Saturday December 3rd 2016

The practice of ethics

RNs learn, discuss issues

When, if ever, should a nurse give a placebo to a patient? And how does one manage acute pain in a 15-year-old?

What should an ICU nurse do when he knows an elderly patient wants life-saving measures to stop, but the physician and family pursue aggressive treatment, thinking the patient will eventually recover? What if the unit culture supports extreme interventions at all costs?

Those were two of the cases presented to participants at the March 2011 National Nursing Ethics Conference, “Advocacy – Making a Difference for Patients,” that yielded rich discussions on ethics and everyday, professional practice.

“All nurses face ethical issues — some almost every day,” said Laurie Badzek, JD, MS, RN, LLM,  director of the American Nurses Association’s (ANA) Center for Ethics and Human Rights and a professor at West Virginia University, in welcoming nurses to the Los Angeles-based event. She pointed out that about 350 staff nurses, nurse managers, educators, administrators, and researchers from nearly every state were attending the two-day event, co-hosted for the first time by ANA and the non-profit organization, Ethics of Caring.

The conference included numerous plenary, break-out, and poster sessions on topics ranging from taking the “difficult” out of challenging cases to palliative sedation and existential suffering to lateral violence and bullying in the workplace. The event also provided nurses with continuing education and networking opportunities.

The first keynote speaker was ANA President Karen Daley, PhD, MPH, RN, FAAN, who presented “Empowering Nurses: Nurses Make the Difference.” She addressed how two of nursing’s foundational documents developed by ANA, the Code of Ethics for Nurses and Nursing’s Social Policy Statement: The Essence of the Profession, support nurses’ vital role as patient advocates.

Daley noted that advocating for patients can be fraught with difficulties, from navigating the complexities of patient care to potentially risking one’s job by going up against the system.

“Yet failure to act or inaction likely can result in moral distress when we haven’t met our obligation to our patients,” she said.

Daley also spoke of the importance of nurse advocacy beyond individual patient care, and she shared her personal journey of becoming a strong advocate for safe needle devices and practices after sustaining a life-altering needle-stick.

“I decided that I would go anywhere, talk to anybody, and put a face to an issue that has been affecting nurses for decades,” Daley said. Her advocacy helped win needle-stick prevention legislation in her home state of Massachusetts, as well as federal legislation.

Looking at empowerment strategies, Daley stressed that nurses must see themselves as the experts on nursing practice that they are. She also told conference participants to never underestimate their individual power. And she urged them to also engage in action through membership in ANA and other professional associations to bring about positive changes to the profession and health care.

Also serving as a keynote speaker on March 23 was Carol Taylor, PhD, RN, an ANA member who presented “Rethinking Nursing’s Advocacy Obligations in 2011: Are We Measuring Up?”

Taylor, a senior research scholar in the Center for Clinical Bioethics and professor of medicine and nursing at Georgetown University, noted that few patients and families are able to use the health care system effectively, leaving many people vulnerable.

“When we show up for practice, we hold in our hands the power to determine how people are born, live, suffer, and die,” she said. “Nursing has always been at the forefront for advocating for the marginalized. [But] is that still true?”

She asked participants to consider what constitutes a good day for their own nursing practice, especially given the fast-paced and complex health care environment.

“Are you able to say, ‘I made a critical difference for my patients, for my team? Or does a good day mean, ‘I didn’t get in trouble’ or ‘I got to go home early.’”

If it’s the latter, then advocacy isn’t likely occurring.

Taylor also highlighted best practices, which include the following:

• Ensuring ongoing, honest communication — with listening being the first rule.

• Having an identifiable professional “point person” for each patient who is responsible for coordinating care and communicating with the family. In turn, identifying a point person for the family with whom the professional team and other family members can communicate.

• Including a coversheet on the patient chart that is reviewed weekly and determines the need for patient care conferences. It should include crucial information, such as identifying the person with decision-making capacity, any advance directives, the goal of treatment, such as restoration and cure or preparing for a comfortable and dignified death, and special family needs.

• Establishing patient-family advocacy as a core competency for every clinician, and carrying out interdisciplinary team training so that everyone is able to speak up about a patient concern or report an error — no matter their role.

Addressing non-beneficial treatment

There also were a number of nurses who presented or led discussions in plenary and break-out sessions. Among them was Katherine Brown-Saltzman, MA, RN, co-director of the UCLA Health System Ethics Center, co-founder and president of Ethics of Caring, and an ANA\California member.

In her plenary session, “The Complexities of Non-Beneficial Treatment: How do we Respond?”, Brown-Saltzman asked participants to consider factors that surround the complexities of non-beneficial treatment, such as maintaining hope, respecting life’s limits, honoring patient autonomy, creating harm, and a dissolving trust in medicine.

And she detailed why patients and their families want non-beneficial treatment. These reasons include confusion over why they would be offered a treatment that would not benefit them, unresolved grief or guilt, an idealistic belief in science and medicine, and a denial of their condition.

“Every time we have a family meeting, we have an opportunity to change family members’ expectations, shift patients’ expectations and hopes,” Brown-Saltzman said. “We also need to assure them that we are amplifying symptom management and presence while withdrawing treatment.”

Looking at physicians, Brown-Saltzman noted that they provide non-beneficial treatment for various reasons, including the inherent difficulty of making a definitive prognosis and a focus on cure against the odds, ethical uncertainty, a fear of lawsuits, and religious beliefs.

Brown-Saltzman also pointed to a research study that illustrates the complexity of patient autonomy when aggressive treatment is being deliberated. Shortly after sustaining C3-C4 spinal cord trauma, 90 percent of patients asked to be taken off their respirators. Following their stay in a rehabilitation hospital, 95 percent “were glad to be alive and no longer wished to have their respirators turned off.”

In terms of some strategies, Brown-Saltzman urged nurses to know their institutional policies, such as those focusing on conscientious objection and withdrawing non-beneficial treatment; understand the Code of Ethics for Nurses; speak out about patient care; and join the facility’s ethics committee.

Also presenting were Marsha Fowler, PhD, MDiv, MS, RN, FAAN, who spoke on “Me Too! Self-Regarding Duties; Betty Ferrell, PhD, MA, RN, FAAN, FPCN, who addressed “The Sacred Ethos of the Everyday World of  Nursing;” and Barbara Bennett Jacobs, PhD, MPH, RN, CHPN, who described the “Integration of Art, Suffering and Nursing Ethics.” (Watch for more in-depth coverage of these and other ethical issues in The American Nurse and American Nurse Today.)

Carrying the message beyond the conference doors

Throughout the conference, nurses engaged in lively and thought-provoking discussions. And as it came to a close, participants also expressed their satisfaction with the information they had garnered.

Long-time nurse Susan Chappuis, MS, RN, CNE, a faculty member at St. Joseph’s College of Nursing in Syracuse, NY, and an ANA member, has taught an ethics course for six years and viewed the conference as a way to gain more formal knowledge in this area.

“It’s strengthened my desire to be a better patient advocate,” Chappuis said. “I also want to impart to my students the importance of taking care of themselves and to be aware of factors that contribute to moral distress and burnout, so they won’t experience either.”

LaDonna Crum, BSN, RN, a nurse manager of a step-down unit at Harry S. Truman VA Medical Center in Columbia, MO, attended the conference shortly after being appointed to her facility’s Integrated Ethics Board.

“I’m glad I’m here, because I’ve learned a lot,” Crum said. “The presentations were awesome, because the speakers included personal stories that made me laugh, made me cry, and made me really think of the ethics of different situations.”

Crum added that she plans on presenting highlights of the conference to administrators at her facility.

For more information on ANA’s Center for Ethics and Human Rights, including position statements, go to For more information about Ethics of Caring, go to


A case study in moral distress

The second-day keynote speaker at the ethics conference, Ann Baile Hamric, PhD, RN, FAAN, launched her presentation, “The Price of Advocacy: Dealing with Moral Distress,” with a case study.

She told the story of Lisa, an experienced critical care nurse, who provided care to Mr. Jones for some time and had become close to his family. Because Mr. Jones was not improving with aggressive therapy and room was needed in the ICU, he had to be transferred. It was clear that he would die that day. Lisa asked to go with him to the new unit, but her request was denied. Shortly after his transfer, Mr. Jones died, and his wife had left the hospital before Lisa could finish her shift. Lisa subsequently experienced moral distress, in part, because she felt powerless to act on her core value — being with her patient when he needed her.

“Moral distress occurs when you know or think you know the ethically appropriate action in a situation but you cannot carry it out,” said Hamric, a professor at University of Virginia School of Nursing and a Virginia Nurses Association member. “Moral distress always results in strong negative emotions, but it is distinct from other kinds of emotional distress, such as burnout or compassion fatigue.”

She cited four key features of moral distress: a power differential and feeling of powerlessness, a violation of moral integrity, sense of isolation, and strong negative emotions. She also pointed to research on the “crescendo effect,” in which moral residue — the lasting effects of encountering an event that is morally distressing — builds with each subsequent episode of moral distress. The build-up of moral residue over time can compromise one’s moral integrity, leading a nurse, for example, to leave a position or even the profession, become desensitized to moral aspects of practice, or to conscientious objection.

“We must not assume that damaged moral integrity is an acceptable, natural consequence that must be borne by health care providers,” Hamric said.

She pointed to three root causes of moral distress: clinical situations such as unnecessary or futile treatment, inadequate informed consent, and incompetent caregivers; internal causes such as self-doubt, fear of reprisal, and lack of knowledge of alternatives; and external root causes in organizations such as chronically inadequate staffing, fear of lawsuits, or lack of administrative support.

In terms of initial strategies to prevent or reduce moral distress, Hamric suggested that nurses learn to recognize instances of moral distress, support their colleagues who are experiencing it, and work to change the culture within their unit or health care system so patient issues can be addressed openly.

(For more information on moral distress, see topic number 43: Moral Courage Amid Moral Distress: Strategies for Action, at


Code of Ethics is crucial to practice

The American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements is one of nursing’s crucial foundational documents that guides nurses in their practice every day. For more information on the Code, go to

— Susan Trossman is the senior reporter at The American Nurse.

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