Nurse ethical awareness: Understanding the nature of everyday practice

Abstract

Much attention has been paid to the role of the nurse in recognizing and addressing ethical dilemmas. There has been less emphasis, however, on the issue of whether or not nurses understand the ethical nature of everyday practice. Awareness of the inherently ethical nature of practice is a component of nurse ethical sensitivity, which has been identified as a component of ethical decision-making. Ethical sensitivity is generally accepted as a necessary precursor to moral agency, in that recognition of the ethical content of practice is necessary before consistent action on behalf of patient interests can take place. This awareness is also compulsory in ensuring patient good by recognizing the unique interests and wishes of individuals, in line with an ethic of care. Scholarly and research literature are used to argue that bolstering ethical awareness and ensuring that nurses understand the ethical nature of the role are an obligation of the profession. Based on this line of reasoning, recommendations for education and practice, along with directions for future research, are suggested.

Keywords

Care ethics ethical sensitivity ethics moral sensitivity nursing

Introduction

Nursing codes of ethics delineate the ethical obligations of practicing nurses “in all aspects of their work”¹ (p. 4), including obligations related to ethical dilemmas and everyday practice. Resolving ethical dilemmas in practice tends to be multidisciplinary in nature, and a growing body of literature explores the specific role of nurses in this context. Less attention has been paid, however, to the issue of whether nurses understand the ethical nature of everyday practice.

Ethical nursing care is viewed as any action taken to address patient needs in accordance with the profession’s goals and perspectives.² Ethical nursing care, therefore, is synonymous with good nursing care. This perspective is in line with an ethic of care, as discussed shortly, and is also in line with the profession’s aims of promoting health and alleviating suffering while accounting for the unique needs of each individual in need of nursing care. The premise that every nursing action has ethical content is not universally acknowledged by nurses, however. Moreover, even when this premise is understood, and nurses can ascertain what would be “good” for a particular patient, they are often unable to enact these ideals due to a variety of systemic and contextual issues. Awareness of the inherently ethical nature of nursing practice is critical for consistently good patient care and is a necessary, if insufficient, component of nurse ethical sensitivity.

This article evolved from experiences over several years in a critical care setting which manifested in concern about nurses in practice and the varying degrees with which they enact moral agency. To delve more deeply into the issue, a fairly comprehensive, computer-assisted literature review was undertaken, in order to explore what was known in general about sensitivity to the ethical nature of professional practice and in particular what is known about nurse ethical sensitivity. Furthermore, it was important to include articles that linked nurse ethical sensitivity to their willingness and ability to act on behalf of a patient’s goals and interests. Both philosophically oriented and research-oriented articles were considered as they were able to provide insights and clarity about the concept. The time frame of inclusion was 1983–2015. In 1983, the concept of ethical sensitivity was introduced by James Rest³ as a result of his extensive review of the research literature on the psychological processes behind moral reasoning. Pertinent findings from this review are summarized as they support the objectives of the article: to affirm the inherently ethical nature of nursing practice, to highlight that this stance entails viewing every nursing action as subject to ethical appraisal, and to propose strategies to bolster nurse acceptance of their professional responsibilities.

Ethical versus moral sensitivity

In much of the extant literature, ethical sensitivity is termed “moral sensitivity.” While some authors choose to differentiate between morals and ethics, others have argued that both terms are applicable for “considerations of professional judgment and action” and can be used “interchangeably to mean those actions most likely to further the goals of the profession”⁴ (p. 9). As the focus of this article is ethical sensitivity in the context of professional responsibility in the healthcare environment, the terms will be used synonymously, in accordance with the terminology used by authors being referenced.

Ethical sensitivity

Important work has been done on the topic of ethical sensitivity in nursing practice. The concept of ethical sensitivity, originally termed moral sensitivity, was first introduced by Rest³ as a result of his extensive survey of literature on moral reasoning. Rest³ defined the concept as a person’s cognitive ability to grasp the ethical aspects of a situation. In the context of nursing and caring literature, the concept of ethical sensitivity has normative implications for healthcare professionals.

According to Rest’s³ Four-Component Model (FCM), ethical (or moral) sensitivity is just one of the interactive processes underlying moral action or an action required to achieve a “good” for another. Moral judgment, moral motivation, and moral character are the other three components of the model. Although Rest³ describes moral sensitivity as one among these four interactive and non-hierarchical cognitive processes, the ability to notice the ethical aspects of a situation is necessary for the engagement of the other processes. In healthcare settings, then, the absence or attenuation of ethical sensitivity makes moral agency on behalf of patient interests less likely to occur.^5,6

Yet, moral agency is an expectation of professional nursing practice. Nurses are obliged by the service promises defined in codes of ethics^2,7 to provide for the good of individuals and society. Furthermore, ambiguities remain about the concept of ethical sensitivity, and issues remain in delineating definitional limitations and scope. These challenges have led nursing scholars to attempt further analyses in order to achieve conceptual clarity, which is needed for the development and assessment of appropriate professional attitudes and characteristics.

Weaver and colleagues⁶ provide an in-depth exploration of “ethical sensitivity” as developed in nursing literature, noting that

despite the large volume of literature on the subject, a more cohesive understanding of the state of knowledge concerning ethical sensitivity has been limited owing to problems of competing descriptors, inadequate exploration of crucial issues, and threats to generalizability and validity. (p. 148)

The authors identify three areas of theoretical development related to the concept: one of Rest’s³ components (operationalized as ethical sensitivity) which emphasizes the role of emotions in engaging cognitive functions, Lutzen and colleagues’⁸ theoretically developed Moral Sensitivity Questionnaire, and the construct as advanced by those outside of the health professions with an interest in professional actions.

Despite the relatively extensive literature related to ethical sensitivity, including acknowledgement of the complexity of its attributes, what is largely missing from the various accounts is the idea of ethical awareness. Ethical awareness is a component of ethical sensitivity, which entails nurses and other healthcare professionals recognizing that all of their actions are subject to ethical appraisal and the maintenance of this awareness in daily practice.

Empirical research has shown that nurses are generally sensitive to the ethical content of traditional “dilemmas” and complex situations where there are no obvious good choices, such as hiding a diagnosis from a patient⁹ or giving medications by force if a patient refuses to take them orally.¹⁰ These difficult clinical situations have been the focus of most ethical sensitivity research to date and are broadly considered to be the main focus of bioethical or medical ethics inquiry. Such problems are usually not amenable to resolution by one person.

Despite understanding its important role in dilemmas, literature has not established the role that ethical sensitivity or its components play in day-to-day nursing practice. Even seemingly routine tasks such as charting vital signs have ethical implications in terms of ensuring accuracy (veracity) and documenting contextual factors that permit appropriate subsequent action (beneficence, non-maleficence). The concept of ethical sensitivity holds promise for ethical nursing practice, yet it still has not been adequately defined and operationalized in the literature. Moreover, the various existing definitions tend to ignore what should be a foundational premise: that all nursing actions, from the day-to-day to the difficult, are essentially ethical in nature. That is, the profession has promised via its codes of ethics to provide a good or service, and all practice actions should aim to meet that promise.^2,7

Definitional limitations of ethical sensitivity

As noted, nursing and allied literature contain multiple, sometimes competing definitions of ethical sensitivity, which makes reaching a conceptual consensus, in order to address practice issues, a challenge. What these definitions seem to lack is an explicit focus on the recognition of the ethical nature of every practice action, beyond dilemmas or other complex situations.

Rest’s³ definition characterizes ethical sensitivity in an interpretive sense as “the awareness of how our actions affect other people,” and as “necessary to become aware that a moral issue is involved in a situation” (p. 22), while Lutzen and colleagues¹⁰ define it as “an understanding of the patient’s situation” and “an awareness of the moral implications of decisions” (p. 521). Both Rest’s³ and Lutzen and colleagues’¹⁰ definitions suggest that ethical sensitivity requires an “awareness” of some sort; however, awareness is itself a complex concept. An awareness of ethical obligations is a necessary, yet insufficient component of ethical sensitivity and subsequent ethical action; this component of the concept warrants further exploration.

Ersoy and Goz⁹ define ethical sensitivity as “the capacity or ability to recognize an ethical problem” (p. 300); however, in their research, the construct was only operationalized in the context of ethical dilemmas; it therefore still does not address the fundamental issue at hand. This is true for the work by Lutzen and colleagues¹⁰ as well; in attempting to assess levels of ethical sensitivity, the authors have focused only on the way the construct operates in dilemma-type scenarios. This is a problem for understanding the way ethical sensitivity operates in nursing practice as a whole.

Weaver and colleagues⁶ explicate ethical sensitivity as

the capacity to decide with intelligence and compassion, given uncertainty in a care situation, drawing as needed on a critical understanding of codes for ethical conduct, clinical experience, academic learning and self knowledge, with an additional ability to anticipate consequences and the courage to act. (p. 610)

This definition, derived as it was from a comprehensive literature review and subsequent concept analysis, nevertheless fails to accommodate the essential problem: a nurse is ethically responsible for every action, taken or not taken, and the mundane as well as the difficult. This understanding can be characterized as the awareness of one’s role responsibilities.

The lack of conceptual clarity that still surrounds the construct necessitates a revised definition of ethical sensitivity, as related to nurses and nursing practice, in order to underpin education, research endeavors, and the translation of research findings into practice. In focusing on ethical awareness as a necessary precursor to ethical sensitivity (however this is eventually defined), the essential issue at hand can be addressed. That is, do nurses recognize that their professional responsibility extends to all aspects of practice, including everyday practice actions.

Ethical awareness

As has been argued elsewhere,⁴ ensuring that nurses understand the ethical nature of the role is an obligation of the profession. The body of ethical sensitivity literature does not account for this foundational understanding of professional practice as it relates to nurses; the extent to which nurses possess this awareness is not known. There is, in fact, evidence to suggest that it is lacking. Krautscheid¹¹ found that nursing students, in a simulated environment, were unable to “deliberately integrate ethical principles” (p. 13) in decision-making. Truog and colleagues¹² argue that “clinicians commonly do not recognize the ethical elements underlying everyday clinical encounters” (p. 12).

Ethical awareness of the nature of role responsibilities in everyday practice is a necessary, albeit insufficient, component of nurse ethical sensitivity. That is, awareness of ethical obligation is necessary before ethical action can take place. Ethical awareness permits the subtleties of patient needs and context, from which potential ethical conflicts eventually emerge, to be rendered visible and addressed. It is a starting point from which the more complex characteristics associated with ethical sensitivity, as synthetically defined by Weaver and colleagues,⁶ may be developed. Ethical awareness, then, requires attention to the implications of all practice actions, not solely attention to their outcomes.

Care ethics

Bolstering ethical awareness is the responsibility of the profession more generally and is in line with both an ethic of care and nursing’s holistic perspective on persons as contextual beings in constant interaction with the environment.¹³ A comprehensive account of care ethics is beyond the scope of this article. However, roughly defined, it is a stance that emphasizes the interrelatedness of human beings with other beings and the environment, along with associated responsibilities, including responsibilities to those more vulnerable than oneself.

Gilligan’s¹⁴ concept of the voice of care developed as a result of insights gained working as a graduate student with Kohlberg on his moral development studies. Kohlberg¹⁵ emphasizes that what is “right is defined by the decision of conscience in accord with self-chosen ethical principles appealing to logical comprehensiveness, universality, and consistency”¹⁵ (p. 632). Moreover, the right action is chosen despite opposition.

In contrast, Gilligan,¹⁴ noticing that women consistently scored lower on the moral development scale, argued that women were focused more on understanding the importance of relationships and associated responsibilities than on impartialist principles. These relationships are the main consideration in framing moral issues and successive decision-making.¹¹ Moreover, rather than viewing “care” as an act taken on behalf of another, Gilligan¹⁴ and other care ethics scholars emphasize the active involvement of the patient; care is co-constructed between the patient and the nurse,¹⁶ at least where the patient’s condition makes this possible. For nurses, an ethic of care necessarily involves an intentional focus on the patient as a way of being (ontology) but also the use of knowledge and skills in order to act in the interests of the patient.

Both the American Nurses Association (ANA) and the International Council of Nurses (ICN) codes of ethics reflect the fact that the profession of nursing is inherently relational in nature.^1,17 Ethical nursing actions are aimed at achieving patient “good” in alignment with patient and professional goals. Professional goals, as established over time in these codes of ethics and in scholarly literature, are those that aim to facilitate “humanization, meaning, choice, quality of life and healing in living and dying” as described by Willis et al.¹⁸ Patient goals become known to the nurse through the process of care, the development of the nurse–patient relationship, and an intentional focus on the patient.

In terms of understanding these patient goals, care ethics scholar Gastmans¹⁹ asks, “What is the best way to care for this patient at this time?” This question is best answered through knowing as much as is possible about the patient and their wishes and needs, and then acting accordingly. Where this cannot be directly known, practitioners must try to piece together their story in order to ensure that nursing actions are congruent with their needs and their likely wishes. Thus, the ethical implications of this relational context are inescapable, and an awareness of the ethical implications of all nursing actions is imperative. Ethical awareness is not sufficient to ensure ethical action (it is a starting point), but without it, resulting care may be misaligned with the goals of the patient and the expectations of the profession. It is therefore essential that nurses are given the opportunity to develop this awareness through education and practice-based interventions.

Bolstering ethical awareness: recommendations

When ethical awareness and sensitivity are lacking, patients are at risk of harm. The absence of ethical awareness either results in inaction, because the nurse has not perceived the ethical implications of the situation, or in routine-based care.⁶ In either of these scenarios, the patient’s goals and preferences are not guiding care, and outcomes may be damaging.

The ANA¹⁷ has designated 2015 as the “Year of Ethics,” highlighting the profession’s emphasis on and interest in providing ethical care. Ethics permeates all aspects of healthcare and nursing practice. Ensuring nurses are ethically aware is crucial to assure patient safety and high-quality care; sensitivity to the ethical content of dilemmas alone is not sufficient.

Several methods have been discussed in the literature which may help bolster ethical awareness, in order to adequately prepare nurses to practice in today’s complex and challenging healthcare environment. These methods are in accordance with Rest’s³ emphasis on the understanding of professional goals, accompanied with the skill and motivation to act. No gold standard for addressing this issue has been established, however. Therefore, a multimodal approach, incorporating several techniques and strategies for bolstering ethical awareness, may be ideal.

Codes of ethics

Knowledge of codes of ethics has been shown to be related to higher levels of ethical sensitivity in nursing students.²⁰ These codes represent professional obligations, and ensuring nurse familiarity with them is a necessary component of ethics education. Methods for teaching codes of ethics and nurse familiarity with these standards vary widely, however.^21,22 Addressing the inconsistency with teaching practices, and ensuring nursing students and nurses in practice are introduced to codes of ethics early, may have a positive influence on the recognition of ethical content.

Multimodal educational interventions

In Krautscheid’s¹¹ study of nursing students, ethics education was considered “unapplied and forgotten,” as students in a simulated environment failed to incorporate ethical principles into decision-making in an everyday practice situation. This is evidence that ethical awareness in nursing students is lacking. In order to ensure that nursing ethics remains in the forefront of practice, research suggests that interventions to develop nurse ethical awareness and decision-making abilities should be multimodal, introduced early in the education and socialization of nurses, and should influence every aspect of care.^23
–25 Hebert et al.²³ and Kim et al.²⁰ emphasize experiential learning, that is, education that does not occur in a silo, devoid of the context of the actual care environment.

Moreover, ethical awareness can be dulled by repeated exposure to toxic and unsupportive environments.^23,26 Studies indicate that medical students at the end of their training have lower levels of ethical sensitivity than students beginning their training.²³ This “routinization of disaster”²⁶ occurs when ethical issues go unaddressed repeatedly over time and eventually become the norm. Multimodal approaches, implemented over time, are necessary to address this issue; practitioners need to be reminded that even seemingly routine practices have ethical implications that require attention.

In addition to the adequate preparation of nursing students, nurses in practice should have opportunities for developing and refining ethical awareness, sensitivity, and moral agency, as these skills can also be lost over time.²³ A recent educational intervention aimed at developing nurse confidence in ethical decision-making abilities resulted in nurses feeling empowered to “represent the patient and family perspective in interdisciplinary settings”²⁷ (p. 655). The authors argue that knowledge of clinical ethics is insufficient in ensuring nurses are able to act as moral agents, so a multimodal approach to learning was taken. Nurses were found to have increased confidence in their moral agency, increased ethical knowledge, and decreased moral distress.²⁸ Interventions such as these are promising tools in helping to develop nurse ethical awareness as a component of ethical decision-making.

Preventive ethics

Nurse ethical awareness enables the early recognition of potential ethical problems in the care environment, as nurses will be more likely to notice these issues as they develop, before they progress to “dilemmas.” Nurses may be the only providers with sustained contact with the patient and family, and thus are optimally positioned to notice emerging problems. If nurses fail to recognize ethical issues early, subsequent decision-making processes may be made without the involvement of the nurse. If nurses are left out of this process and treatment decisions are made without input from the entire care team, moral distress and deleterious patient outcomes can result.

The preventive ethics movement endeavors to identify patients at risk of ethical conflict by taking a proactive approach to address potential triggers²⁹ and also places emphasis on the systems issues that impede quality and ethical care, which tend to be barriers to nurse moral agency. One crucial aspect of this method to addressing ethical issues is that it provides nurses with the resources they need to promptly address and resolve situations they notice. Developing ethical awareness in nurses at the bedside is in line with this method of approaching ethical issues in clinical setting.

Directions for future research

The body of ethical sensitivity literature has established the important role ethical sensitivity plays in the context of dilemmas, yet important areas for study remain. Future research should aim to establish the role ethical awareness and sensitivity play in day-to-day practice, emphasizing these constructs as professional obligations and foundational aspects of ethical action. Because of the construct’s highly theoretical nature, assessing it is methodologically challenging. Future research should use novel methodologies, endeavoring to allow for the translation of research findings into practice and education-based tools.

Conclusion

Nurse ethical awareness involves the willingness and ability to recognize the ethical nature of nursing practice. This recognition is a necessary antecedent to ethical sensitivity and subsequent moral agency and moral action. In order to best design interventions to bolster ethical sensitivity and moral agency, it is necessary to establish whether or not nurses recognize the ethical content of every practice action. Nurses who are ethically sensitive are likely to be vulnerable to increased levels of moral distress, as a heightened awareness may result in more situations in which nurses are unable to do what they recognize as being “right.” Ideally, the recognition of these situations will serve as the impetus for systems change.³⁰

Once it is understood whether nurses possess ethical awareness, in terms of recognition of professional responsibility in all contexts of practice, work can be done to clarify the ambiguities that still surround ethical sensitivity. As described, future research should aim to assess the way ethical awareness and sensitivity operate in the context of everyday practice using innovative methodologies. This understanding will help inform the development of tools to facilitate ethical awareness and sensitivity in all realms of practice.

Footnotes

Conflict of interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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