Assignment: Journal of Nursing Law

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Assignment: Journal of Nursing Law

Assignment: Journal of Nursing Law

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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.


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).


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.

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