Conscientious objection and nurses: Results of an interpretive phenomenological study

Abstract

Background:

While conscientious objection is a well-known phenomenon in normative and bioethical literature, there is a lack of evidence to support an understanding of what it is like for nurses to make a conscientious objection in clinical practice including the meaning this holds for them and the nursing profession.

Research question:

The question guiding this research was: what is the lived experience of conscientious objection for Registered Nurses in Ontario?

Research design:

Interpretive phenomenological methodology was used to gain an in-depth understanding of what it means to be a nurse making a conscientious objection. Purposive sampling with in-depth interview methods was used to collect and then analyze data through an iterative process.

Participants and research context:

Eight nurse participants were interviewed from across practice settings in Ontario, Canada. Each participant was interviewed twice over 9 months.

Ethical considerations:

This study was conducted in accordance with Health Science Research Ethics Board approval and all participants gave consent.

Findings:

Six themes emerged from data analysis: encountering the problem, knowing oneself, taking a stand, alone and uncertain, caring for others, and perceptions of support.

Discussion:

This study offers an initial understanding of what it is like to be a nurse making a conscientious objection in clinical practice. Implications for nursing practice, education, policy, and further research are discussed.

Conclusion:

Addressing ethical issues in nursing practice is complex. The need for education across nursing, healthcare disciplines and socio-political sectors is essential to respond to nurses’ ethical concerns giving rise to objections. Conscience emerged as an informant to nurses’ conscientious objections. The need for morally inclusive environments and addressing challenging ethical questions as well as the concept of conscience are relevant to advancing nursing ethics and ethical nursing practice.

Keywords

Conscience conscientious objection education ethics nursing phenomenology

Introduction

Contemporary nursing practice can be complex and ethically challenging.^1
–3 For example, nurses are consistently encountering ethical issues related to: restrictions in providing quality patient care, or in providing care they do not perceive to be beneficial or ethical to carry out for their patients, and/or encountering care practices they are ethically at odds with, which creates ethical dilemmas and can result in issues of conscience for nurses.^4

–8 At times, nurses may encounter an issue in practice that so strongly conflicts with their personal, ethical beliefs that they may declare a conscientious objection to refrain from participating in or carrying out an aspect of clinical practice. Living through an experience of making a conscientious objection, as a nurse, sheds light on how to weave through the contentious fabric of what it means to be an ethical nurse in today’s world.

Typically, conscientious objections consists of making an objection to something that one is personally, ethically opposed to doing to stay consistent with one’s conscience.⁹ Conscience is a phenomenon that has been defined in a variety of ways, predominantly in philosophical, theological, and healthcare literature.^10

–14 Conscience is that which makes human existence, more fully human, and can be encountered in one’s every day, lived experiences.¹⁵ Conscience in this research study was defined as: an internal moral decision-making process that holds someone accountable to their moral judgment and for their actions.

Currently, voicing a conscientious objection is predominantly discussed in the literature based on theoretical perspectives over what validates nurses’ use of conscientious objection versus how nurses themselves make meaning of this phenomenon. Yet, the prevalence of ethically challenging practice settings in healthcare is increasing.⁶ While conscience is relevant to conscientious objection, there has been minimal research conducted on what it is like for nurses to make meaning of conscience or experience conscientious objection as voiced by nurses themselves. As such, there is a gap in the literature related to how nurses confront their issues of conscience and ethical dilemmas in practice, and what meaning those experiences hold for them. Given the lack of knowledge regarding conscientious objection as it has been taken up in nursing practice as opposed to theorizing how it could be used and the paucity of research on this topic, the experience of making a conscientious objection needs to be brought to light through the perspectives of nurses who have made a conscientious objection themselves. This study begins to address the gap in the literature on nurses’ use of conscientious objection by exploring how nurses have lived with their experiences of voicing a conscientious objection in professional practice settings and what meaning those experiences held for them. The first author’s (C.L.) own experience of making a conscientious objection also prompted this research. Specifically, given her bioethics background, C.L. had the necessary knowledge to address an ethical issue with conscientious objection that did not arise from her nursing epistemology. The authors’ overall exploration of conscientious objection as experienced by other nurses in this study emerged from a sense of compassion for their ethical and moral well-being when providing quality nursing care without compromising their moral integrity, which can be very challenging for nurses who need to balance professional obligations; patient preferences; and personal, ethical convictions.

Research design

Methodology

To address nurses’ moral choices and encounters with ethical issues resulting in their conscientious objections, a methodology was needed that could shed light on the nurses’ experience of voicing a conscientious objection. Phenomenology is a philosophy and method that lends itself well to a purpose of gaining an in-depth understanding of lived experience.¹⁶ Such a purpose allows the researcher to become more aware of what it means to be human as grasped through human-being experiences, acquired through interpretation of encountered phenomena in one’s everyday existence.^17,18 As such, the interpretive phenomenological approach of Martin Heidegger was chosen to guide this study. Being in time were, for Heidegger, the lenses through which someone views their experiences and shape the meaning that can be drawn from them.¹⁹ Heidegger’s term for the mode of human existence is dasein.^18,20 Consistent with the notion of dasein, humans recognize that while they are inextricably bound up in the world they are also distinct from it, allowing them to reflect on their existence as such, through their subjective encounters with the objective dimensions of the world in which they exist, known as an inter-subjectivity. This inter-subjective orientation is further approximated through one’s encounters with their everyday existence, made known to them through their life worlds, or the context of their day-to-day encounters, described as lived experiences.

Van Manen^21,22 describes five fundamental and existential aspects of human life worlds: spatiality, corporeality, temporality, relationality, and materiality. In these different modes of being-in-the-world, one can grasp their experiences as being in a certain space, in time, as beings that relate inter-subjectively to one another and in the material things that one encounters in the world. A life world is the way in which a day-to-day experience presents itself to dasein, such as the daily moments of being a nurse. On a given day, if a nurse makes a conscientious objection, the meaning that can be derived from that lived experience is what an interpretive phenomenological researcher would aim to capture, to understand the meaning embedded in that experience.¹⁸ For example, being (existing) in the now (time), as nurses (life world) shape how an experience (making a conscientious objection) with a phenomenon (conscientious objection) can be understood through relating to patients or colleagues (inter-relationality, corporeality) and through the things (material objects, that is, codes of ethics), that tell nurses something about who they are.²² Meaning within a lived experience becomes clear through interpretations of these encounters presented through text.

Sample

The sampling strategy for this study was purposive and consisted of eight nurses who had made a conscientious objection in professional practice. Participants’ years of practice experience ranged from less than 5 years to over 45 years (Table 1). Areas of clinical expertise varied and were comprised of acute, palliative, mental health, and community care settings. All participants but one had some level of ethics education that was acquired through either: (1) nursing programs or (2) alternate courses that were not acquired through formative nursing programs (Table 1).

Table 1.

Participant demographics.

Name of participant	Level of nursing education	Ethics education in nursing, Yes/No (separate course or integrated with other courses)	Alternate ethics education (Yes/No)	Area of nursing practice	Years of nursing experience
Annie	BScN	Yes	No	Critical care	5–10
Tracey	Masters	No	Yes	Mental health	>40
Beth	Diploma	No	No	Homecare manager	20–30
Robert	PhD	Yes (all three degrees)	No	Palliative care/CNS/nurse educator	30–40
Kate	BScN	Yes	Yes: ethics/philosophy elective in undergrad	Oncology	<5
Nancy	Diploma	Yes	Yes: 1-day ethics conference	Palliative care	30–40
Amy	Masters/NP	Yes	No	Palliative/community care	10–20
Ruth	Diploma	Yes (integrated with other courses)	No	Acute medicine	30–40

Data collection

Data were collected through in-depth, one-to-one, semi-structured interviews. Interviews were held over the telephone or face-to-face with participants. Two interviews were held with each participant.

Data analysis

Data analysis was conducted for this study with Crist and Tanner’s process for iterative analysis complemented with Van Manen’s interpretive phenomenological approach to writing.^{16,17,20
–22} Crist and Tanner’s¹⁷ phased analysis attends to Heidegger’s²⁰ process of interpretation, known as the hermeneutic circle, where each phase of analysis iteratively flows from one to the other, continuously building on interpretations that came before. This method of analysis does not end, but instead rests with the readers of the research since interpretive phenomenology is used to inform and generate a deeper understanding of the phenomena being explored.⁷ Saturation was reached when further discussion with participants did not elicit a clearer understanding of the lived experience, and no new information was forthcoming.¹⁹

Ethical considerations

Ethical approval was obtained through the Health Research Ethics Review at Western University (reference number: 107795). Letters of information were given to every participant, and verbal or written informed consent was obtained prior to conducting interviews. Each participant was knowingly given a pseudonym to protect their anonymity and confidentiality throughout the study and for publication of the study findings. Trustworthiness was attended to in this study through credibility, dependability, transferability, and reflexivity, which involved the use of reflective journaling to maintain awareness of researcher’s stance in the study, member checking, establishing an audit trail, and writing thick descriptions with participant quotes.^23
–25

Findings

Across participants’ narratives, making a conscientious objection in clinical practice was meaningfully experienced by participants as an opportunity to transcend the status quo, to acknowledge that they each had a conscience, and to take a stand to live by a moral code. Conscientious objection meant doing what was right. These nurses wanted to be clear that they did not personally want to do harm, from a professional standpoint, toward themselves, their patients, or their nursing profession. While each of the nurse participant’s experiences were unique, across their collective stories six themes with sub-themes were uncovered from their lived experiences with conscientious objection (Table 2).

Table 2.

Themes and sub-themes.

Encountering the problem

Knowing oneself

Personal and professional

Influencers of moral beliefs

Connecting conscience to conscientious objection

Taking a stand

Transparency

Alone and uncertain

Futility

Caring for others

Perceptions of support

Lack of support

Presence of support

Meaningful support

Encountering the problem

Prior to making their conscientious objections, the nurse informants shared that they each encountered an ethical problem in their professional practice. For seven of the participants, this problem surfaced in the form of the newly legislated Medical Assistance in Dying (MAID) protocol in Canada, which most of the participants individually and collectively expressed as an unethical practice. Nancy shared her concern regarding moral complicity in voicing her conscientious objection over her ethical problem with MAID while she was caring for a resident in advance of their termination date:

The funny thing is our care coordinator said…you don’t have to participate and you don’t have to be involved [in MAID]…after this experience, I said you know what, that’s so not true. Because I said, I was involved, I said I had to talk to her about it, I had to listen to her…the resident’s concerns, I wasn’t involved in the actual procedure, but I was involved.

Nancy recalled this encounter as a time of deep, personal struggle because she did not ethically agree with assisting patients to die, and seeing this person on a day-to-day basis as a nurse brought her close to an issue in her nursing experience that she did not agree with. For Amy, encountering the ethical problem that brought about her decision to become a conscientious objector arose in a moment of epiphany when she confronted the concept of MAID in a gestalt awakening as something that she might have to carry out as a nurse practitioner:

Well, there was surprise initially because of all the discussion, you know, before the legislation [on MAID] went out, was that it was going to be physicians [performing it]. So, at first it was surprise that it was going to be nurse practitioners as well. Well, I think, just reading [the legislation], you go, ok, wow, nurse practitioner, ok that means me, so that was professional association. And that wow, that really expanded the boundaries of the scope of practice…but then, at the same time, it was ah, that means me! And that was really the moment where the tensions really came in and I thought, no, I can’t do this, this is personal.

Amy’s experience of revelation brought to light her decision to be a conscientious objector to MAID in a moment of time in where she made sense of what the legislation would fully mean for her, as a person and as a nurse practitioner.

Knowing oneself

The theme of knowing oneself was abstracted through a sense of personal conviction that each nurse participant had regarding their sense of morality, or what it meant for them to be a moral person in their professional lives. Encountering an ethical problem brought a sense of personal conviction to the forefront of ethical issues in their everyday life world of being a nurse.^22,26 As Annie related, everyone has “an inner voice of what’s right and what’s wrong.” This inner voice denoted Annie’s perception of conscience which she perceived as the basis for making a conscientious objection:

Objecting to what you think is wrong, you make an informed decision based on your own morals and conscience and your beliefs and you just object, you say this is wrong and you don’t want to be a part of it.

The delineation between perceiving something as personally wrong to do from what may be otherwise permitted on a professional scale was echoed in Kate’s perspective on conscience related to making a moral decision:

To a certain extent I think all of us have this gut feeling about right and wrong, but when it gets into the more nitty gritty, and our feelings of, oh it feels right or it feels wrong, sometimes are not right or wrong and I think particularly when it comes to sympathizing with somebody who is going through something and you understand how they are feeling or making the choices that they’re making, you still know it’s wrong.

Personal and professional

An awareness of one’s personal, moral sense of themself in keeping with their professional sense of self was a subtheme abstracted from the arching theme of knowing oneself. Being an integrated person emerged for these nurses as something that ethically superseded a sense of personal, ethical conviction over one’s professional obligations, as Tracey explained:

It’s really high stakes to act on your conscience, well, inform your conscience to know what’s right to do and what’s wrong to do and then, to have the courage to go ahead and act in that way, because acting, like, doing the good, is more important than whether you’re going to keep your job.

Knowing oneself through a personal and professional sense of self was meaningful for these nurses as being contrary to the status quo. Tracey related,

Articulating a decision in a culture, where, you know, it’s not normal to object to an abortion referral, or to administer a medication that might act as a contraceptive…you know, people think you’re really extreme to make this decision.

Influencers of moral beliefs

Influences of these nurses’ moral beliefs in declaring a conscientious objection was another subtheme that was abstracted from the theme of knowing oneself. Amy’s ethical convictions were reinforced as an antecedent to her actions, which she deliberated from a standpoint of reason and not disparate from her religious beliefs:

You have to look at the other things involved…you go more even more micro…there are different decisions along the way…am I comfortable giving information about it [MAID]? It would be the action, that I would be ending somebody’s life…that I would be hastening rather than the palliative perspective…the big difference is that this is not natural, you’re hastening somebody’s death.

Kate shared that as a Catholic, her ethics are informed by her faith, but she noted that her faith is based on reason and working through ethical scenarios with deliberation, which is something that takes moral discernment and education:

As a Catholic I know where that knowledge base comes from…I know whenever I’m not sure I can go read up on or think about the deeper implications of whatever confusing feelings I’m having…I can see other people hitting a bit of a roadblock when they have no moral code…and so some people turn to whatever feels right.

Knowing oneself as a person and as a professional is also based on non-religious perspectives of morality and can extend from one’s upbringing, cultural influences and education. Yet, as Annie pointed out, she also found it disappointing that in nursing, so much research has been done to understand moral issues in practice, yet little supports exist for nurses to address those issues.

Connecting conscience to conscientious objection

For these nurse participants, conscience and conscientious objection were not mutually exclusive—conscience is about discerning what is right for one to do, and making a conscientious objection is based on one’s conscience-based perceptions of morality and then expressed as that right action (ethics). Annie meaningfully perceived conscientious objection as something powerful because it is an action, which she equated with change:

Adding the word objection to it I feel like it has so much more power…you know, kind of doing what is wrong and questioning what’s right, but I feel like this has more positive connotation to it, like you have a choice, you’re not feeling this residual distress and you just have to accept that’s the way it is. I think it almost, it’s a little empowering.

Taking a stand

The limits of the nurses’ moral sense of self being tested by perspectives and practices external to their comprehension of morality and conscience drove them to taking a stand over their encounters with a problem in clinical practice. Taking a stand means lining oneself up with one’s moral convictions and following through on what one believes to be right regardless of what others think. Referencing her decision to make a conscientious objection in the moment of a futile resuscitation experience, Annie’s decision to take a stand and voice her conscientious objection arose in a moment in time where her inter-professional colleagues and nurse managers opposed and remained silent, respectively, to her request to question the benefits of continuing aggressive treatment. In addition to voicing her disagreement, Annie felt compelled to leave the room to fully register her conscientious objection:

I just kind of had to leave. At least, well, I wasn’t there, but I was still outside, you could still hear everything they were saying and yelling out and you could hear them shocking [the patient]. I don’t know how else to respond to that-you do what you try and voice your concerns.

Transparency

Transparency is a subtheme in these nurses taking a stand to make their conscientious objections known. Being transparent is to be clear and denotes a willingness to be open about one’s views.²⁷ To be transparent, Robert stated that open and frank discussion is necessary to flush out ethical concerns for clients and their caregivers.

Alone and uncertain

Alone is term that is defined as being on one’s own, or not being accompanied.²⁸ Uncertainty means not being completely known or left vague and unclear.²⁹ Nurses lived experiences with making a conscientious objection revealed that their decision left many of them feeling alone and uncertain. Tracey shared that she realized her position regarding MAID and objecting to it made her an “outlier…because I thought it was unethical to facilitate our patients being killed and designing a policy that would allow that.” A policy that was otherwise held as the status quo in her workplace. Beth related that when the law for euthanasia was coming forward leading to her voicing a conscientious objection over it, she felt like a “lone soldier” given that this was not an issue her colleagues agreed with her over. Emerging from Robert’s narrative is a sense of stigma. Stigma arises from the Latin word for marking or branding.³⁰ Robert discussed encountering this stigma in the form of automatic dismissal for his perspectives based on other’s instant assumption that he is religious, even though he himself does not offer that as a rationale.

Futility

As a subtheme to alone and uncertain, futility emerged as a feeling that some participants had after voicing their conscientious objection. Futility means failure to bring about a desired result, of being useless, or a wasted effort.³¹ Annie shared her frustration by what she describes as being “powerless” as a nurse to speak up and drive change in practice over moral issues that she perceived needed to be addressed:

I find a lot of times I’m not included in the decision making and it just frustrates me to feel so angry and helpless…being unable to alter and even advocating and trying to make a difference and that didn’t do anything.

Caring for others

Caring, or being compassionate, particularly toward those who are sick came through Tracey’s narrative in her concern for the well-being of her patients as well as her nursing colleagues and profession in her conscientious objection over Medical Assistance in Dying.³² Tracey viewed support of MAID and the perceived silence she received from others in her opposition to MAID as detrimental to patient’s lives and her nursing colleagues who may not have had the opportunity to be informed about all sides of the issue. Beth also cared for those she worked for and she saw providing good care, such as appropriate palliative care and end of life treatment as practice that did not include assisting patients to die. Nancy revealed that when voicing a conscientious objection, it arose out of caring for patients and making ethical nursing decisions that need to be supported, which may only be revealed when a nurse is pressed into a problematic situation, “to be able to help other people…even if the college gets some of this [sharing of her lived experience] they will know from a personal experience the struggle that is out there. And they need to support us.”

Perceptions of support

Perceptions of support came through the nurses’ stories as meaningful to their experience of making a conscientious objection. This theme was highlighted in their narratives as either a lack of support, presence of support or what support meant to them as conscientious objectors.

Lack of support

In Annie’s experience, concrete supports for making a conscientious objection did not exist. When faced with her conscientious objection, she was greeted by silence (nursing managers not saying or doing anything when she made a conscientious objection in front of them), delayed apology but no admittance of wrong (physician), and delayed, or no support (nursing managers).

Presence of support

In voicing their conscientious objection, Tracey, Beth, Robert, Amy, and Nancy mainly received support family, friends, and for some, their grasp of ethics.

Meaningful support

Ruth shared protection for freedom of conscience needed to be implemented institutionally for nurses who make conscientious objections. She noted public awareness is needed to illustrate that not all nurses are ethically amenable to certain practices that may be status quo, such as MAID, since it could be the public’s perception that whatever changes occur in healthcare, is something all health care professionals (HCPs) agree with:

There will be some nurses who can’t participate, so let the public know…I think the public assumes anyone who walks in, assumes we [nurses] are all there for it. We have to have our protection too…just because you [patient] want it you can’t expect me to do it and put me in that position and report me if I don’t do what you say.

Discussion

To address the ethical issues that nurses may encounter, nurses need a sense of self-knowledge that explicates their subjective ability to navigate their ethical problems as evidenced by these nurses who were willing to take a stand to address their ethical problems in practice by way of their conscientious objections. Yet, much of the scholarship around conscientious objection to date has failed to reveal how nurses themselves are informed about their decisions to make a conscientious objection and if their decisions are informed by their conscience. In empirical nursing literature, conscience has been largely perceived as a concept that cannot be universally defined, owing to a dominant belief that conscience is a construction based on individual perceptions, although professionally there is a broadly shared consensus that conscience is a relevant idea in relation to nursing ethics.^4,7,33 Moreover, conscientious objection has been disparately viewed as a phenomenon that is both an extension of conscience and unrelated to conscience given the lack of belief that conscience is, itself, an objective principle.³⁴

However, this research revealed that participants perceived their conscientious objections as meaningfully arising from their conscience. This is consistent with philosophical and bioethical literature on the works of primary authors on conscience, where the idea that conscience is inherent to humankind has been stipulated for centuries, although this view has been largely neglected in post-enlightenment, contemporary approaches to conscience in the ethics and healthcare literature.^35,34 Yet, across these nurses’ experiences of conscientious objection, conscience held true as a phenomenon that leant meaning to their conscientious objections as something that existed for each nurse, to hold each nurse accountable to right action. This meaning could shed some light on how nurses and other healthcare professionals could facilitate ethical dialogue by way of a common appreciation for conscience. Instead, these nurses shared that their conscientious objections were largely met with silence or dismissal by their nurse managers, regulatory bodies, political leaders, or physician colleagues, which might have proven otherwise if conscience were a valued phenomenon intersecting healthcare professionals, practice, and political stakeholders. This research reveals the need for dialogue among nurses, between inter-professional healthcare disciplines and with socio-political stakeholders to advance nursing ethics by explicating the ethical challenges nurses face, regardless of how challenging, and rather due to, how ethically controversial, those conversations may be.

Nurse participants’ experiences revealed that nurses who encounter ethical problems and dilemmas often do so in the context of healthcare practice related to conflicting viewpoints with other HCPs and professional, as well as socio-politically sanctioned practices that fundamentally differ from individual as well as collective nurses’ moral and ethical perspectives. For example, most of the nurse participants had a mutual objection to MAID, although the circumstances surrounding their experiences were individually contextualized. To bring their conflicting perspectives to light and to face their ethical problems or dilemmas in practice can require nurses to act with moral courage.³⁶ Researchers have found that conscience can be a positive force, driving nurses to question the status quo, adhere to their values, address challenging situations, and debate dominating perspectives, which resonated with the nurses in this phenomenological study who adhered to what they valued to be moral and be ethically transparent about their decisions, even though this often went against the status quo.³⁷ Yet, staying true to their conscience was part of how they balanced their personal beliefs with their professional obligations.

This research also highlights the need for nursing ethics education in formative and ongoing capacities. Nurses’ responses to the ethical problems and dilemmas that they conscientiously encounter require extensive moral deliberation, ethical analysis and the ability to articulate a moral stance in light of their professional obligations and patient care requests. As these participants’ experiences reveal, the nursing profession needs to awaken to the moral needs of nurses and support their ethical decision-making through a robust attention to the philosophical underpinnings of ethical analysis. For example, incorporating moral philosophy into nursing courses in bioethics would be one epistemological approach that could support an in-depth framework of critical argument to delineate the difference between moral issues, rationale, moral deliberation, and gut feeling, where the latter is typically a signal of a deeper problem that needs to be further articulated.

Cultural awareness over diverse opinions on ethical issues within the nursing community itself would have also been supportive in making a conscientious objection for these nurses. Nursing regulatory bodies to date have stipulated that nurses be transparent in making their conscientious objections known, but little direction or evidence exists on how to integrate conscientious objection into nurses’ education, practice or to direct nursing managers on how to support themselves or other nurses when conscientious objections occur.³⁸ Notably, researchers in the Canadian context have been heavily involved in restricting the conscientious objections of HCPs across the country.^39
–41 However, the work of these researchers has extensively failed to address the rights of, and reasons for, HCPs to stay true to their right to freedom of conscience as expressed by HCPs themselves.⁴² This is also problematic considering nurses dominate the healthcare workforce and make a significant contribution to the Canadian healthcare system.⁴³

Despite some of the negative perspectives that exist over conscientious objection, care was a motivating, relational factor for nurses living with making a conscientious objection in their professional practice. Their expression of this motivating factor materialized as a sense of compassion for the suffering of their patients and a desire to see that suffering decreased either through the cessation of futile treatment or as re-directed with palliative care as an alternate to Medical Assistance in Dying. Suffering is a part of the human experience and may be described as needing a cooperative approach in which people as care providers and care receivers can appreciate the suffering of one another.⁴⁴ In this sense, suffering has been perceived as something that is relational, and a way to connect one human to another by way of considering the fundamental implications of what it means to be, fully human.⁴⁵ Wojtyla⁴⁶ noted that the fundamental characteristic of humanity is to act, which is expressed ethically as doing that which one considers to be right, not only for oneself, but as an extension of what it means to do what is good, in relation of oneself to another. The theme, caring for others, reveals that those who make a conscientious objection may do so not just for themselves, but to challenge what might otherwise signal an ethical erosion of what can be perceived to be good for individuals and a society at large. In this research, MAID was perceived as such an example in which nurses would not participate in a practice that would both morally and physically harm the patient who requested it, the moral integrity of the nurse who assisted in it, and the moral fabric of a society who had sanctioned that taking someone’s life could be a social good.

Implications

Findings of this research offer new insights into what it is like to be an ethical nurse voicing a conscientious objection in clinical practice. Nurses’ perspectives on these concepts speak to the relevance of being able to address their ethical problems and issues of conscience by way of making a conscientious objection. However, participants did not have a conceptual understanding of conscience or conscientious objection by way of formal nursing education. Nurse educators can use these findings as a foundation for ethics education on conscience and conscientious objection to ensure that nursing students, practicing nurses and nurse managers are aware of the ethical options available to them in professional practice, should the need arise where they would consider making a conscientious objection, or when a nurse manager would need to support a staff nurse voicing one.

Insights from this research can support nursing regulatory bodies in an international context to increase public awareness, create policies, and professionally recognize that nurses need explicit support for their conscience issues and conscientious objections through the creation of freedom of conscience and conscientious objection clauses in workplace settings and codes of ethics. Nurses and nurse practitioners can use the findings to support their conscientious objections in practice until such clauses materialize and become incorporated into nursing practice. Results from this study also offer evidence for regulatory bodies to support nurses by increasing public awareness on nurses varied, ethical stance to practices such as MAID and to protect them from taking part in practices they deem to be unethical. Without protection for, and further education on, conscientious objection, and moral inclusion for nurses’ conscientious care practice, the profession of nursing risks the loss of ethically oriented nurses and increases the need for moral courage to become a standard of nursing practice, which is disconcerting given that nursing is an ethical profession in the first place. To ensure that nurses deliver excellent ethical patient care, the ethical needs of nurses must first be addressed so that they can articulate their ethical concerns and the ethical concerns of their patients, to provide ethical patient care and be ethical forerunners in nursing ethics today and into the future.

Conclusion

The findings of this study reveal that there are substantial gaps in the literature related to the meaning of conscientious objections for nurses as voiced by nurses themselves over how conscientious objection is taken up in nursing practice. 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’ conflicts of conscience. Exploring the phenomena of conscience and conscientious objection as meaningful in the context of nurses bridges a gap between research and practice by explicating what is known and what needs to be clarified further. This phenomenological study offers an initial way forward by providing insights for advancing ethical nursing practice centered on addressing what conscientious objection and conscience mean for nursing practice. The search for meaning continues.

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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