advice. The nurse should schedule a follow-up visit with the physician to discuss options and decisions before the two-week deadline by which the doctor wants to perform the procedure.

Nurses frequently find themselves involved in conflicts during patient care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.

An ethical dilemma can involve conflicting patient’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.

Table 6.3a Examples of Ethical Issues Involving Nurses

WorkplaceOrganizational ProcessesClient Care

• High client acuity
• Inadequate staffing
• Overuse of agency staff
• Improper use of assistive personnel
• Practicing beyond one’s scope of practice
• Floating to other units without appropriate orientation
• Horizontal violence/workplace bullying
• Impaired coworkers
• Violation of client privacy on social media

• Paperwork and administrative task requirements
• Substituting outpatient for inpatient care
• Spending limits on care based on reimbursement codes for medical conditions
• Discharging clients too soon and expecting family members to provide care

• Reproduction Issues
  • Abortion
  • Birth control methods
  • Sterilization
  • Alternative conception

• End-of-Life Issues
  • Physician-assisted suicide
  • Withdrawal of food/fluids
  • Withdrawal of life support
  • DNR/DNI
  • Full code despite a persistent vegetative state

• Genetics
  • Screening
  • Stem cell research
  • Cloning
• Organ transplantation
• Patient refusal of medications or treatments

Read more about Ethics Topics and Articles on the ANA website.

According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors:

• Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
• An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements
• Knowledge of ethical principles and their application to ethical decision-making
• Motivation and skills to implement an ethical decision

Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.” See Figure 6.7 for an illustration of nurses’ moral courage.

Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up. Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during patient care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.

Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations. Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs. Read more about self-care strategies to address feelings of burnout in the “Burnout and Self-Care” chapter.

Frameworks for Solving Ethical Dilemmas

Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model. When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.

Nursing Process Model

The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.

Table 6.3b Using the Nursing Process in Ethical Situations

Nursing Process StageConsiderationsAssessment/Data Collection

• What is the issue?
• Who is involved?
• What are the facts (health status, pain, treatment)?
• What are the stakeholder (client, family, health care team, community) concerns?
• What ethics resources exist (such as an organization’s ethics committee)?

• Analyze the facts and stakeholder values using ethical principles, ethical theories, the ANA Nursing Code of Ethics, or another ethical framework model.
• Document the ethics resources consulted.

• Determine the care context and issues, including areas of agreement and conflict.
• Consider the entire context, including the client, family, health care team, and institutional circumstances.

• Establish a goal based on client autonomy.

• Identify a range of options, realizing there may only be “best available” options when possibilities are limited.

• Ensure the option chosen is right, suitable, and appropriate. Be aware that not all options are appropriate in all contexts.
• Implement the plan in collaboration with the client, family, and other stakeholders.

• Evaluate what happened and what can be learned after every ethical dilemma.

Four-Quadrant Approach

The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features. See Table 6.3c for sample questions used during the four-quadrant approach.

Table 6.3c Four-Quadrant Approach

Health Care Indications

(Beneficence and Nonmaleficence)

• What is the diagnosis/prognosis?
• What are the goals of treatment/care?
• What is the likelihood of success of treatment?
• Will the proposed treatment plan benefit the client and avoid harm?

(Respect for Autonomy)

• What are the client’s preferences?
• Does the client understand their condition?
• Has the client provided informed consent, and do they understand the risks and benefits of the proposed treatment?
• Is the client competent and capacitated to make decisions? If not, are there advance directives in place?

(Beneficence, Nonmaleficence, and Respect for Autonomy)

• What is the probability of the client’s return to normal life with or without treatment?
• Would the person experience any physical, mental, or social deficits even if the treatment succeeds?
• Do the health care providers have any biases that might prejudice their evaluation of the client’s quality of life?
• Has forgoing treatment been discussed?
• Are there plans for comfort and/or palliative care?

(Justice and Fairness)

• Are there family or provider issues, such as implicit bias, that might influence treatment decisions?
• Are there religious, financial, social, racial, or legal issues that might affect treatment decisions?
• Are there issues related to allocation of resources that might affect treatment?

MORAL Model

The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.,

Table 6.3d MORAL Model

M: Massage the dilemmaCollect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal.O: Outline optionsGenerate several effective alternatives to reach the goal.R: Review criteria and resolveIdentify moral criteria and select the course of action.A: Affirm position and actImplement action based on knowledge from the previous steps (M-O-R).L: Look backEvaluate each step and the decision made.

PLUS Ethical Decision-Making Model

The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:

• P: Policies, procedures, and guidelines of an organization
• L: Laws and regulations
• U: Universal values and principles of an organization
• S: Self-identification of what is good, right, fair, and equitable

The seven steps of the PLUS Ethical Decision-Making model are as follows:

• Define the problem using PLUS filters
• Seek relevant assistance, guidance, and support
• Identify available alternatives
• Evaluate the alternatives using PLUS to identify their impact
• Make the decision
• Implement the decision
• Evaluate the decision using PLUS filters

Conflict resulting from competing values that requires a decision to be made from equally desirable or undesirable options.

The willingness of an individual to speak out and do what is right in the face of forces that would lead us to act in some other way.

Feelings occurring when an individual is uncertain about what values or principles should be applied to an ethical issue.

Feelings occurring when correct ethical action is identified but the individual feels constrained by competing values of an organization or other individuals.

Feelings occurring when an individual witnesses immoral acts or practices they feel powerless to change.

Distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.

What are the nursing responsibility in ethical dilemmas?

What is the role of a nurse in resolution of ethical dilemmas among the health care team members?

What are the correct steps to resolve an ethical dilemma?

What is the first step in resolving ethical dilemmas faced by nurses?