Conscience,conscientious objection,and nursing: A concept analysis

Abstract

Background:

Ethical nursing practice is increasingly challenging, and strategies for addressing ethical dilemmas are needed to support nurses’ ethical care provision. Conscientious objection is one such strategy for addressing nurses’ personal, ethical conflicts, at times associated with conscience. Exploring both conscience and conscientious objection provides understanding regarding their implications for ethical nursing practice, research, and education.

Research aim:

To analyze the concepts of conscience and conscientious objection in the context of nurses.

Design:

Concept analysis using the method by Walker and Avant.

Research context:

Data were retrieved from Philosopher’s Index, PubMed, and CINAHL with no date restrictions.

Ethical consideration:

This analysis was carried out per established, scientific guidelines.

Findings:

Ethical concepts are integral to nursing ethics, yet little is known about conscientious objection in relation to conscience for nurses. Of note, both concepts are well established in ethics literature, addressed in various nursing codes of ethics and regulatory bodies, but the meaning they hold for nurses and the impact they have on nursing education and practice remain unclear.

Discussion and conclusion:

This article discusses the relevance of conscience and conscientious objection to ethical nursing practice and proposes a model case to show how they can be appreciated in the context of nurses. Conscientious objection is an option for ethical transparency for nurses but is situated in contentious discussions over its use and has yet to be fully understood for nursing practice. Conscience is an element in need of more exploration in the context of conscientious objection. Further research is warranted to understand how nurses respond to conscience concerns in morally, pluralistic nursing contexts.

Keywords

Concept analysis conscience conscientious objection ethics nursing practice

Introduction

Nursing can be an ethically complex profession. Conscience is an ethical concept fundamental to nursing and found to positively influence nursing practice, driving forward ethical nursing care.^1,2 Conversely, nurses’ troubled conscience and stress of conscience have been shown to have negative impacts on their practice when they cannot live up to their abilities to provide quality patient care, crossing over and affecting their personal lives, as well as causing burnout.^3,4 Conscience issues can also arise when nurses’ ethical perspectives conflict with professional norms of practice. Guided by ethics education and codes of ethics around the world, nurses can turn to these philosophically rooted guidelines to address such conflict of conscience by making a conscientious objection. An internationally recognized option for nurses to object to care that conflicts with their personal beliefs is conscientious objection, which is a widely debated concept, but it is not clear in the literature what impact conscientious objection has for practicing nurses. Given the relevance of ethics and ethical concepts to nursing, further understanding is needed to appreciate the meaning conscience and conscientious objection hold for nursing practice to generate further knowledge for nursing ethics. This article offers a conceptual analysis of conscience and conscientious objection in the context of nurses, as well as a discussion of results, recommendations for further research, and implications for nursing practice and education. Conscience and conscientious objection outside a nursing context will not be addressed in this article as that is beyond the scope of this analysis.

Background

A conceptual analysis of conscience and conscientious objection for nurses fills the current gap between nursing theory and clinical practice. Healthcare environments are moral communities, and nursing ethics is a standard of nursing education and practice.⁵ Yet, little is understood about how nurses make personal responses to ethically contentious issues in professional settings. Conscientious objection is a critical, ethical concept theoretically situated in nursing, but remains ambiguous in clinical practice. While conscientious objection is generally supported by regulatory nursing bodies and professional codes of ethics emerging from philosophical and ethical theories, the codes do not always capture the complexities of the ethical dilemmas that nurses face. Subsequently, nurses also have to rely on their ethical decision-making abilities and leadership for support.⁶ However, study findings indicate that nurses and nursing leaders do not always understand what conscientious objection is, and how to utilize this option in professional practice.^6,7 Furthermore, ethical views in the literature diverge on the meaning of conscience and the relevance of conscientious objection to healthcare and nursing practice. Lack of conceptual clarity can make it challenging to advance education and research on conscience and conscientious objection relevant to evidence-based nursing practice.^8,9 Achieving conceptual clarity on conscience and conscientious objection is relevant since addressing ethical issues and making ethical decisions are vital to nursing care. Given these considerations, further research is necessary to more fully explicate conscience and conscientious objection as meaningful concepts for advancing nursing science. A reasonable starting point is to establish how conscience and conscientious objection are currently situated in nursing scholarship.

Methods

The aims of this analysis are to explore and shed light on the concepts of conscience and conscientious objection in relation to nursing practice to gain a fuller appreciation of how these terms apply to the context of nurses, in keeping with the method laid out by Walker and Avant.¹⁰ The method consists of the following: (1) choosing concepts and outlining the aims of the analyses, (2) identifying uses and current definitions of the concepts, (3) noting attributes, antecedents, consequences, and empirical referents, and (4) generating model, borderline, and contrary cases to further illustrate the concepts.

Literature search

To conduct a concept analysis on conscience and conscientious objection in nursing, databases were used to retrieve articles on the concepts. The literature was searched between January 2014 and November 2016. Databases searched were PubMed, CINAHL, and Philosopher’s Index. While no date limits were set for the literature search, articles retrieved were dated between the late 20th and the 21st centuries. Words used to guide the search were as follows: conscience and nursing, conscience and nursing practice, conscientious objection and nursing, conscientious objection and nursing practice, and conscience and conscientious objection. Inclusion criteria consisted of full-length, English articles retrieved from peer-reviewed journals that addressed either concept in direct relation to nursing and nursing practice. Articles that did not address either concept directly and in relation to nursing and nursing practice were excluded. Reference lists were scanned across the articles retrieved and cross checked with other articles. A search-for-concept analysis on conscience and conscientious objection in PubMed yielded one result on conscientious objection and nursing comprised of a hybrid concept analysis that reviewed conscientious objection but not conscience and only in the context of neonatal intensive care unit (ICU) nurses.¹¹ Initial searches on conscience and nursing yielded a high volume of 318 articles. When re-searched with the term nursing practice, the number was reduced to 76 and eventually only 18 were included. Articles were reviewed in full only if they met the inclusion criteria. Articles that did not were excluded. Searches for conscientious objection and nursing, as well as nursing practice, generated significantly lower results. In PubMed, for example, the initial results were 37 and 12, respectively. Again, given the inclusion criteria and article overlap between databases, only 12 were retained for analyses. In total, 30 articles comprising empirical and theoretical literature on conscience and conscientious objection directly related to nursing practice were included for analysis. Nursing codes of ethics were also reviewed online. A search-for-concept analysis as a method was additionally explored, and the concept analysis is based on the results of the search.

Results

This section provides a discussion of the search results in keeping with the method laid out by Walker and Avant.¹⁰ Landscaping these concepts offers a foundation for further research on conscientious objection for nurses. Implications for nursing practice and education are discussed.

Definitions and use of the concepts

The word conscience arises from Latin, conscienta, and French, conciense. Translated from their original languages, conscience can be defined as the internal sense of what is right or wrong, and one’s ability to choose between, as well as act upon, what one perceives to be the right thing to do.¹² Conscience is largely taken up in nursing practice as a cornerstone for ethics relevant to ethical nursing care.¹³ In nursing, conscience is broadly perceived as an authority, a warning signal, demanding sensitivity, an asset, a burden, inherent in nursing, and culturally dependent.^13

–17 When nurses can follow their conscience guiding them to provide quality care, conscience is positively perceived.¹⁶ Nurses who can follow their conscience are less likely to encounter conflicts of conscience in practice.²

Conversely, nurses who cannot follow their conscience report having a troubled conscience. Nurses’ troubled conscience have been associated with feelings of guilt when (1) nurses’ core beliefs conflict with social or professional beliefs, (2) nurses cannot fulfill their care obligations to patients due to time constraints, and (3) nurses are placed in scenarios where they feel they are working against their conscience.^18
–20 A troubled conscience can also occur when external factors such as workload compromises nurses’ ability to provide appropriate care, generating internal misgivings over perceptions of fallen standards.¹⁹ Stress of conscience is that type of stress that can arise for nurses when they repeatedly experience stressful situations that trouble their conscience.^19,20 When nurses have stress of conscience, this can negatively affect their practice, cause them to act against their conscience, and spill over into their personal lives, creating disharmony between their professional and personal sense of self.^4,20,21 Stress of conscience is also related to burnout, where nurses report deadening their conscience to be able to carry on working in relation to lack of professional supports; nurses who view conscience as an asset and can effectively address their conscience issues in practice report less stress of conscience.^3,22

Currently, the discourse on conscience focuses more on the conscience-related issues of a troubled conscience and stress of conscience than it does on the meaning of conscience itself. It is therefore unclear if a nurse’s understanding of conscience is related more to a sense of wrongdoing than it is to feelings of personal inadequacy. This differentiation is important for contextualizing the degree of personal or professional compromise a nurse may encounter and to what extent their conscience issues need to be addressed. For example, depending on how one’s conscience is perceived or troubled can influence a moral outcome. If a nurse’s conscience becomes troubled due to not living up to his or her own standards of quality care provision, this could be markedly different on a moral scale then if they complied with a graver act such as providing an illicit amount of medication to hasten a patient’s death. While it is important for nurses to be able to provide quality patient care and external limitations such as budgetary restrictions, increased workload and time constraints have been found to restrict nurses’ self-reported ability to do so, the nature of the limitations imposed on a nurse that bothers their conscience and how, as well as to what extent, they address those limitations need to be further laid out.²⁰

Another important discussion largely missing from the literature on conscience and conscience-related issues in nursing is a concerted delineation between stress of conscience and closely related concepts such as moral distress. While moral distress can ensue when a nurse is not able to follow through on what they perceive to be right, stress of conscience denotes a buildup of stressful situations arising from a disturbed sense of conscience, which encompasses one’s core sense of fundamental morality.^20,23 The main distinction between moral distress and stress of conscience is that the latter explicitly addresses stress based on one’s conscience, which is the faculty that helps one to determine their moral actions. Examining stress of conscience therefore aims to look at nurses’ moral concerns from their formative source and not only as descriptor of actions resulting from it. However, conscience itself is not fallible, and stress of conscience needs to be further addressed to reveal how nurses personally form their conscience, as well as how, why, and to what extent they act on it to further explicate the moral conditions that nurses contend with in practice.²⁴ While no theoretical articles directly addressing the meaning of conscience in nursing were discovered, currently, one way of addressing personal, conscience issues in nursing practice is through conscientious objection.

Conscientious Objection, defined as an objection based on conscience to observing a requirement, has traditionally been used by pacifists to opt out of wars they perceive to be unjust.^25,26 For the last half century, conscientious objection has been used by healthcare professionals (HCPs) to make objections over patient care provision and professional norms of practice they deem unethical because they strongly conflict with their personal moral and/or religious beliefs.²³ While current definitions and perceptions of conscience are widely variant, they are consistently brought up in conjunction with conscientious objection and conscience-related issues in healthcare practice. Conscience has been appreciated as that which grounds human existence, and in connection to conscientious objection, as authenticating one’s actions in keeping with their moral decision-making process.^27,28

In healthcare, conscientious objection has been identified as a mechanism where one can be transparent in their moral behavior. Physicians and nurses have been known to object to performing or referring for abortions, contraception, and euthanasia.^29

–32 Pharmacists in more recent years have been exercising their right to conscience in making a conscientious objection over dispensing contraception and the morning after pill.³²

Nurses’ use of conscientious objection has been minimally reported. Research available shows that nurses may use conscientious objection in response to ethical dilemmas and conflict of conscience that arise in professional settings.^7,11,33,34 For example, nurses have made objections to continuing to provide acute interventions for patients at the end of life because they are not in a position of authority to make the decision to switch patients to comfort care.¹¹ Nurses have also relayed that they are hesitant to make a conscientious objection related to confusing the concept with patient abandonment, perceived stigma, and beliefs they do not have the right to go against patient decisions or professional authority.⁷ Additionally, nurses might find it challenging to declare a conscientious objection due to the lack of their leaders’ knowledge about conscientious objection, who could support nurse’s objections in practice settings.^7,28

Conscientious objection is also addressed in nursing codes of ethics and federations across various countries. The language around nurses’ ability to object differs in each code, although each aligns nurses’ use of conscientious objection with voicing their objections to someone in authority. For Canadian nurses, conscientious objection is clearly, although briefly, defined, entailing that nurses need to request permission to make their objections.²³ The American Nurses Association Code of Ethics stipulates that nurses can voice personal objections, make conscientious objections known in morally limiting situations and when nursing practice is at risk, acknowledge that conscientious objections may stem from moral courage, and that nurses should make their reservations known as soon as possible to leadership.³⁵ In even more depth, the Australian Nursing and Midwifery Foundation outlines at length the expectations and process for nurses to make conscientious objections.³⁶ Stipulations include accommodating nurses to make conscientious objections based on moral and religious convictions, to not make them in life-saving situations, encouraging nurses to make objections in advance when possible, and explicate that no adverse measures should be taken against nurses for their objections.³⁶

Conversely, Britain’s Nursing and Midwifery Council notes that there are only two scenarios in which nurses can lawfully declare an objection with respect to abortion provision and embryonic research.³⁷ In one sense, the UK Code of Ethics’ grounding in legal statutes reflects a proximate relationship of ethics and law. This could be beneficial, given that nurses’ conscientious objections would be legally, as well as professionally, protected, consistently upholding nurses’ fundamental freedom of conscience and creating precedent for maintaining conscience rights in places where codes of ethics do not include conscientious objection clauses. Notably, conscience and conscientious objection are not addressed in the International Council of Nurses’ Code of Ethics.³⁸ A concern arising from the disparity in the language found in these codes, however, is that nurses could receive varying degrees of professional support in some countries over others, unless they have an overarching awareness that their rights to freedom of conscience, belief, and expression are often protected in laws that are not reflected in all the codes. Protection of conscience exists in individual countries specifically, such as in the Canadian Charter of Rights and Freedoms or in wider jurisdictions, as in Article 9 of the European Convention on Human Rights.^39,40

What these codes and reference to fundamental freedoms provide is an insight into the gravity that is involved with making a conscientious objection, because while they may offer a difference of belief, they are not to be misconstrued with mere opinion. The beliefs and values each person espouses are core to how they perceive themselves and others, and register on a moral level, what it means for someone to be a good person. At times, objecting to an established norm of behavior could signal a deeper commitment to be fundamentally, morally aligned than with what appears at face value. As Lachman⁴¹ points out, when faced with moral questions, nurses need to respond with what they ought to do, in correspondence to their conscience-based decisions, such as conscientious objection.

However, research available indicates that front-line nurses and nursing leaders do not always understand what conscientious objection is, exposing a gap between these guidelines and how they are taken up by practicing nurses, which could pose a problem at a professional level on how to enact conscientious objections in practice, beyond a comprehensive understanding of national laws and statutes.^6,7,11

The theoretical literature on conscientious objection lays out some of the criticisms for conscientious objection in nursing. Tensions in this scholarship largely pivot on patient versus provider rights where some question the legitimacy of nurses objecting to care provision, and stating objections could lead to patient abandonment and neglect of care services.^31,42

–45 Conversely, codes of ethics, such as the Canadian Nurses Association Code of Ethics, offers a clear definition of conscientious objection which could support mitigating between conflicting concepts such as patient abandonment.²³ However, such confusion may also indicate that conscientious objection is not sufficiently delineated from patient abandonment in nursing codes of ethics, as well as nursing ethics education.²³ Conscientious Objection within the theoretical scholarship is also perceived as a right within the valid, ethical scope of nursing practice and parameters have been set out to ground nurses’ objections based on the premise that maintaining moral integrity is necessary to ethical practice, nurse well-being and quality, and patient care provision.^6,28,29,41 Ultimately, to move theoretical discussion forward, further dialog could be enhanced with supportive empirical evidence over nurses’ use of conscientious objection in clinical settings.

Defining attributes

Defining the attributes of concepts can help differentiate and clarify the meaning between the concepts being analyzed.¹⁰ Key attributes of conscience have been described in the nursing literature as follows: (1) an inner sense of responsibility that influences right and wrong actions, (2) the result of internalization of parental norms and customs of the culture, and (3) a reflection of the integrity and wholeness of the person.²⁸ Attributes of conscientious objection have been defined in the nursing context as follows: (1) being assigned to care a nurse can carry out, (2) the orders are determined by the nurse to be wrong, (3) the nurse decides they are harmful and not for the good of the patient, based on the ethical principles of non-maleficence and beneficence, (4) the nurse is morally distressed, (5) the orders risk the nurses’ moral integrity and conscience, (6) pondering cultural diversity does not resolve the issue for the nurse, (7) the nurse desires to care for the patient overall, and (8) all other options have been exhausted.¹¹ A concern with these existing attributes is that they do not take into consideration a wider scope of bioethical principles and approaches to ethical decision-making, such as virtue ethics or personalism, and instead, are predicated on only some of the main elements of principalism, namely, non-maleficence and beneficence, but make no mention of autonomy or justice. Furthermore, there is little evidence to suggest that making a conscientious objection is accompanied by moral distress, or that a nurse needs to experience moral distress before making a conscientious objection. Given the lack of conceptual clarity in the nursing scholarship on conscience itself, there is also a lack of evidentiary and theoretical support on which to base these attributes of conscience. A more concerted discussion needs to occur to comprehensively attend to the meaning of conscience in the literature before laying out attributes that would define it.

Antecedents and consequences

Antecedents consist of the conditions prior to when a concept occurs, whereas consequences are the events that happen after a concept occurs, often generating new ideas or approaches to researching the concept or aspects of the concept itself.¹⁰ Antecedents to conscience were limited in the search for this analysis. However, it has been noted that violating any of the attributes to conscience results in a moral conflict because it risks the moral integrity of a person.⁴¹ This suggests that encountering something that awakens one’s inner sense of right or wrong is necessary to experience the effects of conscience: be they negative or positive. Antecedents for conscientious objection have been generated in the empirical literature and consist of the following: (1) nurses understand that consequences may ensue to objecting, (2) accept the consequences and risks to objecting for self and to the profession, (3) ensure the patient is not abandoned and arrange for replacement, and (4) commit to their objection.¹¹ A concern with these antecedents is that abandonment needs to be specifically constituted, since there may be occasions in which a nurse is not in the position to re-assign care, for example, the only nurse on a night shift at a nursing home, or in the case of rural practice. In such instances, a nurse may be the only one available to provide the care to which they may be objecting. In theory, creating parameters for conscientious objection is relevant to delineating between a nurse’s duty to care and patient’s right to access care, yet this is assuming all scenarios involving conscientious objection can be foreseen.

Consequences of conscience can be psychological, such as feelings of guilt when acting against or in conflict with one’s conscience.¹⁹ When nurses cannot follow through on the care they perceive to be necessary standards of good care, they may experience feelings of inadequacy and having a bad conscience.⁴⁴ A troubled conscience or stress of conscience can actually lead to better care in some cases, but also contributes to nurses’ avoiding ethical aspects of care, burnout, changing clinical areas, or leaving the profession.^1,7,20 Consequences of conscientious objection can be loss of job, mockery from others, or consensus with the objection resulting in alterations to care practice.¹¹

Empirical referents

Empirical referents consist of tools to measure concepts.¹⁰ No referents seemingly exist for conscience and conscientious objection together. Measurement tools for concepts related to conscience are the Perceptions of Conscience and Stress of Conscience Questionnaires.^13,20 Formal measurement tools for conscientious objection were not discovered although two studies exist where the researchers created surveys that included questions about conscientious objection for nurses in both close- and open-ended formats.^11,33

Case studies

In conceptual analyses, case studies serve to more fully explicate what the concepts mean and how they are taken up in practice. The cases presented in the analysis are fictitious and based on the primary author’s clinical experience. The case examples consist of scenarios where conscience and conscientious objection would be taken up in an ideal, a less ideal, and a contrary manner.¹⁰

Model case and analysis

Georgia is an emergency-room nurse who is assigned a patient who routinely comes in for pain control. Georgia suspects this patient is addicted to pain medication and thinks it is wrong to feed into the addiction, prompting her to refuse to give him the medication. She approaches the physician on duty and shares with her that she cannot, in conscience, follow through on the order for analgesia.

This case demonstrates a scenario where conscience and conscientious objection are relevantly attributed. In this case scenario, Georgia’s opinions could be considered contrary to the patient’s best interest, based on an assumption that the patient is not telling the truth, and if that is the case, then Georgia could be aligning her conscientious objection with less than commendable purposes. However, this case showcases that Georgia’s actions could also be virtuously aligned based on the concept of justice and verity, where the nurse is challenging accepted norms of behavior to appreciate what is truly going on below face value. For example, as far as Georgia is concerned, the patient is due a full consideration regardless of habit, wherein making a judgment about his drug-seeking behavior could be an astute observation to go deeper and not merely a superficial acceptance that pain is whatever the patient indicates and that HCPs have no right to contradict a patient’s care request. Ultimately, Georgia is making the case for conscientious objection because (1) she has weighed the interests of the patient, (2) found that the care is not adequate to serving the patient’s needs based on a lack of justice in offering him a full range of treatment options, and (3) to stay true to what she thinks is right based on the dictates of her conscience that are contrary to popular opinion, and she refuses to give the pain medication and voices her conscientious objection to the physician. What this case reveals is that making a conscientious objection can be layered in prejudice against those voicing one, as the literature points out, and the case for conscientious objection needs to be more deeply examined to flush out motivating factors and rationale to engage in rich discussions over issues that sometimes nurses may be objecting over.

Borderline case and analysis

Amy is a dialysis nurse assigned to float to the critical care unit to dialyze a patient. Upon arrival, Amy discovers the patient is unconscious with severe, underlying multi-system organ failure. A chart review of the case and a discussion with the patient’s nurse reveal that the patient is still being actively treated by family request and the ICU attending has ordered the dialysis in keeping with the family’s wishes. Amy is conflicted because her assessment tells her that performing dialysis is not clinically indicated and while she wants to care for the patient, she thinks she will cause him harm and undue suffering if she does so. She approaches the physician most responsible for the case, who refuses to change the orders. Amy feels distressed over this situation and believes that following the orders would be wrong for her to do.

The nurse in this scenario has the attributes of conscience as existing with a view to commit to what she perceived to be right and her actions are conscience-dependent. Attributes of conscientious objection are fulfilled because Amy will have to follow a care plan appropriate to her nursing role but she sees this care as not clinically indicated. She is conflicted because her assessment indicates that she could cause the patient to suffer and that her actions will cause her patient harm outweighing the benefits to the treatment; she is distressed over a moral issue because she cannot do what she perceives to be right in not dialyzing the patient. This action will go against her conscience, threatening her moral integrity and appreciating cultural diversity, as well as addressing her ethical concerns with the physician do not resolve the dilemma. Amy wants to care for her patient, but does not view active treatment of his underlying condition as ethically warranted.

This case is borderline to making a conscientious objection because it does not fully articulate a personal conviction contrary to professional nursing standards. Amy is experiencing a tension of competing interests verging on a case of futile treatment versus comfort care; in her professional opinion, offering dialysis to a patient near the end of life could be a contraindication to palliative care. Given the severity of disease, the patient’s prognosis which indicates he is not clinically expected to recover and that it will cause his death in the foreseeable future, aggressive treatment could cause undue suffering and Amy’s conscience could certainly be involved in making efforts to address the treatment plan. On a personal level, Amy could also be following her conscience, prompting her to address the issue further, if the physician in charge disagrees with her perspective. In this scenario, choices for Amy to advocate for the patient before making a conscientious objection could involve ascertaining the patient’s wishes in the form of a living will or substitute decision maker. Moreover, Amy could verify her clinical judgment with a nursing colleague or nursing manager and suggest to the physician that they call the clinical ethicist to offer a mediating perspective.

In terms of cultural diversity, it would be important for Amy to locate her own appreciation for what constitutes futile care and comfort care, and cultural aspects that could be influencing the patient, the patient’s family, or the physician and institutional beliefs of what comprises quality patient care provision, as well as futile and comfort care measures. If, after all these considerations, it comes to light that the patient is receiving unwarranted treatment based on professional differences of opinion, or that the patient and family wish to continue treatment due to cultural or faith beliefs, Amy might be faced with voicing a conscientious objection stemming from her personal conviction that she would be doing harm that she cannot personally reconcile with professional objectives. However, it may also be that Amy thinks that she has done due diligence and while still uncomfortable with providing the dialysis, can do so in line with patient wishes, should that be the motivating factor for dialysis, in line with professional standards and ethical principles. What this case study shows is that a difference of professional opinion does not necessarily warrant a conscientious objection at the outset, but it can if the HCPs in question are seriously at odds with the parameters of care provision that conflict between what providers consider ethical to provide.

Contrary case and analysis

Josh is a nurse assigned as the overnight charge nurse in a complex continuing care unit. As the only nurse on shift, Josh cannot leave until the next nurse comes in to replace him in the morning. For the last 6 months, Josh has been working overtime since the hospital is short staffed. Josh feels the demands of his job building up and consistently feels like he is neglecting his patients because he barely has enough time to assess them and administer their medications. Due to staffing shortages and time restrictions, Josh feels consistently guilty at work over not providing quality care to his patients. His work hours are taking a toll and he is finding it hard to balance work demands, as well as having the energy for taking care of his children and supporting his wife at home. Near the end of his shift, Josh receives a call from his manager asking him to stay an extra half shift since there is shortage of nurses again. Exhausted, Josh is upset and while he wants to care for his patients, he considers telling the manager to come in to take care of the patients as he does not feel safe administering more medications with his level of exhaustion. However, he does not want to abandon his patients, but feels uncomfortable with the situation he is in.

In this case, the nurse encounters a scenario where it could be an issue of conscience as the nurse is concerned over not being able to provide care in a way that is safe and beneficial to his patients and qualities he conscientiously values in his patient care delivery. He is carrying out care appropriate to a nursing role, and while he is conflicted in evaluating his options, he is limited in how he can address his concerns since there are no other nurses available and he is left to face his manager as the only option. This situation could be morally distressing as Josh is not able to do what he perceives to be right, related to workplace restrictions. However, he could address the concern with his manager and try to negotiate a plan that would accommodate his level of safety where the manager could come in to cover some of the shift or check the medications with him. Short- and long-term discussions are warranted with nursing management to prevent burnout for this nurse’s conscience concerns and to better support the patients, as well as the nurse, in this scenario. Making a conscientious objection in this case is contrary to the scenario since Josh’s frustrations revolve around external constraints, that, while distressing for him, encapsulate time management and safety issues that are a concern because they are not consistent with nursing best practice and patient safety, but do not necessitate a situation of serious, personal conflict of conscience resulting in a conscientious objection.

Discussion

The results of this study to analyze the concepts of conscience and conscientious objection using the method laid out by Walker and Avant reveal that there are substantial gaps in the literature related to (1) the meaning of conscience for nurses, (2) conceptual differentiation between prominent topics such as moral distress and stress of conscience, and (3) antecedents and consequence of conscience in nursing care, regarding conscientious objection and how conscientious objection is taken up in nursing practice.¹⁰ An extensive review of the literature showed that while conscience is defined in various ways, it is largely perceived as an important component to ethical nursing care and can have positive, as well as negative, connotations for advancing or restricting nurses’ care practice. However, most of the research available on conscience consist of studies which address factors related to it and do not focus on the meaning of conscience in nurses’ everyday practice. Nurses’ reports on issues of conscience predominantly relate to their perceptions of the concept as opposed to how they address their conscience concerns by acting on, as well as resolving their troubled conscience or stress of conscience in professional settings.

Similarly, limited studies have been conducted on conscientious objection for nurses to date. Definition of the concept shows that conscientious objections arise from one’s efforts to comply with their conscience and findings from Ford’s research on conscience issues support that nurses may opt to voice a conscientious objection on issues that conflict with their conscience.⁷ However, research on conscientious objection also does not fully establish how nurses have used conscientious objection to address their conscience issues. Evidence is needed to substantiate a link between conscience and conscientious objection to explore the ways in which nurses’ conscience issues can be addressed in practice settings. In the studies included in this analysis, conscientious objection was considered an option that nurses have reported using or desiring to use in situations where they struggled ethically to carry out futile treatment plans, contentious practices such as withholding of treatment, and indicated that in some circumstances they would consider voicing a conscientious objection for care that conflicted with their personal, ethical beliefs.^11,33,34 Yet, considering the antecedents available for conscientious objection and the range of guidelines for nurses in various codes of ethics regarding conscientious objection in nursing practice, the findings of the studies available do not articulate specific situations in which nurses have encountered an ethical issue, resolved that a conscientious objection was their only, ethical course of action, report how they have made their objections known, and what the consequences were for their actions.

In addition, while clauses and codes of ethics protect conscientious objection for nurses in various countries, stringent attributes in the literature stipulate that nurses need to be willing to give up their jobs as a consequence to making a conscientious objection, which does not reflect many of the current codes and guidelines supporting nurses’ appropriate objections. These inconsistencies in the empirical research indicate that conscience and conscientious objection have not been conceptually established in the empirical literature and further research is needed to outline their implications for nursing theory and evidence based practice. In addition, some studies show that nurses may not fully understand what conscientious objection is in countries where conscientious objection is addressed in their respective codes of ethics.^6,7 Consequently, strategies for nursing ethics education could support conceptual awareness, and understanding of conscientious objection for practicing nurses, as well as nursing students, to ensure their awareness of ethical options available to them in professional practice, should the need arise where they would consider making a conscientious objection.

Conclusion

Analyzing concepts relevant to nursing supports theory development and evidence-based practice.¹⁰ This conceptual analysis demonstrates an initial appraisal of conscience and conscientious objection for nurses to date. Conscience is an essential component of ethics, as well as moral nursing practice, offering a medium for nurses to think through and act on what they perceive to be right. Conscientious objection is an option that can proactively address nurses’ conflict of conscience over personal, ethical concerns and patient care issues, which can be taken up by nurses accompanied by supportive guidelines and knowledgeable leadership. Critically examining the concepts of conscience and conscientious objection as currently situated in the context of nurses fills a gap between research and practice by explicating what is known and what needs to be clarified further. This concept analysis offers a way forward for advancing nursing ethics centered on addressing what conscience and conscientious objection mean for nursing practice, and outlining implications for further research.

Limitations

Perspective on ethics and ethical concepts in nursing can vary greatly with scholarship advancing from various sectors on a frequent basis, posing a challenge to capturing all the nuances that exist in association with ethical concepts. While this search focused on the nursing context for conscience and conscientious objection, the content was based on empirical studies, as well as theoretical articles, in ethical nursing scholarship. An analysis of the concepts in nursing texts and articles related to ethics education would be valuable going forward.

Implications for nursing research

Appreciating conscience and conscientious objection as ethical components for nursing care is an opportunity to advance nursing ethics through research, education, and practice. Studies that could emerge from findings of this concept analysis include explicating nurses’ experiences with making conscientious objection to support (1) evidence-based models on conscientious objection for professional policies, (2) teaching strategies and exemplars for nursing education and leadership, and (3) fostering inter-professional discourse outlining the ethical situations of nurses and the value that inter-professional roles can have in resolving nurses’ issues of conscience since they are not in a position of authority to make care decisions, although their input to patient care is considerably valuable. Generating further knowledge on the meaning conscience holds for nurses offers an opportunity to enhance nursing philosophy and theory for conscience-based, ethical decision-making. Research that measures nurses’ conflict resolution in response to their conscientious objections in practice could be a strategy for evaluating the effectiveness of nursing knowledge based on current guidelines supporting nurses’ objections.

While research on conscience-related issues are becoming more apparent in the nursing literature, the meaning of conscience and conscientious objection individually and in relation to each other are minimally, empirically researched. For example, the nursing context lacks studies on nurses’ experiences of using conscientious objection and the impact such objections have for their nursing practice. Studies are needed to generate empirical knowledge on conscience in relation to conscientious objection to more fully explicate how nurses and other HCPs respond to conflicts of conscience.

More research is warranted to practically support and evaluate nurses’ theoretical understanding and actual encounters with conscience and conscientious objection. Given the relevance of conscience and conscientious objection to nursing ethics, evidence is needed to shed light on how conscience-related concepts can be positively incorporated in today’s ethically diverse practice settings. Efforts are needed to reduce the negative implications conscience issues can hold for nurses and to begin to formally address the conflicts that could give rise to their conscientious objections.

Implications for nursing practice

At a time when patient care needs are increasing and becoming more technologically and ethically complex, nurses with strong ethical knowledge are needed to respond to the practical, ethical demands of their profession. This concept analysis supports a way forward to expand on ethics-based nursing theory, nursing education, and ethical nursing practices regarding conscience and conscientious objection. The perspectives on both concepts are diverse, signaling a greater need to address issues of conscience conflict occurring in nursing through focused research and education. Awareness of, and commitment to, an ethical orientation is a requisite for contemporary nurses, made possible by their ability to address conscience issues through transparency of conscientious practice.

Footnotes

Conflict of interest

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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