essay on ethical dilemma in nursing

20 Common Examples of Ethical Dilemmas in Nursing + How to Deal With Them

If you are a nurse, chances are you have faced situations where you had to make decisions based on your belief of whether something is right or wrong, safe or unsafe. This type of decision is based upon a system of ethical behavior. It is essential that all nurses develop and implement ethical values into nursing practice. If this sounds familiar, you may be asking, "What are the common examples of ethical dilemmas in nursing?" There are many things that could be considered an ethical dilemma in nursing, and it is important for nurses to know how to address them when they occur. In this article, I will share the 20 most common examples of ethical dilemmas in nursing and offer some insight into handling them.

What Is An Ethical Dilemma In Nursing?

5 main reasons why nurses face with ethical dilemmas in nursing.

1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing

How To Identify Ethical Dilemmas In Nursing?

What are the common examples of ethical dilemmas in nursing, example #1: pro-life vs. pro-choice, ethical dilemma:, how to deal with this ethical dilemma:, example #2: protecting the adolescent’s right to privacy, example #3: empirical knowledge vs. religious beliefs, example #4: parent refuses to vaccinate child, example #5: personal and professional boundaries related to social media, example #6: nurse is instructed to have patient with low literacy level to sign consent for treatment, example #7: end-of-life decision-making, example #8: inadequate resources to provide care, example #9: former patients - to date or not to date, example #10: informed consent, example #11: inadequate staffing, example #12: spirituality vs. science, example #13: patient addicted to prescription pain medication, example #14: duty and compassion do not align with facility safety protocols, example #15: patient does not have an advanced directive, example #16: incompetence among nursing peers, example #17: disclosing the seriousness of medical conditions, example #18: questioning physician orders, example #19: asked to work in a department without training, example #20: beneficence vs. autonomy, 4 consequences of avoiding ethical dilemmas in nursing, 1. nurses can quickly experience burnout., 2. avoiding ethical dilemmas in nursing can lead to legal issues., 3. nurses who avoid ethical dilemmas could lose their jobs., 4. loss of licensure:, my final thoughts.

10 Examples of Ethical Dilemmas in Nursing

When caring for human lives, the decisions you have to make as a nurse are anything but black and white. In addition to taking vital signs and doing dressing changes, there are a realm of tough choices and ethical dilemmas that nurses have to face every day.

Picture this: a nurse finds himself torn between respecting a patient's right to refuse treatment and their deteriorating health. Moral puzzles like these leave even the most experienced nurses scratching their heads and feeling caught between a rock and a hard place. However, understanding how to handle ethical dilemmas isn't just a theoretical exercise. It's a crucial skill that nurses need to have in their toolkits. 

The nursing code of ethics acts as a guide for nurses to help in these decisions, but it can be helpful to see actual examples of ethical dilemmas in nursing and what a nurse should do with each of them. That’s exactly what this article is about. 

10 Common Ethical Dilemmas in Nursing 

While there are many different situations in which a nurse may find themselves dealing with an ethical dilemma, here are 10 common ethical dilemmas in nursing to consider and how a nurse might deal with them:

1. Patient Autonomy vs. Beneficence

Balancing a patient's right to make decisions about their own care with the nurse's duty to promote their overall well-being.

Let's say a patient diagnosed with diabetes refuses to take insulin, despite it being essential for controlling their blood sugar levels and preventing serious complications. 

In dealing with this situation, a nurse should follow the nursing code of ethics and take the following steps:

Respect Autonomy: Respect the patient's right to make decisions about their own care, even if they disagree with those decisions. 

Provide Information: Ensure the patient has accurate and comprehensive information about the treatment, including its benefits, risks, and alternatives. This allows the patient to make an informed decision.

Assess Understanding: Engage the patient in open and non-judgmental communication to assess their understanding of the treatment and the potential consequences of refusing it. 

Collaborative Decision-Making: Engage the patient in collaborative decision-making. Involve them in discussions and explore alternatives that align with their values and preferences. This approach fosters a sense of working together and mutual respect.

Seek Additional Perspectives: If the patient's decision still conflicts with the nurse's professional judgment and poses a significant risk to the patient's health, the nurse should seek guidance from the healthcare team and the nurse manager or supervisor they report to.

Document the Process: Throughout the decision-making process, carefully document all discussions, assessments, and the patient's decisions. This documentation serves as evidence that the nurse has fulfilled their ethical and professional responsibilities.

>> Related: What is Autonomy in Nursing?

2. Confidentiality vs. Duty to Warn 

Struggling with maintaining patient confidentiality while also considering the potential harm to others if vital information is not shared.

Imagine a scenario where a nurse working in a mental health facility becomes aware that a patient with a history of violent behavior has confided in the nurse about their plan to cause harm to their former partner. 

The nurse finds themselves in a challenging ethical dilemma: on one hand, they have a duty to maintain the confidentiality of the patient's personal information, and on the other hand, they have an obligation to protect other people from harm.

To deal with this situation, the nurse should take the following steps:

Evaluate the Severity of the Threat: Carefully assess the level of risk involved in the patient's intentions. Is there an immediate and credible threat to the safety of the potential victim? Consider factors such as the patient's history, current mental state, and access to means for carrying out the harm.

Engage in a Therapeutic Relationship: Explore the underlying issues and reasons behind the patient's harmful intentions. Attempt to address any underlying issues or triggers that may contribute to their behavior and encourage them to seek alternative ways to cope.

Seek Supervision and Consultation: It’s important for the nurse to consult with their supervisor or team members about the appropriate course of action to ensure the safety of the potential victim.

Follow Legal and Ethical Guidelines: Be aware of local laws and regulations regarding the duty to warn or protect. If there is a legal obligation to disclose information in order to prevent harm, the nurse should adhere to those requirements while minimizing the breach of confidentiality to the extent possible.

Document the Process: Document all steps taken, including the patient's disclosure, assessments, consultations, and decisions made. This documentation serves as evidence that the nurse acted ethically, responsibly, and in line with professional standards.

3. End-of-Life Care

Managing the ethical complexities around decisions about withdrawing or withholding life-sustaining treatment, considering the patient's wishes, quality of life, and family dynamics.

For example, consider the situation where a nurse is caring for an elderly patient with a terminal illness. The patient expresses the desire to die a peaceful death without aggressive interventions. However, the patient’s family opposes this and wants “everything medically possible” to be done to save the patient’s life. 

The nurse finds themselves in a complex ethical dilemma, torn between honoring the patient's wishes and respecting the concerns of the family.

Here’s how the nurse might address this situation:

Communication and Education: Engage in open and compassionate communication with both the patient and the family about the patient's medical condition. Discuss the patient’s prognosis, available treatment options, and the potential benefits and downsides of continuing or discontinuing life-sustaining measures. 

Respect for Autonomy: Advocate for the patient's right to self-determination and respect their wishes regarding end-of-life care.

Collaboration and Mediation: Facilitate a respectful and open dialogue, promoting a collaborative decision-making process. The nurse can involve the healthcare team, including palliative care specialists and social workers, to provide support, guidance, and mediation to resolve this situation.

Consider Ethical Decision-Making Frameworks: The nurse should use ethical principles in the nursing code of ethics, such as beneficence, non-maleficence, autonomy, and justice, to analyze the situation and guide their actions. By considering the patient's values, goals, and potential impact on their quality of life, the nurse can advocate for the most ethically appropriate course of action.

Supportive Care: Regardless of the final decision made, the nurse should provide holistic and supportive care to the patient and their family. This includes addressing physical, emotional, and spiritual needs, ensuring optimal comfort, and facilitating open communication to foster a sense of trust and understanding.

4. Resource Allocation

Facing the difficult task of distributing limited resources fairly and ethically among patients, especially during times of scarcity or emergencies.

Consider this scenario: During a severe flu outbreak, a nurse working in a hospital emergency department faces the ethical dilemma of resource allocation. The hospital is overwhelmed with patients and the available resources, such as beds, ventilators, and medications are limited. The nurse must make decisions about which patients receive the resources, balancing the needs of the patients in their care while also considering the needs of other patients in the hospital.

The nurse should manage this situation with fairness and transparency, using the following steps:

Prioritization and Triage: Follow established guidelines and protocols for triaging patients based on the severity of their condition and their likelihood of benefiting from the available resources. This ensures that decisions are made based on clinical needs rather than personal biases.

Open Communication: Maintain open and transparent communication with patients and their families. Explain the challenges faced due to limited resources and the criteria being used for resource allocation. This promotes understanding and trust, even in difficult circumstances.

Collaboration and Consultation: Work collaboratively with the healthcare team, including physicians and hospital administrators, to make informed decisions about resource allocation. Seeking input from multiple perspectives helps ensure fairness and accountability.

Consider Ethical Decision-Making Frameworks: Use the ethical principles of fairness and justice in the nursing code of ethics to guide the nurse’s actions. By considering factors like the potential benefits, risks, and overall impact on patients and the community, the nurse can strive to allocate resources in an equitable and ethical manner.

Advocacy and Support: Advocate for the well-being and rights of their patients, even when difficult decisions must be made. 

5. Informed Consent

Ensuring patients have a clear understanding of the risks, benefits, and alternatives of proposed treatments or procedures before they provide consent.

Here’s an example of how this ethical dilemma could occur: A nurse assists a physician who is rushing to obtain informed consent for a surgical procedure, despite the patient's pain and anxiety. However, the nurse quickly recognizes the patient's limited understanding of the procedure’s implications, raising ethical dilemmas regarding informed consent.

To handle this situation, the nurse should follow these steps:

Ensure Adequate Information: Intervene respectfully but assertively and ask the physician to slow down and provide the patient with complete information about the procedure, risks, benefits, potential outcomes, and available alternatives. 

Clarify Patient Understanding: Speak with the patient and assess their understanding of the information provided. Encourage the patient to ask questions and address any concerns they may have. 

Advocate for Time and Support: If the patient appears overwhelmed or is struggling to comprehend the information, the nurse should advocate for additional time or resources, such as involving a family member or providing educational materials or an interpreter (if appropriate) to support the patient in making an informed decision. 

Document the Process: Document the steps taken to address the concerns related to informed consent. Be sure to include any discussions, explanations provided, patients' questions, and their ultimate decision. Accurate documentation demonstrates the nurse's commitment to upholding ethical standards and professional accountability.

6. Cultural and Religious Beliefs

Navigating conflicts between a patient's cultural or religious values and the standard practices or protocols of healthcare.

In a multicultural society, nurses often encounter ethical dilemmas when a patient's cultural or religious beliefs clash with the standard practices or protocols of healthcare. An example is when a nurse is caring for a patient from a cultural background who strongly believes in traditional healing methods and is hesitant to accept Western medicine.

In this situation, the nurse should have a culturally sensitive discussion with the patient and demonstrate respect for diversity. Here are the steps the nurse should take:

Culturally Competent Assessment: Conduct a culturally competent assessment to understand the patient's cultural and religious beliefs, values, and preferences regarding healthcare. This requires active listening, open-mindedness, and avoiding assumptions or stereotypes.

Establish Trust and Rapport: Build a trusting relationship with the patient by acknowledging and respecting their cultural and religious beliefs. This can be achieved through effective communication, empathy, and demonstrating cultural humility.

Collaborative Decision-Making: Engage the patient and their family in collaborative decision-making regarding their healthcare. Respectfully discuss the patient's beliefs and preferences, and explore opportunities to integrate traditional healing practices with evidence-based Western medicine. 

Consultation and Education: If there are concerns about the patient's well-being or the appropriateness of certain traditional healing methods, the nurse should seek guidance from a cultural consultant, interpreter, or healthcare team. 

Advocacy and Liaison: Serve as an advocate for the patient, ensuring their cultural and religious rights are respected within the healthcare system. This may involve facilitating communication between the patient and healthcare providers, ensuring the provision of culturally competent care, and addressing any cultural or religious barriers that may arise.

7. Impaired Colleague

Grappling with the ethical responsibility of reporting concerns about a colleague's impairment due to substance abuse or mental health issues.

This situation might occur when a nurse becomes aware that a nursing colleague is impaired while on duty. The impaired nurse exhibits erratic behavior and smells strongly of alcohol. The nurse who witnesses this behavior finds themselves in a challenging ethical dilemma, torn between their duty to ensure patient safety and their loyalty to their colleague.

Nevertheless, the nurse needs to prioritize patient safety and act professionally by following these steps:

Immediate Concern for Patient Safety: The nurse's primary responsibility is to ensure the safety and well-being of patients. If they observe signs of impairment in their colleague that could compromise patient safety, they should take immediate action.

Reporting: The nurse should report their observations and concerns to the appropriate authority within the healthcare facility, such as the nurse manager or supervisor. This report should be made objectively without personal judgments or assumptions and with a focus on patient safety.

Confidentiality and Professionalism: Maintain confidentiality throughout the reporting process, being mindful not to disclose personal details of the impaired colleague unless necessary for the investigation.

Collaboration and Support: Collaborate with the healthcare team and support the impaired colleague's well-being by encouraging them to seek appropriate help and support, such as employee assistance programs or counseling services. 

Ethical Obligation: Nurses have an ethical obligation to protect the welfare of patients and maintain the standards of the nursing profession. This includes recognizing and addressing impairment issues among colleagues to ensure safe and quality care.

8. Professional Boundaries

Striking a balance between providing compassionate care and maintaining appropriate professional boundaries, particularly when it comes to personal relationships with patients.

In this example, let’s look at a scenario where a nurse develops a close friendship with a patient and begins sharing too many personal details about their own life unrelated to the patient’s healthcare needs.

When the nurse realizes what’s happening, they need to prioritize maintaining professional boundaries and act in the best interest of the patient by following these steps:

Recognize the Boundary Issue: Use personal reflection to recognize when professional boundaries are being crossed or compromised. Acknowledging this ethical dilemma is the first step toward resolving it.

Reflect on the Nurse-Patient Relationship: The nurse should remind themselves of their professional role, the duty of care, and the need to maintain objectivity and professional distance.

Reestablish Boundaries: Take appropriate actions to reestablish and reinforce professional boundaries with the patient. This may involve redirecting conversations back to the patient's healthcare needs, avoiding personal disclosures, and focusing on the patient's well-being.

Seek Guidance and Supervision: If the situation becomes challenging to resolve alone, the nurse should seek help from a supervisor, nurse manager, or experienced nursing team member. Consulting with experienced professionals can provide valuable insights and support in addressing this ethical dilemma.

Continuous Professional Development: Engage in ongoing professional development and education regarding nursing ethics and setting professional boundaries. Staying current on ethical guidelines and participating in discussions and training on maintaining professional boundaries can help prevent future boundary issues with patients.

9. Whistleblowing

Facing the ethical dilemma of reporting concerns about wrongdoing or unethical practices within the healthcare system, despite potential professional and personal repercussions.

An example of whistleblowing would be when a nurse becomes aware that a colleague is stealing controlled substances from the medication supply. The nurse decides to report this to their supervisor because it compromises patient safety and violates professional and legal standards. However, the nurse is worried about their colleague being disciplined and possibly losing their license.

Here are the steps the nurse should follow:

Gather Evidence: Collect factual evidence such as documentation discrepancies in medication records, witnessing the colleague's actions, or capturing any other supporting documentation. 

Consult with Colleagues: Seek advice from trusted colleagues, supervisors, or mentors within the healthcare organization. Discuss the situation and determine the best course of action. It’s important to maintain confidentiality during these discussions to protect both the patient and the nurse making the report.

Follow the Proper Chain of Command: Follow the established reporting channels within their healthcare organization. This typically involves reporting concerns to a supervisor, nurse manager, or a designated ethics or compliance hotline. Ensure that the report is made in writing and contains all relevant details and evidence.

Protection and Confidentiality: Be familiar with the whistleblower protection policies and laws in their jurisdiction. The nurse should ensure that their report is treated confidentially and that appropriate steps are taken to protect them from retaliation.

Documentation: Keep a detailed record of all actions taken, including the date and time of the incident, any conversations or consultations, and copies of the report submitted. This documentation helps demonstrate the nurse's commitment to reporting and acting in accordance with professional and ethical standards.

10. Ethical Use of Technology

Considering the ethical implications of using technology in healthcare, such as maintaining patient privacy and security, avoiding biases in algorithms, and ensuring equitable access to care.

An example of this ethical dilemma could occur when a nurse becomes concerned about potential biases in an algorithm and decides to report this to her supervisor. She recognizes that an algorithm where she works may disproportionately allocate resources based on patient factors such as age, race, and gender, resulting in inequitable access to care.

The nurse should advocate for equitable care by taking these steps:

Investigate and Evaluate: Become familiar with the AI algorithm being used and investigate its development process. Assess whether the algorithm has been validated and tested for biases and fairness. 

Raise Concerns: If the nurse identifies biases or inequities in the algorithm, they should communicate their concerns to the appropriate individuals, such as nurse leaders, healthcare administrators, or the technology implementation team. 

Collaborate for Improvement: Engage in collaborative discussions with the healthcare team, including the nursing supervisor, IT specialists, and data scientists. Work with the team to develop strategies to eliminate biases and ensure equitable use of the technology for all patients.

Promote Patient Advocacy: Advocate for the rights and well-being of the patients who may be affected by the technology. This involves ensuring informed consent and transparency regarding the use of AI algorithms. Patients should have the opportunity to understand and discuss the potential biases and their impact on their care.

Continuous Evaluation: Advocate for ongoing evaluation and monitoring of all AI technology being used in patient care to identify and resolve biases or unintended consequences. 

Ethical dilemmas are common in nursing and can be difficult to deal with. But you don’t have to make the decisions about these issues alone. Seek out the support and input of your nursing colleagues, supervisor, or nurse manager. By doing so, you will feel more comfortable and confident about how to handle the ethical dilemma you find yourself in.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Leona Werezak BSN, MN, RN is the Director of Business Development at NCLEX Education. She began her nursing career in a small rural hospital in northern Canada where she worked as a new staff nurse doing everything from helping deliver babies to medevacing critically ill patients. Learning much from her patients and colleagues at the bedside for 15 years, she also taught in baccalaureate nursing programs for almost 20 years as a nursing adjunct faculty member (yes! Some of those years she did both!). As a freelance writer online, she writes content for nursing schools and colleges, healthcare and medical businesses, as well as various nursing sites.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Nursing ethical considerations.

Lisa M. Haddad ; Robin A. Geiger .

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Last Update: August 14, 2023 .

• Definition/Introduction

Ethical values are essential for any healthcare provider. Ethics comes from the Greek word “ethos,” meaning character. Ethical values are universal rules of conduct that provide a practical basis for identifying what kinds of actions, intentions, and motives are valued. [1]  Ethics are moral principles that govern how the person or a group will behave or conduct themselves. The focus pertains to the right and wrong of actions and encompasses the decision-making process of determining the ultimate consequences of those actions. [2]  Each person has their own set of personal ethics and morals. Ethics within healthcare are important because workers must recognize healthcare dilemmas, make good judgments and decisions based on their values while keeping within the laws that govern them. To practice competently with integrity, nurses, like all healthcare professionals, must have regulation and guidance within the profession. [3]  The American Nurses Association (ANA) has developed the Code of Ethics for this purpose.

• Issues of Concern

The onset of nursing ethics can be traced back to the late 19 century. At that time, it was thought that ethics involved virtues such as physician loyalty, high moral character, and obedience. [3]  Since that early time, the nursing profession has evolved, and nurses are now part of the healthcare team and are patient advocates. The first formal Code of Ethics to guide the nursing profession was developed in the 1950’s. Developed and published by the ANA, it guides nurses in their daily practice and sets primary goals and values for the profession. Its function is to provide a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. It provides a nonnegotiable ethical standard and is an expression of nursing’s own understanding of its commitment to society. The Code of Ethics has been revised over time. The current version represents advances in technology, societal changes, expansion of nursing practice into advanced practice roles, research, education, health policy, and administration, and builds and maintains healthy work environments. [3]

The Code of Ethics for Nurses is divided into nine provisions to guide the nurse. The following is a summary of the American Nurses Association Code of Ethics for Nurses: 

Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 

The nurse must have a high level of respect for all individuals, and allow dignity in regards to dealings in care and communication. It's important that patient's families are also treated with respect for their relationship to the patient. Nurses must understand the professional guidelines in communications and work with colleagues and patient families. It's important to understand the proper professional relationship that should be maintained with families and patients. All individuals, whether patients or co-workers have the right to decide on their participation in care and work.

Provision 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

The patient should always be a first and primary concern. The nurse must recognize the need for the patient to include their individual thought into care practices. Any conflict of interest, whether belonging to external organizations, or the nurse's habits or ideals that conflict with the act of being a nurse, should be shared and addressed to not impact patient care. Collaboration with internal and external teams to foster best patient care is a necessity. Understanding professional boundaries and how they relate to patient care outcomes is important.

Provision 3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

It is important for the nurse to understand all privacy guidelines with regards to patient care and patient identifiers. Nurses involved in research must understand all aspects of participation including informed consent and full disclosure to the patient of all aspects required to participate in the study. The nurse must understand any institutional standards set in place to review his/her performance; this includes measurements of progress and the need for further review or study to meet performance standards. To become a nurse, competence must be demonstrated in clinical and documentation prowess. Standards of competence will continue at institutions and academic organizations that employ the nurse. If there is witness or recognition of questionable healthcare practice, it is important that the patient is protected by reporting any misconduct or potential safety concern. And finally, the nurse will not provide patient care while under the influence of any substance that may impair thought or action, this includes prescription medication.

Provision 4 . The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

As a nurse, it's inherent that accountability for all aspects of care aligns with responsible decision making. Use of authority must be professional and about all aspects of individualism and patient, ethical concerns. Nursing decisions must be well thought, planned, and purposefully implemented responsibly. Any delegation of nursing activities or functions must be done with respect for the action and the ultimate results to occur. 

Provision 5 . The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

A nurse must also demonstrate care for self as well as others. An ideal nurse, will have self-regard towards healthcare practices and uphold safe practice within the care setting and at home. It's important for a nurse to have a high regard for care as an overall inert ability once the profession is entered. A character becoming a nurse would include integrity. Nurses should be concerned for personal growth in regards to continued learning of the profession. The ability to grow as a nurse with improvements to care, changes or trends in care should be adapted to maintain competence and allow growth of the profession.

Provision 6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

As a nursing profession, standards should be outlined within and external to institutions of work that dictate ethical obligations of care and need to report any deviations from appropriateness. It's important to understand safety, quality and environmental considerations that are conducive to best patient care outcomes.

Provision 7 . The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Nurse education should include principles of research, and each nurse should understand how to apply scholarly work and inquiry into practice standards. Nurse committees and board memberships are encouraged to contribute to health policy and professional standards. The ability to maintain professional practice standards should continue, changing and enhancing as developments in practice may over time.

Provision 8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 

Through collaboration within the discipline, maintaining the concept that health is a right for all individuals will open the channels of best practice possibilities. The nurse understands the obligation to continue to advance care possibilities by committing to constant learning and preparation. The ability of the nurse to practice in various healthcare settings may include unusual situations that require continued acts of diplomacy and advocacy.

Provision 9. The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Nurses must continue to gather for committees and organize groups where they may share and evaluate values for accuracy and continuation of the profession. It is within these organizations that nurses may join in strength to voice for social justice. There is a need for continued political awareness to maintain the integrity of the nursing profession. The ability of the nurse to contribute to health policy should be shared among the profession, joining nurses throughout the world for a unified voice.

American Nurses Association. (2015). Code of ethics with interpretative statements. Silver Spring, MD

• Clinical Significance

Ethical values are essential for all healthcare workers. Ethical practice is a foundation for nurses, who deal with ethical issues daily. Ethical dilemmas arise as nurses care for patients. These dilemmas may, at times, conflict with the Code of Ethics or with the nurse's ethical values. Nurses are advocates for patients and must find a balance while delivering patient care. There are four main principles of ethics: autonomy, beneficence, justice, and non-maleficence.

Each patient has the right to make their own decisions based on their own beliefs and values. [4] . This is known as autonomy. A patient's need for autonomy may conflict with care guidelines or suggestions that nurses or other healthcare workers believe is best. A person has a right to refuse medications, treatment, surgery, or other medical interventions regardless of what benefit may come from it. If a patient chooses not to receive a treatment that could potentially provide a benefit, the nurse must respect that choice.

Healthcare workers have a duty to refrain from maltreatment, minimize harm, and promote good towards patients. [4]  This duty of particular treatment describing beneficence. Healthcare workers demonstrate this by providing a balance of benefits against risks to the patient. Assisting patients with tasks that they are unable to perform on their own, keeping side rails up for fall precautions, or providing medications in a quick and timely manner are all examples of beneficence.

All patients have a right to be treated fair and equally by others. Justice involves how people are treated when their interest competes with others. [5] . A current hot topic that addresses this is the lack of healthcare insurance for some. Another example is with patients in rural settings who may not have access to the same healthcare services that are offered in metropolitan areas.

Patients have a right to no harm. Non-maleficence requires that nurses avoid causing harm to patients. [6]  This principle is likely the most difficult to uphold. Where life support is stopped or patients have chosen to stop taking medication that can save their lives, the nurse is put in a morally challenging position.

Nurses should know the Code of Ethics within their profession and be aware and recognize their own integrity and moral character. Nurses should have a basic and clear understanding of key ethical principles. The nursing profession must remain true to patient care while advocating for patient rights to self-identify needs and cultural norms. Ethical considerations in nursing, though challenging, represent a true integration of the art of patient care.

Nurses have a responsibility to themselves, their profession, and their patients to maintain the highest ethical principals. Many organizations have ethics boards in place to review ethical concerns. Nurses at all levels of practice should be involved in ethics review in their targeted specialty area. It is important to advocate for patient care, patient rights, and ethical consideration of practice. Ethics inclusion should begin in nursing school and continue as long as the nurse is practicing.

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Disclosure: Lisa Haddad declares no relevant financial relationships with ineligible companies.

Disclosure: Robin Geiger declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Haddad LM, Geiger RA. Nursing Ethical Considerations. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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20 Most Common Ethical Dilemmas in Nursing & Solutions

As a nurse, you often find yourself in situations that require you to make tough decisions, balancing the best interests of your patients with ethical considerations. These ethical dilemmas can arise due to conflicting values, legal obligations, or scarce resources.

In this article, we will explore some common examples of ethical dilemmas in nursing, each accompanied by a real-life scenario that highlights the complexities faced by healthcare professionals. Let’s dive in.

Example #1: Balancing Patient Autonomy and Beneficence

Example #2: maintaining patient confidentiality vs ensuring public safety, example #3: disclosure of medical errors to patients, example #4: allocating limited resources during a pandemic, example #5: end-of-life decision-making, example #6: balancing patient confidentiality and duty to protect, example #7: cultural sensitivity and respect for diversity, example #8: conflict of interest in healthcare decision-making, example #9: informed consent and pediatric patients, example #10: boundaries and professional relationships, example #11: confidentiality and reporting child abuse, example #12: patient autonomy and end-of-life decision-making, example #13: balancing autonomy and well-being for a dementia patient, example #14: medication administration and patient refusal, example #15: resource allocation during a pandemic, example #16: cultural competence and end-of-life care, example #17: confidentiality and risk of harm, example #18: patient autonomy and non-adherence to treatment, example #19: informed consent and decision-making capacity, example #20: privacy and confidentiality in the age of electronic health records.

Scenario: Imagine you’re a hardworking nurse in a busy hospital. One day, you face an interesting challenge. You have a 75-year-old patient, Mrs. Johnson, who needs to undergo a surgical procedure due to her chronic heart condition. But during your talk about the operation, she shares her fears about possible complications and not waking up from anesthesia. She insists on not having the surgery even though it could save her life. As her nurse, you know how important it is to listen to your patient’s wishes but also want to do what’s best for their health.

Ethical Dilemma: This situation creates a serious ethical problem for you. On one hand, there’s the need to respect the patient’s choice in their healthcare decisions, called “patient autonomy.” Here it would mean acknowledging Mrs. Johnson’s concerns and respecting her decision not to have the surgery. However, on the other hand, there’s an equally important principle of doing good for your patient – that is “beneficence”. From this perspective, moving forward with the surgery could dramatically improve her quality of life and may be crucial for her survival.

This conflict between respecting a patient’s wishes and wanting to ensure their well-being can be tough for nurses like you. You’re expected to support your patients’ choices but also have a duty towards promoting their health. In Mrs.Johnson’s case, because she doesn’t want necessary surgery due to fear of complications, it becomes tricky for you and your team to balance these principles while providing top-notch care.

As part of your responsibility as a healthcare professional, it falls upon you to educate patients like Mrs.Johnson so they understand their situation fully and can make sound decisions about their own health care based on facts rather than fears alone.

Solution and Tips: Tackling ethical dilemmas in nursing calls for patience and careful thinking while keeping the principles of beneficence (doing good) at heart along with recognizing patient’s autonomy (their right). Here are some simple tips that will help:

• Open communication: Make sure all lines of communication with your patients are open; encourage them to share worries or doubts they might have.
• Patient education: Explain all options clearly; tell them what could happen if they choose each option.
• Joint decision-making: Include everyone – patients, families and medical teams – in deciding what steps should be taken next.
• Ethical guidelines: Keep revisiting principles like autonomy (patient independence), beneficence (doing good), non-maleficence (not causing harm) etc., as these provide guidance when faced with difficult situations.
• Consultation: If needed don’t hesitate consulting colleagues or ethics committee members who are knowledgeable in such matters; this can provide varied perspectives which might prove useful in resolving issues.

Scenario: Imagine you’re a nurse at a psychiatric facility. One day, Mr. Anderson, a patient dealing with severe mental illness, shares his violent thoughts towards someone outside the facility with you. As a nurse, you value patient confidentiality and their privacy. But, you also have an essential role in ensuring public safety and preventing harm.

Ethical Dilemma: This situation presents a challenging ethical dilemma – how to balance between protecting patient confidentiality and ensuring public safety? When you respect privacy in healthcare, patients trust you more. But Mr. Anderson’s violent intentions put the welfare of others at risk.

This ethical dilemma is about finding the right balance between maintaining patient confidentiality and fulfilling your duty to protect potential victims from harm. It’s not easy to navigate this boundary – protecting Mr. Anderson’s rights and well-being on one hand while also addressing the potential harm that might fall upon others on the other hand.

Keeping your patients’ information confidential helps develop trust and makes them feel safe when sharing sensitive information with you. But if there’s danger involved for people outside your healthcare setting, it creates a moral quandary for healthcare professionals like yourself.

Solution and Tips: Resolving such dilemmas involves careful thought process paired with abidance by legal and ethical guidelines:

• Check how serious the threat is: Try to gauge if the threat is credible, immediate or severe enough to act upon it. Discuss with other healthcare professionals like psychiatrists and supervisors for additional insights.
• Know your ethical and legal boundaries: Make sure to know your organization’s rules about patient confidentiality, mandatory reporting, etc., which will guide your decision-making.
• Collaborate with others: Include psychiatrists, psychologists, social workers or legal experts in your discussions for their unique perspectives on possible interventions while keeping patient rights in mind.
• Discuss consequences with the patient: Have an open conversation with Mr. Anderson about potential risks to others as well as possible legal implications of his threats.
• Involve authorities if needed: If there is an immediate risk to others which can’t be managed internally, report it following proper protocols while sticking to legal obligations.

Scenario: Imagine you’re a nurse in a busy hospital. One day, while giving medicine to your patient, you accidentally give them the wrong amount. Even though nothing bad happens to them right away, you notice your mistake and face a big moral question. Should you tell them about the mistake and risk losing their trust in healthcare, or should you keep quiet to avoid upsetting them?

Ethical Dilemma: As a nurse, your job is to look after the patient’s health and safety. But if you were to reveal a mistake, it might upset the patient, break their trust in healthcare professionals, or even lead to legal problems.

The challenge here is finding the right balance between being honest about mistakes and keeping the patient’s trust. Nurses must think about doing good (beneficence), avoiding harm (non-maleficence), and telling truth (veracity). While open communication is crucial, they also have to weigh how telling might affect the patient emotionally and their view of healthcare.

Telling patients when there has been a mistake is important for many reasons. It respects their freedom of choice by letting them make informed decisions about their care. It’s also good for transparency and helps build trust with your patient because you’re including them in decision-making. However, nurses must be mindful of how they tell patients so as not upset them while fulfilling their ethical duty to report errors.

Solution and Tips: When reporting medical errors, here are some simple tips:

• Admit it: Accept your mistake and take responsibility.
• Check on your patient: See how severe the error might be for the patient. Ask other healthcare professionals or supervisors for advice on understanding what happened.
• Pick the right time and place: Look for somewhere where your patient will feel at ease and won’t be disturbed.
• Speak clearly but kindly: Use simple words instead of medical terms so that they understand what happened. Be kind and let your patient express how they feel.
• Offer solutions: Talk about what can be done to fix any fallout from an error and prevent it from happening again in future.
• Support your patient: Show empathy towards your patient’s feelings or fears related to this incident.
• Follow rules at work: Be sure to follow any rules set by your workplace for reporting errors so that everything is handled properly.

Scenario: Imagine you’re a nurse in a hospital amidst a devastating pandemic. The patients needing critical care far outnumber available resources like ventilators, ICU beds, and medical staff. Now, you’re caught in a difficult ethical dilemma where you have to decide who gets what when the resources are running low.

Ethical Dilemma: In this real-life situation, you face an ethical battle because of limited resources. You have to determine who should get priority based on their survival chances and potential gains from treatments. As a nurse, you have to balance justice, beneficence, and fairness while making these tough calls that could save or end lives.

The ethical challenge here is about equitable distribution of scant resources during a crisis. You have the responsibility of acting in your patients’ best interests but also thinking about the greater good and overall public health impact. In such situations, deciding how to allocate resources can be both emotionally draining and ethically taxing.

You might find yourself asking questions like who should get critical care? Who has better survival odds? How can I ensure everyone gets a fair chance? Your decisions will inevitably affect individual lives, families, and the entire community.

Solution and Tips: To overcome this ethical dilemma of resource allocation during a pandemic, you need an organized approach rooted in ethics. Here are some simplified tips:

• Know your ethical frameworks: Make sure you understand core ethical principles like justice, utility, and proportionality. Use guidelines from professional bodies and healthcare institutions for decision-making during resource scarcity.
• Set up an ethical triage system: Together with an interdisciplinary team, create an equitable triage system considering things like medical urgency, expected outcomes and fair resource distribution.
• Be transparent with communication: Talk openly with patients and their families about allocation challenges. Explain your decision-making process stressing that it’s based on medical facts, ethics and achieving maximum benefits.
• Regularly reassess decisions: Keep reviewing your allocation decisions as conditions change – this could mean altering allocation strategies to uphold fairness while optimizing patient outcomes.
• Fight for more resources: Rally for additional support from healthcare institutions, governments or community at large. Highlighting the effects of resource limitations can help rally support to tackle the crisis.
• Get ethical consultation when needed: When complex decisions arise don’t hesitate to seek guidance from ethics committees or experts ensuring well-balanced perspective.

Working through these steps systematically may help make these hard choices slightly easier for you

Scenario: Imagine you’re a nurse in a palliative care unit. You’ve been taking care of Mr. Thompson, a terminally ill patient, for several weeks. Sadly, his health has considerably worsened and he can’t communicate his end-of-life care preferences anymore. His family members have different views on what should be done next, creating a tough ethical challenge for you.

Ethical Dilemma: The ethical problem here involves decision-making at the end of life. As a nurse, you are drawn between the principles of autonomy, beneficence, and non-maleficence. Your task is to respect Mr. Thompson’s independence while ensuring his well-being and considering the needs and values of his family.

This ethical issue arises because Mr. Thompson’s family members don’t agree on how to handle his end-of-life care. As a nurse, it is your duty to advocate for what’s best for the patient while also taking into account what the family wishes and balancing principles of autonomy and beneficence.

Respecting a patient’s autonomy is crucial but gets tricky when they are no longer able to make decisions themselves. In these situations, you need to work with the patient’s family to ensure their decisions align with any known wishes, values or beliefs expressed by the patient in earlier times. When there are differing opinions within the family, reaching an agreement that respects the patient’s interests can be emotionally taxing as well as ethically challenging.

Solution and Tips: Handling ethical dilemmas like this demands sensitivity, empathy, and open communication. Here are tips to guide you:

• Communicate openly: Make sure all involved feel safe expressing their thoughts and feelings.
• Identify previous wishes: Review any advance directives or living wills left by Mr.Thompson that may guide decision-making.
• Hold Family Meetings: Organize gatherings with all key family members where everyone can share their ideas about prognosis and treatment options.
• Ask Experts: Get advice from ethics committees or palliative care teams who specialize in these situations.
• Promote shared decision-making: Together with the family consider Mr.Thompson’s best interests aiming for consensus respecting his autonomy whilst promoting his well-being.
• Consider Beneficence & Non-Maleficence Principles: Weigh up potential benefits against potential burdens of various treatment options aiming always for maximum comfort dignity quality of life minimum unnecessary suffering.
• Seek Legal Advice if necessary: If disagreements continue getting legal advice will ensure legal obligations are met

Scenario: Put yourself in the shoes of a community healthcare center nurse. One day, a teenage patient named Sarah shares with you that she’s involved in dangerous activities that could harm her and others. She insists you keep this a secret. As a nurse, your duty is to protect everyone from harm, which includes Sarah and anyone her actions might affect. You’re caught in a tough ethical dilemma – do you respect Sarah’s wish for secrecy or prioritize safety?

Ethical Dilemma: In this situation, the ethical problem arises from having to choose between respecting patient confidentiality or ensuring safety – both critical parts of your role as a nurse. The principles of autonomy, beneficence, and non-maleficence guide nursing ethics and require you to find balance between preserving patient privacy and preventing potential harm.

This ethical dilemma revolves around conflicting needs – Sarah’s plea for confidentiality versus the necessity to ensure her safety alongside others’. Nurses should foster trust by maintaining a confidential environment but also need to step in when there’s risk of harm, especially with vulnerable individuals like teenagers.

You must juggle respecting Sarah’s trust while thinking about the potential impacts of her dangerous behaviors. The challenge is figuring out an approach that minimizes harm, maintains confidentiality as much as possible, and still supports Sarah.

Solution and Tips: Solving such an ethical dilemma requires thoughtful deliberation and needs to be focused on the patient. Here are some simple tips:

• Evaluate the risk: Look at how serious or immediate the harm from Sarah’s actions could be. Talk with other healthcare experts like supervisors or mental health specialists for advice.
• Promote open conversation: Provide a safe space where Sarah can talk about her concerns without feeling judged.
• Explain confidentiality limits: Let Sarah know when sharing information might be necessary for preventing harm.
• Get input from other professionals: Seek advice from other experts such as psychiatrists, social workers etc., who can offer different perspectives.
• Ask for informed consent if disclosure is needed: If involving others (like parents or guardians) becomes necessary, discuss this possibility with Sarah first.
• Document everything: Keep detailed records of all decisions made along with their reasons.
• Provide ongoing support: Connect Sarah with resources such as counseling services or support groups.

Remember, it’s crucial for you as a nurse to balance between respecting privacy rights while fulfilling your duties towards safety.

Scenario: Picture this – you’re a nurse in a healthcare setting that’s brimming with multicultural diversity. One day, you find yourself face to face with a situation where one of your patients, Mrs. Rodriguez, insists on relying on her traditional healing methods rather than following the recommended medical treatment. Your challenge here is an ethical one – how do you respect Mrs. Rodriguez’s cultural autonomy while making sure she gets access to safe and effective healthcare?

Ethical Dilemma: What we have here is an ethical quandary. How do you balance between giving due respect to cultural beliefs and pushing for evidence-based healthcare? As a nurse, your guiding principles should be cultural sensitivity, respect for autonomy, benevolence, and non-maleficence. The tricky part is navigating the thin line between respecting cultural diversity and ensuring patient well-being.

The issue boils down to the clash of cultural beliefs against evidence-based healthcare practices. As a nurse, it’s expected of you to deliver patient-centered care that respects and integrates cultural values alongside preferences. However, there’s also your duty as a professional to push for the best possible health outcomes while ensuring patient safety.

In this case, Mrs. Rodriguez’s strong belief in her culture’s healing methods puts you in a spot – how can you accept her beliefs while balancing the need for evidence-based medical interventions? How can you reach a solution that is sensitive towards her culture and respects her autonomy yet ensures she has access to proper healthcare?

Solution and Tips: Finding solutions for such complex ethical dilemmas requires a thoughtful approach. Here are some tips:

• Embrace cultural competence: Understand diverse cultures by learning about their practices, beliefs, and values continually.
• Create trusting relationships: Build trust through open communication with Mrs.Rodriguez by listening actively and asking questions respectfully.
• Collaborate with interpreters or cultural liaisons: If language or culture forms barriers in communication consider getting help from qualified interpreters.
• Educate patients sensitively: Help Mrs.Rodriguez understand the recommended medical treatment in terms of benefits, risks, potential outcomes promoting informed decision-making.
• Promote shared decision-making: Encourage participation from Mrs.Rodriguez’s family so decisions are made considering their beliefs alongside medical recommendations.
• Consultation & support: Seek advice from colleagues or ethicists who can guide through these dilemmas providing valuable perspectives.
• Push for culturally sensitive policies: Advocate developing procedures prioritizing cultural sensitivity along with training programs enhancing understanding among healthcare professionals.

Scenario: Say you’re a nurse in a private healthcare clinic and one day, you stumble onto an ethical challenge. You find out that your colleague, Dr. Wilson, has been prescribing certain medications to patients because he’s getting financial benefits from a pharmaceutical company. As a nurse, you’re meant to look out for your patients’ best interests. Tackling this conflict of interest is tough.

Ethical Dilemma: The main concern here is about conflict of interest in healthcare decisions. As a nurse, ethical principles like integrity, doing good (beneficence), and fairness (justice) guide you. The dilemma emerges when these principles clash with situations that can potentially harm patient care and trust.

This ethical problem surfaces when the doctor’s desire for financial gain clashes with his responsibility to deliver unbiased, patient-oriented care. In such cases, you may wrestle with the potential damage caused by this conflict of interest as it can shake the very foundation of patient trust in healthcare decisions.

Now imagine yourself dealing with this situation – wanting to uphold your nursing ethics while addressing your colleague’s actions. The issue involves standing up for patient welfare, encouraging transparency, and confronting the conflict of interest without damaging team integrity.

Solution and Tips: Addressing conflicts of interest calls for moral courage and devotion towards patient advocacy. Here are some simplified tips:

• Reflect on personal ethics: Think about your own values and professional ethics related to patient care.
• Understand professional guidelines: Get familiar with any codes of ethics or policies about conflicts of interest in your profession.
• Collect information: Gather accurate data about this situation including verbal exchanges or documents related to the financial rewards.
• Talk it over: Discuss it with colleagues or ethics committees who share similar values.
• Take action: If it feels right and aligns with procedures, report it via appropriate channels in your organization – like a supervisor or an ethics committee.
• Promote transparency: Encourage honesty in decision-making within the organization by advocating policy changes that tackle conflicts of interests.
• Stay committed to patients: Keep assessing all decisions from the point-of-view of the patient’s welfare.

Remember managing such conflicts demand continuous vigilance so keep striving to uphold high standards in all aspects.

Scenario: You’re a nurse in a pediatric hospital. One day, you’re asked to help get informed consent for a medical procedure for Ethan, a 10-year-old boy. Ethan’s parents are divorced and can’t agree on whether to go ahead with the procedure. You face an ethical dilemma about informed consent and what’s best for Ethan.

Ethical Dilemma: This real-life situation presents an ethical problem between parental rights, the child’s welfare, and the idea of informed consent. As a nurse, you follow ethical principles like autonomy, doing good (beneficence), and avoiding harm (non-maleficence). You have to handle the difficult task of parental decisions while ensuring Ethan’s well-being.

The ethical problem comes from Ethan’s parents disagreeing about his healthcare choices. As a nurse, you need to think about what’s best for Ethan, respect both parents’ views, and stick to legal rules about getting informed consent from minors. Balancing parents’ rights and children’s rights is tricky in this situation.

In this case, your responsibility is looking out for Ethan’s well-being while making sure his rights are respected. The challenge includes understanding legal and ethical rules for informed consent, helping communication between the parents, and making decisions that focus on what is best for Ethan.

Solution and Tips: To solve this ethical problem about informed consent with kids like Ethan requires careful thought and team work with others involved. Here are some tips:

• Understand legal requirements: Learn local laws about getting informed consent from minors.
• Promote open talk: Help both of Ethan’s parents communicate their concerns openly.
• Focus on the child: Always put the child’s interests first when deciding.
• Get help if needed: If disagreements continue between parents, consider getting help from a mediator or lawyer.
• Ask experts: Get advice from ethics committees or other healthcare workers experienced in children’s ethics.
• Keep records: Keep detailed notes of all talks about decisions made with reasons given.
• Re-evaluate regularly: Keep checking how things are going as new information arrives or situations change.

The goal is always to ensure that decisions taken prioritize Ethan’s welfare above all else.

Scenario: Imagine you’re a nurse in a long-term care facility. One day, you encounter a tricky ethical situation when one of your patients, Mr. Johnson, shows romantic feelings for you. You have to balance professional responsibilities and personal emotions while also addressing Mr. Johnson’s emotional needs. The challenge lies in showing compassion while maintaining professional relationships.

Ethical Dilemma: In this scenario, the ethical issue revolves around keeping professional boundaries intact and preserving the integrity of your relationship with the patient. As a nurse, you are bound by the principles of beneficence, integrity, and professionalism. You need to manage these multiple facets of your role – setting proper boundaries while addressing emotional needs of your patients.

The ethical problem stems from a potential breach in professional boundaries due to Mr. Johnson’s romantic interests towards you. It’s crucial for nurses like yourself to focus on patient care, foster trust, and stick to professional rules. Balancing empathy with appropriate boundary-setting is difficult in such circumstances.

In this situation, you have the responsibility to ensure that your therapeutic relationship remains focused on Mr. Johnson’s healthcare needs while considering his emotional vulnerability. The predicament involves upholding professionalism, outlining clear boundaries without compromising the quality of nursing care provided.

Solution and Tips: To resolve this dilemma about professional boundaries requires careful consideration and commitment to uphold nursing standards:

• Reflect on your responsibilities: Review your own values and duties as a nurse including maintaining boundaries within nurse-patient relationships.
• Set clear boundaries: Communicate openly with Mr.Johnson about the professional nature of your relationship.
• Practice active listening: Show understanding through active listening and empathetic responses that address his emotional needs without crossing any lines.
• Involve others: Consult with other team members or supervisors for guidance or different perspectives.
• Provide resources: Direct Mr.Johnson towards support groups or counseling services beyond what can be given within the confines of the nurse-patient relationship.
• Keep records: Document all interactions accurately as evidence of upholding professional standards.
• Seek ethical consultation if necessary: If things get more complicated or you need further advice, don’t hesitate to consult ethics committees or experts who can provide helpful insights.

The key lies in balancing compassion with professionalism while providing optimal patient care without breaching any ethical or professional boundaries.

Scenario: Imagine you’re a nurse in a children’s clinic. One day, you see injuries on a young patient named Emily that look like she might be being physically abused. Emily trusts you with this secret but pleads with you not to tell anyone, especially her parents. As a nurse, you’re faced with a tough ethical choice of respecting patient confidentiality or reporting suspected child abuse.

Ethical Dilemma: In this situation, the ethical issue is about balancing the need to keep patient information private and the responsibility to protect children from harm. As nurses, your guiding principles include doing good (beneficence), avoiding harm (non-maleficence), and ensuring fairness (justice). The challenge here is finding the right balance between keeping Emily’s secret and fulfilling your duty to keep her safe.

The ethical dilemma here stems from suspecting child abuse and Emily’s request for secrecy. You have to prioritize safety especially for vulnerable individuals like children while also being respectful of their privacy. This calls for maintaining trust while carrying out your duty.

In Emily’s case, it’s about safeguarding her well-being while respecting her secrecy. It’s crucial that you understand the legal requirements for reporting child abuse, communicate sensitively with Emily, and make decisions that are in her best interest.

Solution and Tips: Resolving this ethical dilemma requires kindness and knowledge. Here are some tips:

• Assess risk level: Check how severe or immediate the suspected abuse could be to Emily’s well-being. Speak to other healthcare professionals or child protection services for further insights.
• Speak openly but kindly: Make sure Emily feels safe enough to talk about her experiences and feelings. Explain why it’s important for her safety that the abuse be reported.
• Know your legal duties: Understand local laws around reporting child abuse so you follow them rightly.
• Involve experts: Work closely with child protection services or psychologists who are experts in dealing with cases of suspected child abuse.
• Maintain records: Write down details of any visible injuries or evidence of abuse as well as conversations with Emily which can help during any potential investigation.
• Provide support: Make sure Emily knows she is supported by offering information on counseling services or support groups.
• Take care of yourself: Dealing with suspected cases of child abuse can be emotionally draining so remember to practice self-care and speak about your experiences with colleagues or mental health professionals if needed..

Scenario : imagine you’re a nurse in an oncology ward. One day, you’re assigned to Mr. Anderson, who is terminally ill. He wants to stop life-sustaining treatments and choose palliative care instead. But his family doesn’t agree with his decision; they want him to continue with intensive medical treatments. Now, you’re facing a tough ethical situation: should you respect Mr. Anderson’s autonomy or try to balance the feelings and concerns of his family?

Ethical Dilemma: The dilemma here is about patient autonomy and end-of-life decisions. Nurses follow ethical principles like autonomy, beneficence, and non-maleficence. They must deal with the complicated dynamics of respecting patient autonomy while considering how it affects the patient’s family and their duty to offer compassionate care.

The ethical problem comes from Mr. Anderson’s end-of-life wishes clashing with his family’s opposition. As a nurse, you need to weigh the patient’s autonomy—his right to decide about his own treatment- against the emotional stress and diverse opinions of the family members.

In this situation, your challenge is upholding Mr. Anderson’s autonomy while also managing the concerns and emotions of his loved ones.

Solution and Tips: To solve this tricky problem of patient autonomy and end-of-life decision-making, you’ll need empathy, good communication skills, and teamwork:

• Open up communication: Make sure there’s a safe space for Mr. Anderson and his family where they can share their worries, fears, and hopes without judgment.
• Understand patient wishes: Have thorough discussions with Mr. Anderson so that you understand what he truly wants from his treatment at this stage of life. Explain patients’ rights: Inform the family about patients’ rights in making decisions regarding their own care.
• Promote shared decision-making: Help start discussions where everyone is heard respectfully.
• Seek advice from ethics committees or healthcare professionals: They can guide on how best to handle such complex situations ethically. Offer emotional support as well as counseling services or connect them with appropriate support groups: These resources can help everyone involved deal better emotionally during these challenging times.
• Work closely with other team members like doctors or spiritual guides: An interdisciplinary approach ensures all aspects are covered when advising on treatment decisions.

Remember always that it takes teamwork between healthcare providers, patients, families for best outcomes in such difficult situations.

Scenario: You are a nurse taking care of Emily, a 68-year-old woman who is admitted to the hospital for a severe respiratory infection. You have noticed that Emily seems confused and disoriented, which raises concerns about her ability to make informed decisions about her medical care. After investigating further, you discover that Emily has dementia, and her current mental state is due to the progression of her condition. This presents you with a difficult ethical dilemma regarding autonomy and obtaining informed consent.

Ethical Dilemma: The ethical dilemma in this situation involves balancing respect for Emily’s autonomy with ensuring her well-being as someone with diminished decision-making capacity due to dementia. As a nurse, you must navigate the complex task of upholding patient autonomy while providing necessary care and protection for those who cannot make informed decisions.

The dilemma arises from Emily’s cognitive impairment caused by dementia. You need to consider how much she can participate in decision-making processes and whether she can understand the potential risks, benefits, and alternatives to medical interventions. Striking a balance between respecting autonomy and ensuring her well-being becomes challenging in this situation.

In this case, you face the responsibility of respecting autonomy while also considering what’s best for Emily. The dilemma involves assessing Emily’s capacity for decision-making, involving her family members or legal representatives, and ensuring that her medical care aligns with her values and overall well-being.

Solution and Tips: To resolve this ethical dilemma:

• Evaluate decision-making capacity: Assess Emily’s ability to make decisions by considering her cognitive impairment, fluctuating abilities, and understanding of medical information. Consult with other healthcare professionals for a thorough evaluation.
• Involve family members or legal representatives: Have discussions with Emily’s family members or legal representatives to understand her values and preferences regarding medical care. Collaborate with them to make decisions that are in line with what is best for Emily.
• Use supported decision-making strategies: Explore approaches that involve the patient, family members, and healthcare providers making decisions together in the patient’s best interests. This may include using visual aids or simplified explanations or involving a trusted person who understands Emily’s values and preferences.
• Refer to advance directives or living wills: Review any documents that Emily may have created in the past, such as advance directives or living wills, which can provide guidance on her healthcare preferences.
• Seek ethical consultation: Get guidance from ethics committees or other healthcare professionals experienced in decision-making for patients with dementia. They can offer insights and support to help navigate the challenges and ensure ethical practice.
• Continuously reassess decision-making capacity: Regularly reassess Emily’s ability to make decisions as her cognitive status may change over time. Involve the healthcare team and family members in these evaluations to ensure decisions are made in her best interests.
• Document decision-making processes: Keep accurate and detailed records of all discussions, evaluations, and decisions made regarding Emily’s medical care. This documentation serves as a record of the ethical considerations taken into account and steps taken to ensure her well-being.

By following these steps, you can navigate this complex ethical dilemma while providing the necessary care for Emily, respecting her autonomy as much as possible, and ensuring her overall well-being.

Scenario: You are a nurse working in a busy emergency department. Today, you have been assigned to take care of Mr. Johnson, a 45-year-old man who is experiencing severe pain. The doctor has prescribed a strong pain medication for him, but when you approach Mr. Johnson to give him the medication, he refuses. He is worried about potential side effects and addiction. This puts you in a difficult situation because you want to respect his wishes while also making sure that his pain is managed properly.

Ethical Dilemma: The ethical dilemma here is about respecting patient autonomy and giving medication. As a nurse, you follow the principles of autonomy (letting the patient make decisions), beneficence (doing good for the patient), and non-maleficence (avoiding harm). It’s challenging to balance Mr. Johnson’s right to choose with your responsibility to provide effective care.

The ethical dilemma arises because Mr. Johnson doesn’t want to take the prescribed pain medication because he’s afraid of side effects and addiction. You must respect his right to decide about his own care while considering the consequences of unmanaged pain on his well-being.

Your challenge is finding a way to respect Mr. Johnson’s autonomy while ensuring that he gets adequate pain relief. You’ll need open communication, education about the medication, and addressing his concerns to help him feel comfortable.

Solution and Tips: To solve this ethical dilemma and handle Mr. Johnson’s refusal of medication effectively, follow these tips:

• Open communication: Have a respectful conversation with Mr. Johnson to understand why he refuses the medication. Listen carefully without judgment and acknowledge his right to make decisions.
• Education and addressing concerns: Provide clear information about the prescribed medication, explaining its benefits, possible side effects, and how addiction risks can be managed. Correct any misunderstandings or fears he might have using evidence-based knowledge.
• Exploring alternatives: Discuss other ways to manage his pain, such as non-medication methods or different medications if available. Work with the healthcare team to create a personalized pain management plan that considers Mr. Johnson’s preferences and concerns.
• Respecting autonomy: If, after discussion and education, Mr. Johnson still refuses the medication, respect his decision. Document his informed refusal and make sure he understands the possible consequences of unmanaged pain. Offer ongoing support for his comfort and well-being.
• Involving the healthcare team: Seek input from doctors and pain management specialists by involving them in the decision-making process. Collaborate on a comprehensive approach that balances Mr. Johnson’s autonomy with the goal of effective pain management.
• Assessing and monitoring pain levels: Continuously evaluate Mr. Johnson’s pain levels to ensure they are appropriately managed. Regularly communicate with him to check if the chosen pain management strategies are working well or if adjustments are needed.
• Documentation: Keep accurate records of your discussions, education provided, Mr. Johnson’s concerns, and the agreed-upon pain management plan. This documentation demonstrates adherence to ethical principles and helps with continuity of care.

By following these steps, you can navigate this complex situation ethically while ensuring that Mr. Johnson’s pain is properly managed and that he feels heard and respected in making decisions about his own care.

Scenario: You are a nurse working in a busy hospital during a severe pandemic outbreak. The hospital doesn’t have enough resources like ventilators and intensive care beds to meet the needs of all the patients. You have to make tough decisions about who gets these limited resources.

Ethical Dilemma: The ethical dilemma is about deciding how to distribute limited resources during a pandemic. As a nurse, you have to balance providing good care for everyone with being fair and equal in distributing the resources.

The problem is that there aren’t enough ventilators and intensive care beds for all the patients who need them. You have to decide which patients should get these resources based on their illness severity, chances of getting better, and chance of survival.

Solution and Tips: Your challenge is to provide the best care possible while using the limited resources fairly and equally. The goal is to make decisions that maximize overall patient outcomes while treating everyone fairly.

Here are some tips to help you navigate this difficult situation:

• Set up guidelines: Work with your healthcare team and ethics committees to create rules for distributing resources. Consider things like fairness, overall benefit, and prioritizing those who need it most.
• Use a fair system: Create a transparent process for deciding who gets what resources. Use an objective system that looks at how urgently someone needs help, how sick they are, and their chances of getting better.
• Work together: Get input from doctors, ethicists, administrators, and other healthcare professionals when making decisions. Consider different perspectives so that choices are well-informed and follow the ethical guidelines.
• Be honest with patients: Talk openly with patients and their families about resource shortages. Explain how decisions are made and listen to their concerns. Offer support during this difficult time.
• Review your choices: Regularly check if the resource allocation system is working well. Keep track of patient outcomes and learn from your experiences. Make changes if needed to make the process better.
• Fight for more resources: Advocate for more support from healthcare organizations, policymakers, and the community. Push for strategies that can help reduce shortages, like increasing capacity and public health interventions.
• Take care of yourself: Understand that this situation can be emotionally tough. Take care of yourself by seeking support from colleagues or mental health professionals. Participate in debriefing sessions to process your feelings and prevent burnout.

Scenario: You work as a nurse in a hospice facility that cares for people nearing the end of their lives. One day, you’re assigned to take care of Mr. Chen, an elderly patient with a Chinese cultural background and strong family support. However, you notice that the family’s beliefs about death and dying are different from what’s usually done at the hospice. This puts you in a tough situation where you have to decide between respecting their culture and providing good end-of-life care.

Ethical Dilemma: The ethical dilemma here is about cultural understanding and end-of-life care. As a nurse, it’s important to respect different cultures, let patients make choices for themselves, and give them compassionate care. But sometimes, there can be conflicts between cultural beliefs and the rules we follow in healthcare.

The problem comes from the clash between the family’s beliefs about death and the usual things we do at the hospice. You need to find a way to give culturally appropriate care while also making sure Mr. Chen gets relief from pain, comfort, and support during his final time.

Solution and Tips: To solve this dilemma, try these tips:

• Learn about different cultures: Take time to understand and appreciate diverse practices and values. Learn specifically about how Chinese culture views death, dying, and grieving. Use resources or ask experts for help in becoming more knowledgeable.
• Talk openly with Mr. Chen’s family: Create an environment where they feel comfortable sharing their thoughts without judgment. Listen carefully to their concerns, fears, and wishes regarding end-of-life care.
• Make decisions together: Involve Mr. Chen, his family, and other healthcare team members when deciding what’s best for him. Consider their cultural beliefs along with medical needs like managing pain or providing emotional support.
• Educate gently: Offer sensitive explanations about hospice goals and principles tailored to their culture. Help them understand why pain management, symptom control, and emotional support are important during this time. Clear up any misunderstandings they might have.
• Adjust care within cultural boundaries: Adapt the care plan to respect their cultural beliefs as long as it doesn’t compromise safety or ethical rules. Explore alternative methods of pain relief, spiritual rituals, or ways for family to be involved that align with their culture.
• Get guidance and support: Seek advice from experienced colleagues in cultural understanding or ethics. Consult cultural advisors or interpreters who can help you navigate these challenges. Their expertise can provide valuable insights.
• Reflect on yourself: Continuously think about your own biases, assumptions, and cultural beliefs. Keep learning and being self-aware to improve how you provide patient-centered care to people from different backgrounds.

Scenario: You are a nurse working in a mental health facility. One day, you receive a call from someone claiming to be Sarah’s close friend. They tell you that Sarah has been talking about self-harm and suicide. You now face an ethical dilemma regarding patient confidentiality and the duty to prevent harm.

Ethical Dilemma: As a nurse, you have to balance respecting patient privacy with ensuring their safety. This dilemma arises because you have information about Sarah’s risk of self-harm but need to decide how to handle it while maintaining trust and autonomy.

The challenge is addressing the immediate risk of harm without breaching patient confidentiality or damaging the therapeutic relationship with Sarah. You must make ethical decisions that prioritize her safety while still respecting her trust and autonomy.

Solution and Tips: To navigate this situation:

• Prioritize safety and assess risks carefully: Take the information seriously and evaluate how severe the situation is by considering factors like immediate danger, past self-harm attempts, and available support systems.
• Communicate openly with Sarah: Create a safe space for her to express her thoughts and emotions without revealing what her friend shared directly.
• Build rapport and trust: Show empathy, listen actively, and provide non-judgmental support to establish a trusting relationship with Sarah.
• Involve other healthcare professionals: Seek input from psychologists, psychiatrists, or social workers who can provide different perspectives on managing the risk of self-harm. Collaborate on a comprehensive care plan for Sarah’s safety and mental health needs.
• Respect patient autonomy within limits: Whenever possible, involve Sarah in decisions about her care by discussing potential interventions, explaining recommendations, and seeking her input when feasible.
• Balance confidentiality and duty to warn: Consider legal responsibilities related to duty to warn or protect when there is a high risk of self-harm or harm to others. Consult ethics committees or legal advisors for compliance.
• Document your decision-making process: Maintain accurate records of discussions, assessments, interventions, and referrals related to Sarah’s risk of self-harm. Document the reasons behind your decisions to demonstrate adherence to ethical principles and legal requirements.

Scenario: You are a nurse working in a community healthcare clinic. One of your patients, Mr. Rodriguez, has been diagnosed with a chronic condition that requires consistent adherence to medication and lifestyle modifications. However, during his recent visit, Mr. Rodriguez reveals that he has been non-compliant with his treatment regimen due to personal beliefs and concerns about potential side effects. As a nurse, you find yourself facing a challenging ethical dilemma regarding patient autonomy and the promotion of health outcomes.

Ethical Dilemma: In this situation, you are faced with the ethical dilemma of respecting Mr. Rodriguez’s autonomy while also recognizing the importance of adherence to recommended care for his overall well-being and disease management. Balancing these factors becomes crucial as you navigate through this complex scenario.

Solution and Tips: Resolving the ethical dilemma of patient autonomy and non-adherence to treatment requires effective communication, education, and collaboration. Here are some tips to help you navigate this challenging situation:

• Establish open and non-judgmental communication: Create a safe space where Mr. Rodriguez feels comfortable expressing his concerns and beliefs. Foster open dialogue to understand his reasons for non-adherence and address any misconceptions or fears he may have.
• Explore underlying reasons and beliefs: Engage in discussions to uncover the underlying reasons for Mr. Rodriguez’s non-compliance. Listen attentively and empathetically to gain insight into his beliefs, concerns, and expectations regarding treatment.
• Provide comprehensive education: Offer clear information about the prescribed treatment, its benefits, potential side effects, and long-term consequences of non-adherence. Tailor the education to address Mr. Rodriguez’s specific concerns, providing evidence-based information to alleviate his fears.
• Engage in shared decision-making: Collaborate with Mr. Rodriguez to develop a care plan that considers his beliefs, values, and treatment preferences while balancing optimal health outcomes. Involve him in decision-making processes when appropriate.
• Address barriers and offer support: Identify any barriers contributing to Mr.Rodriguez’s non-adherence and provide resources, tools, or support to help overcome them – such as reminders or referrals to support groups – thus promoting adherence.
• Engage the healthcare team: Collaborate with the healthcare team, including physicians, pharmacists, and other specialists. Discuss Mr. Rodriguez’s concerns, explore alternative treatment options if available, and seek their input and expertise to find solutions that align with his values.
• Continuously assess and reassess: Regularly monitor Mr. Rodriguez’s progress and reassess adherence to the treatment plan. Adapt the care plan as needed based on his evolving beliefs, concerns, and health outcomes. Maintain open communication to address any new challenges that may arise.

By following these tips and approaches, you can navigate this ethical dilemma while striving to respect Mr. Rodriguez’s autonomy and promote his overall well-being in the context of his personal beliefs.

Scenario: You are a nurse in a surgical unit, and one of your patients, Mrs. Thompson, needs a complex surgery for a life-threatening condition. However, you notice that she’s having trouble making decisions because of cognitive decline. This puts you in an ethical dilemma about getting her informed consent while also keeping her safe.

Ethical Dilemma: As a nurse, you face the challenge of obtaining informed consent from Mrs. Thompson when she can’t make clear decisions due to her cognitive decline. You must balance respecting her autonomy with ensuring her safety and well-being.

Solution and Tips: The problem is that Mrs. Thompson can’t fully understand or agree to the surgery because of her cognitive decline. You need to find a way to respect her wishes while protecting her best interests.

To solve this dilemma, you need to assess Mrs. Thompson’s decision-making capacity, involve someone who can make decisions for her (a family member or legal representative), and follow the rules and guidelines for informed consent.

Here are some tips to help you resolve this ethical dilemma:

• Assess decision-making capacity: Evaluate how well Mrs. Thompson can make decisions by considering her cognitive abilities and understanding of the surgery. Get help from experts who specialize in assessing decision-making capacity if needed.
• Involve a surrogate decision-maker: If Mrs.Thompson can’t make decisions, identify someone who can act on her behalf (like a family member or legal representative). Talk to them about Mrs. Thompson’s preferences and values regarding healthcare choices.
• Provide information: Give clear explanations about the surgery, including risks, benefits, and alternatives, to the surrogate decision-maker so they can make an informed choice for Mrs.Thompson.
• Follow rules and guidelines: Make sure you follow all local laws, regulations, and hospital policies related to informed consent for patients with impaired decision-making capacity. Seek advice from ethics committees or legal professionals if necessary.

Scenario: You’re a nurse in a hospital that recently started using electronic health records (EHR). During your shift, a friend from another department asks if they can access the medical records of someone you both know who is currently a patient. This puts you in an ethical dilemma about privacy and keeping patient information confidential in the digital age.

Ethical Dilemma: The problem is deciding how to balance privacy and confidentiality with the new EHR system. As a nurse, you have to follow rules about keeping patient information private. But now you have to figure out how to do that while also dealing with personal relationships at work.

Solution and Tips: You need to protect the patient’s privacy while managing your friend’s expectations. It’s tough because you want to be loyal to your friend, but you also have professional responsibilities and legal obligations.

Here are some tips for resolving this tricky ethical situation:

• Know the rules: Learn about the laws and policies that govern patient privacy and EHR use. Understand what happens if someone accesses patient information without permission.
• Explain why it matters: Talk to your friend about why patient privacy is so important. Help them understand the ethical and legal reasons for not sharing sensitive information. Encourage them to respect boundaries at work.
• Say no politely: Politely decline your friend’s request, making it clear that you can’t share patient information because it goes against professional ethics and legal obligations. Stress that protecting patient privacy is crucial.
• Report if necessary: If your friend keeps asking or if you feel uncomfortable, report the situation to your supervisor or someone higher up in your organization. They can help guide you on what steps to take next and address any breach of confidentiality.
• Promote confidentiality: Encourage a culture of privacy and confidentiality at work by advocating for education on privacy laws and ethical standards for using EHRs. Remind colleagues about their responsibility to keep patient information secure.
• Think about relationships: Consider how personal relationships can affect professional responsibilities. Be mindful of any conflicts of interest and maintain professional boundaries to protect patient privacy and your own integrity.
• Protect information: Take steps to safeguard patient information in the EHR system. Use strong passwords, log out when you’re done, and report any suspicious activity or unauthorized access.

Remember, keeping patient information private is crucial for building trust between patients and healthcare providers. By following ethical guidelines and promoting confidentiality, you can handle this dilemma while staying true to your professional values.

Sophia Miller

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Ethical Dilemmas in Nursing (Essay Sample)

Table of Contents

Instructions:

Write a paper of 750-1,000 words in which you describe your professional moral compass. As you write your paper, include the following:

• What personal, cultural, and spiritual values contribute to your worldview and philosophy of nursing?
• How do these values shape or influence your nursing practice?
• Define values, morals, and ethics in the context of your obligation to nursing practice. Explain how your personal values, philosophy, and worldview may conflict with your obligation to practice, creating an ethical dilemma.
• Reflect and share your own personal thoughts regarding the morals and ethical dilemmas you may face in the health care field.
• How do your personal views affect your behavior and your decision making?

Do not be concerned with the use of ethical terminology for this paper.

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Introduction

Dilemmas, as far as they go, exist in virtually every type of profession. All fields of work come about with some form of exceptionalities which comprehensively eliminate the aspect of a perfect profession. To a greater extent, ethical dilemmas complement each profession. On an outer look, nursing is perceived as one of the most fulfilling professions around the globe. Challenges in any profession are inevitable. Nursing from an inner look is faced with challenges and most profoundly the ethical dilemmas on a daily basis. Ethics in any profession are a set of regulations or principles through which decisions based on ethics are made. The major purpose of these mechanisms is the fostering of ethics of very high standards. The core business of nursing includes health promotion, easing of pain and illness prevention. The code of ethics, however, dictates that apart from that, the respect to human life must be part of the job. Respect to human life means cultural rights, right to choice and life and respectful and dignified treatment among others.

The nursing profession, like the larger medical field, is compounded with various dilemmas. Ethical dilemmas make nurses encounter moral distress. This is because, in most situations, they feel that they failed or were restricted to do what they consider ‘right’ (Wood, 2014). Some nurses, on the encounter of this, dare to speak it out with the colleagues or the management while others don’t. Such a scenario is often compounded by the Hippocratic Oath that these individuals have to take when commencing their careers. They often heave under such challenges, but again cannot be allowed to speak about them. Here are some of the most common ethical dilemmas that nurses encounter while performing their duties and what can be done.

Honesty in controversial to information

Nurses need to acquire information about the patient’s history to attain quality care. At the same time, they need to give the information about the patient’s condition with the patient or the family of the patient. This becomes a hurdle because they are not sure of the kind of information, the time and the manner in which they can present it to the parties in question (Carlise & Zoboli, 2015). The dilemma comes in if they should tell the patient’s condition or if they should let the patient enjoy a stress-free life during their last days. It is therefore up to the intelligence and common sense of the nurse to determine and ascertain the best course of action to take under such circumstances. This, is never easy. Families, on the other hand, withdraw or fail to provide truthful information about the patient for the purposes of protecting them. The misinformation may lead to adverse outcomes which lead to unethical conduct to the respective nurse.

The Nurse Control against the Freedom of the Patient

This is one of the most common ethical dilemmas in the nursing profession. Incorporated in the principles of ethics is the right to choice and cultural rights. The two give the patient the freedom of rejection of the medical advice given by the nurse or the physician. Remember, nurses are highly educated and experienced professionals who understand the most efficient and profound clinical course to tackling an action. If the patient refuses their advice, doesn’t that mean that they will have to comply with the course the patient wants even if it gives the less optimal outcome? But again, what can ,and should the nurse do, when it gets to this?

Closely related to this are personal, religious or cultural beliefs of a patient in controversial to a nurse’s empirical and science-based knowledge (Shapira, 2009. Even though it is a matter of life and death, some religious or cultural beliefs forbid some of the medical procedures. For instance, blood transfusion; there are some cultures and religions that forbid it.  In case of such an incidence that the nurse will have nothing but to watch a patient die, builds up moral distress.

The Reproductive Rights

This is another huge dilemma faced by nurses. The argument is seen between the pro-life and the pro-choice individuals. If the nurse is pro-life, it will be hard for them to respect the decision of a patient who wants to terminate a pregnancy. The other side’s hurdle comes in, in the manner that a patient wants to keep a pregnancy yet from the assessment, it threatens their life. The pro-choice nurses are faced with the dilemma of if they should support the patient’s decision or not. Once again, it is up to the nurse’s discretion to try and choose what would be the best course of action to take under such circumstances.

The Management of Resources

This usually happens when the cost of treatment is too high due to the patient’s critical conditions which can be described as the vegetative or futile state. The resources to save the lives of these patients could be costly, and it thus becomes a very difficult decision for the nurses to redirect the costs to the patients. It becomes nigh hard to draw a line of this decision from being personal to financial. The family is grieving, and when it comes to ensuring that a loved one’s life is saved, there is no resource that is not well spent. The nurse thus takes this decision, but they are eventually charged with the ‘big picture’ maintenance perspective while in real senses, they are dealing with critical personal situations.

The ethical challenges in nursing have mostly been taken as part of the job. In one way or the other, there is nothing normal with what makes one uncomfortable. Nurses, therefore, do not have to sit back but should seek for help. There are organizations that help nurses with ethical dilemma issues, for instance, the American Nursing Association. The organization offers statements on human rights and ethics. The statements could help nurses to overcome their challenges. Other hospitals have organized committees to deal with such (Wood, 2014). Nurses are very important part of the healthcare system-they care.

• Carlise, N. R. D., Vieira, M & Zoboli, P. C. L. E. (2015). Ethical Problems Experienced by Nurses in Primary Health Care. Retrieved fromhttp://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-14472015000100112
• Shapira, L. O. (2009). Ethical Dilemma in Nursing: The Experiences of Israel Nurses. Retrieved from http://education.biu.ac.il/files/education/shared/QHR_FINAL_ORLY_SHAPIRA.pdf
• Wood, D. (2014). 10 Best Practices for Addressing Ethical Issues and Moral Distress. Retrieved from https://www.amnhealthcare.com/latest-healthcare-news/10-best-practices-addressing-ethical-issues-moral-distress/

• Open access
• Published: 28 March 2024

Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study

• Rachel Gilbert 1 &
• Daniela Lillekroken   ORCID: orcid.org/0000-0002-7463-8977 1  

BMC Nursing volume  23 , Article number:  216 ( 2024 ) Cite this article

109 Accesses

Metrics details

Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto’s theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

The content analysis generated five categories that were labelled similar to Tronto’s five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses’ autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto’s theory contributes to greater reflectiveness around what may constitute ‘good’ end-of-life care.

Conclusions

Tronto’s care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto’s care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what ‘good’ end-of-life care should be.

Peer Review reports

In recent decades, improving end-of-life care has become a global priority [ 1 ]. The proportion of older residents dying in nursing homes is rising across the world [ 2 ], resulting in a significant need to improve the quality of end-of-life care provided to residents. Therefore, throughout the world, nursing homes are becoming increasingly important as end-of-life care facilities [ 3 ]. As the largest professional group in healthcare [ 4 ], nurses primarily engage in direct care activities [ 5 ] and patient communication [ 6 ] positioning them in close proximity to patients. This proximity affords them the opportunity to serve as information brokers and mediators in end-of-life decision-making [ 7 ]. They also develop trusting relationships with residents and their next-of-kin, relationships that may be beneficial for the assessment of residents and their next-of-kin’s needs [ 8 ]. Moreover, nurses have the opportunity to gain a unique perspective that allows them to become aware of if and when a resident is not responding to a treatment [ 9 ].

When caring for residents in their critical end-of-life stage, nurses form a direct and intense bond with the resident’s next-of-kin, hence nurses become central to end-of-life care provision and decision-making in nursing homes [ 10 ]. The degree of residents and their next-of-kin involvement in the decision-making process in practice remains a question [ 11 ]. Results from a study conducted in six European countries [ 12 ], demonstrate that, in long-term care facilities, too many care providers are often involved, resulting in difficulties in reaching a consensus in care. Although nurses believe that their involvement is beneficial to residents and families, there is a need for more empirical evidence of these benefits at the end-of-life stage. However, the question of who should be responsible for making decisions is still difficult to answer [ 13 ]. One study exploring nurse’s involvement in end-of-life decisions revealed that nurses experience ethical problems and uncertainty about the end-of-life care needs of residents [ 14 ]. Another study [ 10 ] reported patients being hesitant to discuss end-of‐life issues with their next-of-kin, resulting in nurses taking over; thus, discussing end-of-life issues became their responsibility. A study conducted in several nursing homes from the UK demonstrated that ethical issues associated with palliative care occurred most frequently during decision-making, causing greater distress among care providers [ 15 ].

Previous research has revealed that there are some conflicts over end-of-life care that consume nurses’ time and attention at the resident’s end-of-life period [ 16 ]. The findings from a meta-synthesis presenting nurses’ perspectives dealing with ethical dilemmas and ethical problems in end-of-life care revealed that nurses are deeply involved with patients as human beings and display an inner responsibility to fight for their best interests and wishes in end-of-life care [ 17 ].

Within the Norwegian context, several studies have explored nurses’ experiences with ethical dilemmas when providing end-of-life care in nursing homes. One study describing nurses’ ethical dilemmas concerning limitation of life-prolonging treatment suggested that there are several disagreements between the next-of-kin’s wishes and what the resident may want or between the wishes of the next-of-kin and what the staff consider to be right [ 18 ]. Another study revealed that nurses provide ‘more of everything’ and ‘are left to dealing with everything on their own’ during the end-of-life care process [ 19 ] (p.13) . Several studies aiming to explore end-of-life decision-making in nursing homes revealed that nurses experience challenges in protecting the patient’s autonomy regarding issues of life-prolonging treatment, hydration, nutrition and hospitalisation [ 20 , 21 , 22 ]. Other studies conducted in the same context have described that nurses perceive ethical problems as a burden and as barriers to decision-making in end-of-life care [ 8 , 23 ].

Nursing, as a practice, is fundamentally grounded in moral values. The nurse-patient relationship, central to nursing care provision, holds ethical importance and significance. It is crucial to recognise that the context within which nurses practice can both shape and be shaped by nursing’s moral values. These values collectively constitute what can be termed the ethical dimension of nursing [ 24 ]. Nursing ethos and practices are rooted in ethical values and principles; therefore, one of the position statements of the International Council of Nurses [ 25 ] refers to nurses’ role in providing care to dying patients and their families as an inherent part of the International Classification for Nursing Practice [ 26 ] (e.g., dignity, autonomy, privacy and dignified dying). Furthermore, ethical competence is recognised as an essential element of nursing practice [ 27 ], and it should be considered from the following viewpoints: ethical decision-making, ethical sensitivity, ethical knowledge and ethical reflection.

The term ‘end-of-life care’ is often used interchangeably with various terms such as terminal care, hospice care, or palliative care. End-of life care is defined as care ‘to assist persons who are facing imminent or distant death to have the best quality of life possible till the end of their life regardless of their medical diagnosis, health conditions, or ages’ [ 28 ] (p.613) . From this perspective, professional autonomy is an important feature of nurses’ professionalism [ 29 ]. Professional autonomy can be defined based on two elements: independence in decision-making and the ability to use competence, which is underpinned by three themes: shared leadership, professional skills, inter- and intraprofessional collaboration and a healthy work environment [ 30 ].

As presented earlier, research studies have reported that nurses experience a range of difficulties or shortcomings during the decision-making process; therefore, autonomous practice is essential for safe and quality care [ 31 ]. Moreover, autonomous practice is particularly important for the moral dimension in end-of-life care, where nurses may need to assume more responsibility in the sense of defining and giving support to matters that are at risk of not respecting ethical principles or fulfilling their ethical, legal and professional duties towards the residents they care for.

To the best of the researchers’ knowledge, little is known about nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents; therefore, the aim of this study is to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Theoretical framework

Joan Tronto is an American political philosopher and one of the most influential care ethicists. Her theory of the ethics of care [ 32 , 33 , 34 ] has been chosen as the present study’s theoretical framework. The ethics of care is a feminist-based ethical theory, focusing on caring as a moral attitude and a sensitive and supportive response of the nurse to the situation and circumstances of a vulnerable human being who is in need of help [ 33 , 34 , 35 ]. In this sense, nurses’ caring behaviour has the character of a means—helping to reach the goal of nursing practice—which here entails providing competent end-of-life care.

Thinking about the process of care, in her early works [ 32 , 33 , 34 ], Tronto proposes four different phases of caring and four elements of care. Although the phases may be interchangeable and often overlap with each other, the elements of care are fundamental to demonstrate caring. The phases of caring involve cognitive, emotional and action strategies.

The first phase of caring is caring about , which involves the nurse’s recognition of being in need of care and includes concern, worry about someone or something. In this phase, the element of care is attentiveness, which entails the detection of the patient and/or family need.

The second phase is caring for , which implies nurses taking responsibility for the caring process. In this phase, responsibility is the element of care and requires nurses to take responsibility to meet a need that has been identified.

The third phase is care giving , which encompasses the actual physical work of providing care and requires direct engagement with care. The element of care in this phase is competence, which involves nurses having the knowledge, skills and values necessary to meet the goals of care.

The fourth phase is care receiving , which involves an evaluation of how well the care giving meets the caring needs. In this phase, responsiveness is the element of care and requires the nurse to assess whether the care provided has met the patient/next-of-kin care needs. This phase helps preserve the patient–nurse relationship, which is a distinctive aspect of the ethics of care [ 36 ].

In 2013, Tronto [ 35 ] updated the ethics of care by adding a fifth phase of caring— caring with —which is the common thread weaving among the four phases. When care is responded to through care receiving and new needs are identified, nurses return to the first phase and begin again. The care elements in this phase are trust and solidarity. Within a healthcare context, trust builds as patients and nurses realise that they can rely on each other to participate in their care and care activities. Solidarity occurs when patients, next-of-kin, nurses and others (i.e., ward leaders, institutional management) engage in these processes of care together rather than alone.

To the best of our knowledge, these five phases of caring and their elements of caring have never been interpreted within the context of end-of-life care. The ethics of care framework offers a context-specific way of understanding how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with Tronto’s five phases, which has motivated choosing her theory.

Aim of the study

The present study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The current study has a qualitative descriptive design using five individual interviews and one focus group to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Setting and participants

The setting for the study was four nursing homes located in different municipalities from the South-Eastern region of Norway. Nursing homes in Norway are usually public assisted living facilities and offer all-inclusive accommodation to dependent individuals on a temporary or permanent basis [ 37 ]. The provision of care in the Norwegian nursing homes is regulated by the ‘Regulation of Quality of Care’ [ 38 ], aiming to improve nursing home residents’ quality of life by offering quality care that meets residents’ fundamental physiological and psychosocial needs and to support their individual autonomy through the provision of daily nursing care and activities tailored to their specific needs, and, when the time comes, a dignified end-of-life care in safe milieu.

End-of-life care is usually planned and provided by nurses having a post graduate diploma in either palliative nursing or oncology nursing– often holding an expert role, hence ensuring that the provision of end-of-life care meets the quality criteria and the resident’s needs and preferences [ 39 ].

To obtain rich information to answer the research question, it was important to involve participants familiar with the topic of study and who had experience working in nursing homes and providing end-of-life care to residents; therefore, a purposive sample was chosen. In this study, a heterogeneous sampling was employed, which involved including participants from different nursing homes with varying lengths of employment and diverse experiences in providing end-of-life care to residents. This approach was chosen to gather data rich in information [ 40 ]. Furthermore, when recruiting participants, the first author was guided by Malterud et al.’s [ 41 ] pragmatic principle, suggesting that the more ‘information power’ the participants provided, the smaller the sample size needed to be, and vice versa. Therefore, the sample size was not determined by saturation but instead by the number of participants who agreed to participate. However, participants were chosen because they had particular characteristics such as experience and roles which would enable understanding how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The inclusion criteria for the participants were as follows: (i) to be a registered nurse, (ii) had a minimum work experience of two years employed at a nursing home, and (iii) had clinical experience with end-of-life/palliative care. To recruit participants, the first author sent a formal application with information about the study to four nursing homes. After approval had been given, the participants were asked and recruited by the leadership from each nursing home. The participants were then contacted by the first author by e-mail and scheduled a time for meeting and conducting the interviews.

Ten nurses from four different nursing homes were invited to participate, but only nine agreed. The participants were all women, aged between 27 and 65 and their work experience ranged from 4 to 21 years. Two participants had specialist education in palliative care, and one was currently engaged in a master’s degree in nursing science. Characteristics of the participants are presented in Table  1 :

Data collection methods

Data were collected through five semistructured individual and one focus group interviews. Both authors conducted the interviews together. The study was carried out between April and September 2022. Due to the insecurity related to the situation caused by the post-SARS-CoV-2 virus pandemic and concerns about potential new social distancing regulations imposed by the Norwegian government, four participants from the same nursing home opted for a focus group interview format. This decision was motivated by a desire to mitigate the potential negative impact that distancing regulations might have on data collection. The interviews were guided by an interview guide developed after reviewing relevant literature on end-of-life care and ethical dilemmas. The development of the interview guide consisted of five phases: (i) identifying the prerequisites for using semi-structured interviews; (ii) retrieving and using previous knowledge; (iii) formulating the preliminary semi-structured interview guide; (iv) pilot testing the interview guide; and (v) presenting the complete semistructured interview guide [ 42 ]. The interview guide was developed by both authors prior to the onset of the project and consisted of two demographic questions and eight main open-ended questions. The interview guide underwent initial testing with a colleague employed at the same nursing home as the first author. After the pilot phase in phase four, minor language revisions were made to specific questions to bolster the credibility of the interview process and ensure the collection of comprehensive and accurate data. The same interview guide was used to conduct individual interviews and focus group (Table  2 ).

The interviews were all conducted in a quiet room at a nursing home. Each interview lasted between 30 and 60 min and were digitally recorded. The individual interviews were transcribed verbatim by the first author. The focus group interview was transcribed by the second author.

Ethical perspectives

Prior to the onset of the data collection, ethical approval and permission to conduct the study were sought from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 360,657) and from each leader of the nursing home. The study was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association [ 43 ]: informed consent, consequences and confidentiality. The participants received written information about the aim of the study, how the researcher would ensure their confidentiality and, if they chose to withdraw from the study, their withdrawal would not have any negative consequences for their employment at nursing homes. Data were anonymised, and the digital records of the interviews were stored safely on a password-protected personal computer. The transcripts were stored in a locked cabinet in accordance with the existing rules and regulations for research data storage at Oslo Metropolitan University. The participants did not receive any financial or other benefits from participating in the study. Written consent was obtained prior to data collection, but verbal consent was also provided before each interview. None of the participants withdrew from the study.

Data analysis

The data were analysed by employing a qualitative deductive content analysis, as described by Kyngäs and Kaakinen [ 44 ]. Both researchers independently conducted the data analysis manually. The empirical data consisted of 63 pages (34,727 words) of transcripts from both individual and focus group interviews. The deductive content analysis was performed in three steps: (i) preparation, (ii) organisation and (iii) reporting of the results.

During the first step—preparation—each researcher, individually, read the transcripts several times to get an overview of the data and select units of analysis by searching for recurring codes and meanings and to carefully compare the similarities and differences between coded data. These codes were labelled independently by both researchers and placed into an analysis matrix.

During the next step—organisation—the researchers met and discussed and then compared and revised the labels several times until they agreed about the preliminary findings. During the interpretative process towards developing an understanding of the empirical data, the content of the labels referred to nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with the five phases of Tronto’s theory of ethics of care [ 32 , 33 ], thus assigning them to the five phases of the theory. Following this final refinement, one main category and five categories, each supported by several subcategories, were identified, as presented in Table  3 .

Reporting the results was the last step in the analysis. To enhance the understanding of the study’s findings, the findings are presented with supporting excerpts from the participants.

In qualitative studies, trustworthiness is the main parameter for appraising the rigour of the study [ 45 ]. To enhance the trustworthiness of the study, four criteria—credibility, transferability, dependability and confirmability, as described by Lincoln and Guba [ 46 ]—were applied.

To support credibility, a detailed description of the sample and the sampling process was provided. Furthermore, the interview guide and the questions that the participants were asked during the interviews are made available to the readers. Moreover, although the data were collected from five individual interviews and one focus group, triangulation of two data collection methods allowed researchers to ensure that the study is based on diverse perceptions and experiences, strengthening the credibility and impact of the study’s findings [ 47 ].

Detailed information about the sample and setting supports the assessment of the transferability of the findings. In this way, the readers can recognise and evaluate whether the findings would be applicable to similar contexts with a similar sample. Quotes from the participants’ statements are given to support the findings. Each quote ends with a number representing the code that each nurse was given before conducting the interviews (i.e., Participant in interview 1, PI1 or participant 6 in focus group interview, P6FG).

To increase dependability, the same interview guide was used to ask all participants the same questions. Dependability was also increased by the researchers reading and analysing the interviews independently and then checking the consistency of the data analysis technique with each other and discussing the analytical process until a consensus was reached.

To enhance confirmability, excerpts from the participants’ statements were included when presenting the findings, thus verifying the concordance of findings with the raw data. This demonstrates that the data were not based on preconceived notions.

Trustworthiness was also supported by member checking, meaning that the researchers sent the participants the transcripts of the interviews immediately after data collection; then, the interviews were transcribed. The participants were asked to review the transcripts and check the accuracy of the data; hence, they had the opportunity to add, remove or clarify their statements. Only one participant answered this request, stating that the transcripts were accurate, and she did not have any further comments. Despite encountering a suboptimal response from participants, the authors remain confident in the trustworthiness of the study. Rich data, derived from a combination of individual and focus group interviews, yielded diverse and nuanced responses from participants, reinforcing the credibility of the findings.

Reflexivity is the researcher’s reflection on their position during the research process [ 48 ]. Both researchers have clinical experience in providing end-of-life care to nursing home residents. Therefore, it was critical to be aware of the impact that their clinical backgrounds might have on the research process from information seeking during the analysis of data and discussion of the findings. To avoid early interpretation of the data, the researchers were aware of their preunderstanding and tried to put it on hold. Both authors engaged in discussions regarding apprehensions and reflections, actively participating in the triangulation process throughout the study to prevent potential bias during data collection, analysis, and interpretation. The theoretical framework was brought in the end of the analysis process, which helped label the emerged findings.

The analysis of the empirical data combined with an ethical reflection helped researchers to identify and understand the moral dimension of nurses’ experiences with end-of-life care provided to nursing home residents. During the analysis, an overarching category emerged– ‘The moral dimension of the provision of end-of life care’– describing nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. The participants agreed that end-of-life care is a care process that undergoes several phases, with each phase having its own ethical quality or its own element of care, here according to Tronto’s moral qualities [ 34 ]. In the following section, the findings are described using Tronto’s identified moral qualities for each of the five phases of the care process [ 32 , 33 , 34 , 35 ].

Caring about—being attentive

For the participants, being autonomous was perceived as a feature that increased their awareness of the resident’s caring needs during their last days of life. The participants agreed that the caring process involves paying attention, listening and recognising residents’ unspoken needs. Moreover, it implies nurses being able to make autonomous decisions when deciding which needs to care about at one particular moment.

The participants agreed that the core values of providing end-of-life care were to alleviate suffering, maintain dignity and provide comfort care. The participants perceived caring about as having sufficient knowledge, along with the experience and autonomy in practice, as well as providing comprehensive end-of-life care for residents. For the participants, caring about during the end-of-life process means them being present and dedicated. This implies nurses carefully observing, autonomously acting, and making decisions based on their judgements, and thus, they can decide and choose their course of action promptly based on resident’s condition or side effects. Moreover, caring about involved participants being attentive to perceiving the residents’ needs when the residents could no longer articulate themselves. The participants expressed their worries about resident’s bodily deterioration, leading them to lose their ability to express needs, as shown by the following quote:

There is not much communication when residents go into their last stage of life. Well… some of them are consciously until their death, but most are sedated; therefore, it is necessary to use your knowledge and experience to assess not only their needs for food and liquids or bodily hygiene, but also, we have to monitor their response to pain killers and other medication, and if it’s too much or too little, we need to do what’s needed to reduce or increase the medication and not let them suffer (PI3).

Some of the participants expressed that attentiveness to the residents’ care needs was a skill based on their clinical gaze developed during their careers. Other participants discussed that building a close relationship with the residents while they still could walk and talk was a precondition that helped them develop a clinical gaze, hence facilitating the nurses’ being attentive. Attentiveness allowed the participants to do what was needed when knowing the residents’ needs during the provision of end-of-life care. This may be interpreted as the moral or ethical quality of caring about during the end-of-life caring process, as demonstrated by the following statement:

We have time to know the resident before their health condition worsens… We previously knew what they wanted and how they wanted… their stay at nursing home gives us the opportunity to know their preferences and needs. Morally, we are obliged to provide the same quality of care they received when they could express themselves (PI4).

Caring for—taking responsibility

According to several participants, another phase within the end-of-life caring process was taking responsibility to care for. The participants agreed that monitoring the residents in their last days implies assuming responsibility. Assuming responsibility was perceived as an autonomous caring activity. They also discussed taking this responsibility seriously, which is a moral dimension of the end-of-life caring process and, ultimately, of the nursing profession. Usually, this responsibility was taken by a nurse, but it also involved other healthcare personnel or even next-of-kin. Among these responsibilities, the participants mentioned that the end-of-life caring process included not only caring for the resident’s physiological and psychosocial needs, but also assigning permanent healthcare personnel to continuously monitor the resident. Although the participants were aware that they share responsibilities for the caring process, ‘who does what…’, they ultimately had the overall responsibility for the whole end-of-life caring process.

Another responsibility included communication, which included listening, providing information, and supporting the residents’ next-of-kin. One of the participants expressed this as follows:

When I observe that the resident’s health worsens, I inform the next-of-kin and invite the spouse or the children to a meeting together with the responsible doctor and I, and we inform the next-of-kin what they might expect. The end-of-life care is not only about the resident and their last days, but also is to care for their next-of-kin to meet their needs and to overcome guilt feelings, anger or sadness.… (PI1).

Another way to care for patients was to deliberately increase opportunities to exercise autonomy during the caring process. For instance, the focus group participants discussed issues around advanced life support during the resident’s last days of life. Being prepared and having knowledge were the preconditions that gave them the authority to identify and make decisions about residents’ needs in here-and-now moments, hence exercising their autonomy. Some participants shared their experiences with controversies between next-of-kins’ and nurses’ assessments of what is the best care for the residents during their last days of life. Therefore, the importance of taking the initiative to discuss and clarify the resident’s needs and preferences was emphasised during the focus group interview, as shown in the following quote:

Some next-of-kins express wishes for advance life support and hospitalisation for their loved ones… and sometimes, to meet their needs, we try this, but the resident is suffering. The resident comes back to us after one or two days… To avoid this, clear guidelines, and a dialogue between the resident, their next-of-kin and us at the very beginning [when the resident enters the nursing home] is important… I think that minimalising the occurrence of difficult or conflictual situations and relieving the sufferance is care for both resident and their next-of-kin (P8FG).

Care giving—knowing what, why, how and when

During the interviews, the participants also discussed the caregiving process and provided concrete examples of what their caregiving encompassed. Spending extra time with the resident, choosing to be in the room and holding their hand to maintain physical contact was perceived as an autonomous caring act and a deliberate choice. One participant described this as follows:

For me, it is important that the dying person feels or hears that I am here with him or her… how he or she feels in these moments matters to me. I do it because I want to do it.… (PI5).

Other participants said that being autonomous when they actually provided caregiving to residents helped them make continuous assessments based on knowledge about what , how , how much , when and why to care. Knowledge and skills were decisive factors in providing competent care and making autonomous decisions during the caregiving phase; hence, competence was perceived as a moral dimension of caregiving. One of the participants said the following:

Caregiving at end-of-life is not only about giving morphine according to the doctor’s prescription… it involves all the judgements you have to make, all the skills you have… from preventing the occurrence of bedsores to knowing when to stop feeding but preventing thirst… think about all this knowledge and experience you must have to be able to make autonomous bedside judgements about when , why and so on.… (PI2).

Care giving at the end-of-life was described as all the necessary activities a nurse does to provide comfort and compassionate care to a dying resident. Among these activities, providing fundamental care and keeping residents comfortable and free of pain were seen as parts of the caregiving process. Moreover, adequate pain relief and symptom management were described as the moral dimension of care giving at this stage of end-of-life care, as one of the participants from the focus group interview said:

You cannot be passive when you see that the resident is suffering. I cannot go home and think that I should have done one or the other. It is against the nurses’ code of ethics and my personal moral and ethical principles. You have to act… I have to do what is needed… first thing first… pain relief and then personal hygiene! (P9FG)

Some of the participants mentioned some challenges they encountered during the care giving process. They said that care giving implies also standing in demanding situations. The lack of healthcare personnel with necessary knowledge or formal palliative care education or handling ethical dilemmas was seen as demanding situations that influenced the provision of care giving. Most of the participants felt that they were alone during the decision-making processes, which increased their awareness of their professional autonomy:

Sometimes, during weekends or evenings, I am the only nurse among the healthcare staff, and I have an overall responsibility for all nursing home residents. I have to prioritise who gets my attention and who needs me the most. Things can happen, regardless of whether it is Friday evening or weekend. I have to make a decision and do what is needed: to be with the dying resident and to support his or her next-of-kin in that moment. (PI5)

Care receiving—assessing caregiving

Several participants stated that, during the care-giving process, it was important to assess how the resident receive the care provided at the end-of-life stage. This was possible by monitoring the resident’s state of being but to also assess the outcomes of their care giving activities. They also reflected on their assessments and how they subsequently dealt with those assessments.

All the participants were confident in their knowledge and with their care giving at the end-of-life stage. They were aware that their care activities had consequences for the residents’ physiological and psychosocial needs. The assessment of the resident’s state of being was made by nurses listening, observing and interpreting resident’s response to care giving as signs of comfort or discomfort. One of the participants explained this as follows:

When providing personal care, if the resident presents any signs that can be interpreted as discomfort, I think that priority number one is me not causing more pain or suffering. However, I also understand that this person needs more pain killers, so I have to make sure that this person receives adequate medicine. (PI5)

Some participants also discussed the importance of assessing their care giving activities. They mentioned the importance of their assessments of the benefits of all care giving against the burden of all interventions and treatments. Their professional autonomy allowed them to make decisions about how to eschew care giving that was inappropriately and burdensome and choose the best comforting care for the resident. The participants stated that knowledge and experience were important in making such decisions, and their professional autonomy facilitated making choices of the best and less burdensome care giving. One of the participants said the following:

We have to assess whether the care giving provided meets the resident’s needs or not, whether the care comforts or perceives it as a burden and how the resident responds to this provision of care. (PI4)

During the interviews, some of the participants revealed a feeling of guilt when assessing that care giving altered the resident’s state of being, thus leading to new needs for care. They also discussed that the moral obligation and intention to relieve the suffering of the resident should override the foreseen but unintended harmful effects of care giving, including medication or other care interventions. One of the participants shared her experience as follows:

I still remember the attitude some of us had for a while ago… too much or too often morphine depresses the respiration and leads to death… I was struggling with feelings of guilt and even moral distress when I observed residents were still suffering because the medication they received had little or maybe no effect. I called the doctor and explained the situation… usually, the experienced doctors listen to us… and he [the doctor] prescribed more morphine.… (PI3).

Documentation of the response to care giving was also an issue discussed during the interviews. Some participants emphasised the importance of keeping detailed reports for a proper assessment of the care giving and medication and its outcomes. All reports were digitally written. Informal discussions between nurses and next-of-kin were also documented, especially when next-of-kin evaluated the care their loved ones received. The participants indicated that the more written information there was, the better. One participant acknowledged the following:

There is no such thing as ‘too much information’… being open about the morphine’s side effects and what to expect in the next hours or days is important for them [next-of-kin]. It helps them understand that end-of-life care is a process, not a quick fix procedure. (PI5)

Caring with—It is a teamwork process

During the interviews, most of the participants reflected upon the end-of-life caring process and its occurrence within the context of care in nursing home. The participants discussed that end-of-life care is not only about the responsibilities nurses have towards residents and their next-of-kin, but also the responsibilities of others who may influence the caring process. They perceived the caring process as an interplay between residents, next-of-kin, and themselves, along with how they relate to each other, which influences the caring process. However, as several participants asserted, this process did not occur in a vacuum: it occurred within an organisational context, which then influenced the caring process from the very beginning. One participant emphasised the importance of stable healthcare personnel within a caring organisation:

High staff turnover does not facilitate good end-of-life caregiving. Both residents and their next-of-kin need continuity and predictability in caring for and among healthcare personnel. They need somebody they know and trust… being exposed to new people every day increases their stress levels. (PI1)

Other participants discussed the importance of the leadership style and how the leader’s support influenced the culture of end-of-life care at the ward. The participants revealed that, within a caring context where their natural potential was enhanced through an enabling leadership style, they felt that they could provide competent and compassionate end-of-life care. One of the participants from the focus group stated that a positive leadership style supports nurses’ professional autonomy, thus helping them control the caring process, to have independence and to increase their ability to make clinical decisions and competent judgements regarding resident’s end-of-life care. One participant shared her experience as follows:

My leader gives me the freedom to make decisions when it comes to deciding what is best for the resident… She [the leader] enables me to be autonomous during the caring process, and this makes me aware of what and how to care.… (PI2).

The participants from the focus group interview also discussed how the nursing home’s caring culture influences care practice. They perceived the nursing home’s caring culture as positive, enabling good end-of-life care but also defective and an obstacle to care. They emphasised the importance of providing dignifying end-of-life care for residents. During the focus group interview, two of the participants engaged in a dialogue:

End-of-life care is providing care to the most vulnerable people, and it should be dignified… To do so, I have to provide care in a ‘caring room’ filled with dignity. (P7FG) Although next-of-kin and I have different perspectives of what good end-of-life care might be, we care together, we are a caring team which ensures in our own way that the resident receives competent care.… Yes, you [P7] mentioned this ‘caring room’… maybe we should open the door more often into this room and invite next-of-kin. (P6FG)

The aim of the present study was to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. In the following, we discuss these perceptions in relation to Tronto’s [ 32 , 35 ] ethics of care framework and other supporting literature. To identify the moral dimension of these perceptions, we have related them to the moral qualities corresponding to each phase of the care process, as described by Tronto [ 33 , 35 ].

In the first phase of the care process—caring about—the participants discussed the importance of being attentive to which type of care needs to be provided, which is the moral quality of the first phase of care. Similar to findings from another study [ 49 ], findings from the present study revealed that some participants perceived autonomous practice as carrying out actions based on their decisions. Caring about entails detecting the resident’s needs, hence obliging nurses to ‘do something’ [ 50 ]. This particular skill was seen as an autonomous caring activity, that is, the nurses’ deliberate choice of putting on hold their self-interest and/or agenda and ‘a capacity genuinely to understand the perspective of the other in need’ [ 35 ] (p.34) , here nursing home resident.

In Tronto’s view [ 33 ], nurses’ attentiveness contributes to building up a caring relationship with a patient. The findings from the current study reveal that nurses perceived the provision of competent and compassionate end-of-life care as a result of their clinical gaze developed through certain activities, attitudes and knowledge of the patient, and through mutual relationships between the residents, next-of-kin and them. These results are supported by findings from previous studies that emphasise the importance of the nurse’s past experiences with the resident [ 51 ] and the significance of developing a good relationship with the resident and their next-of-kin [ 8 , 23 , 52 , 53 , 54 ] to provide adequate care. Moreover, similar to findings from other studies [ 55 , 56 ], the present study reveal that, to respond to the resident’s end-of-life care needs, nurses must bring not only their professional knowledge, clinical experience and ability to work autonomously but even ethical sensitivity. These findings enforce Gastman’s [ 50 ] view on caring, in which caring should respond to the patient’s care needs. This involves nurses having empathy, capacity of judgement and the ability to see what is required in a specific situation (here, end-of-life care), which, according to Gastmans [ 50 ], is inherent in the moral dimension of nursing practice.

The second phase of care—caring for—refers to nurses taking on the burden of meeting the needs identified in the first phase, that is, caring about. There was no ambiguity, and the participants had no doubts regarding who had the responsibility for the provision of end-of-life care to nursing home residents. The nurses’ responsibility was seen as a moral dimension of care. In line with Pursio et al.’s study [ 30 ], the present findings indicate that the freedom to make patient care decisions and work independently has a positive impact on the moral dimension of end-of-life care for nursing home residents. However, nurses’ work was not only about meeting residents’ needs, but also to create a safe milieu, a communicative space together with each other and with the resident’s next-of-kin, thus sharing power and control over the care process. Similar findings are displayed in an integrative literature review [ 53 ], demonstrating that a positive culture of collaborative and reciprocal relationships, a willingness to engage and become engaged and nurses communicating with intent to share and support rather than inform all lead to facilitating decision-making in nursing homes. According to Tronto [ 35 ], to facilitate end-of-life decision-making, nurses must take the initiative to allocate responsibilities; otherwise, the nurses withdraw themselves from their responsibility. By exercising their professional autonomy to assign responsibilities, nurses strive to mitigate the power imbalance among residents, their next-of-kin, and themselves, thereby preventing the occurrence of potential power struggles in their relationships [ 34 ]. This proactive approach helps prevent the emergence of end-of-life care dilemmas that could undermine the moral dimension of end-of-life care.

The third phase of care—care giving—requires, according to Tronto [ 35 ], the moral quality of nurses’ competence, meaning nurses directly engaging with care. The findings revealed that the nurses provided end-of-life care, and to do so, they needed to have competence, which implies the nurses having the knowledge, skills and values necessary to know what, why, how and when to provide end-of-life adequately. In addition, good end-of-life care requires the competence to individualise care—to provide competent care based on the resident’s physical, psychological, cultural and spiritual needs [ 57 ] while considering the resident’s context of care. Nurses’ competence is crucial for their autonomy; however, to effectively utilize their competence, nurses must be capable of assessing care needs and responding promptly [ 30 ]. Otherwise, delays in assessing residents’ care needs could undermine the moral dimension of end-of-life care. To provide individualised competent care, it is necessary that nurses make continuous assessments. As the findings reveal, the nurses were concerned with providing competent care, that is, adequate pain management. If the care provided was incompetent and led to more pain for the resident, the nurses perceived psychological distress—a state of being that resulted in response to a variety of moral events—leading to the nurses feeling anger, frustration, guilt, powerlessness and stress [ 58 ]. According to Tronto [ 34 ] (p.17) , ‘incompetent care is not only a technical problem, but a moral one’; however, as the findings reveal, the provision of competent care also depends on the nurses’ ability to prioritise decision-making when standing alone. Although nurses’ professional autonomy enabled them to make decisions and choose the right what , how , how much , when , and why , the lack of adequately educated healthcare personnel make the decision-making process a technical problem, which could weaken the moral dimension of end-of -life care.

The fourth phase—care receiving—involves the moral quality responsiveness. This means nurses being responsive to the reaction of the nursing home residents to end-of-life care process. As the findings have revealed, nursing home residents are vulnerable to nurses’ act of care or lack of care. According to Gastmans [ 59 ], care is a reciprocal practice that occurs within the framework of a relationship between the care provider (nurse) and care receiver (resident). The reciprocity consists of nurses assessing that the care provided actually meets the resident’s needs for pain management and other physiological and spiritual needs. The nurses had to make autonomous end-of-life care decisions to meet the resident’s needs. This involved the nurse’s attention to care giving to not be perceived as power abuse, which could have negative consequences for the moral dimension of end-of-life care provision.

According to Tronto [ 33 ], vulnerability may lead to unequal relationships where power abuse may occur. Nursing home residents are in a vulnerable position because they rely on nurses’ competence and ability to alleviate suffering and assess and reassess the residents’ responsiveness to pain management. To avoid an unequal relationship between resident and nurse, nurses must assess whether the care provided is competent or incompetent. Besides assessing and documenting the care provided and its outcomes, informal discussions between the resident’s next-of-kin and nurses were also assessed as important for next-of-kin perceiving a balanced power and equal position within the relationship. However, because each end-of-life act of care may alter the resident’s state of being, responsiveness requires more attentiveness [ 34 ]. Nurses must therefore meet the resident’s new needs for care with compassion and a commitment to maintaining the highest quality of life throughout the evolving stages of the resident’s end-of-life journey.

The final phase of care—caring with—requires that solidarity and trust are the foundation of all care giving to meet caring needs [ 35 ]. The moral quality of this caring phase is solidarity. The findings from the present study suggest that the nurses felt solidarity with both the residents and their leaders. The nurses felt that they were given the support and freedom to act autonomously when making decisions regarding end-of-life care, but similar to findings from a previous study [ 22 ], they also recognised the impact that organisational factors, such as leadership and care culture, may have on the justice and equality of the care provided when they prioritise care to whom needed it the most. Similar to findings from another study [ 49 ], participants in the present study described autonomy as the ability to make independent decisions and prioritise care for those who needed it most. However, according to Tronto [ 35 ], all nurses have a responsibility to help determine how care activities and responsibilities should be allocated. Residents, their next-of-kin and other healthcare personnel may have different views on how they may perceive appropriate, compassionate and dignified end-of-life care [ 20 , 21 ].Therefore, it is important to have transparency in nurse–resident–next-of-kin relations if the element of power within the relationship should be replaced by trust. Otherwise, the nurses’ autonomy may negatively influence the moral dimension of end-of-life care provided to nursing home residents. By opening the door of the “caring room” and inviting next-of-kin to participate in the care process, nurses may contribute to a greater reflectiveness around what may constitute ‘good’ end-of-life care.

Strengths and limitations

One of the strengths of the study is the use of Joan Tronto’s theory of the ethics of care [ 32 , 34 , 35 ] and its five phases and elements of care to discuss the study’s findings. This allows a deeper understanding of how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. Another strength lies in the utilisation of two distinct methods of data collection: individual and focus group interviews. These approaches provided diverse datasets that shed light on various aspects of how nurses’ professional autonomy impacts the moral dimension of end-of-life care. Furthermore, the inclusion of participants with varying work experiences from four nursing homes enhances the richness and depth of the data generated from the interviews, further strengthening the quality of the study. Member checking ensures that the researcher’s interpretations accurately reflect the participants’ experiences and perspectives, thereby enhancing the validity of the study. This practice can be considered one of the methodological strengths of the study.

The current study has also some limitations that need to be considered. First, a limitation may be related to the size of the participant sample. The sample consisted of only nine nurses, a number that may be seen as a limitation in data collection. To challenge this limitation, the researchers posed follow-up questions during the interviews, thus offering the participants the opportunity to provide rich descriptions of their experiences with end-of-life care. Even though the sample consisted of only nine nurses, these participants reflected on and described their everyday work experiences. The participants’ rich descriptions were evaluated as possessing sufficient information power [ 41 ], thereby enhancing the overall quality of dialogues during interviews– a notable strength.

Second, the findings are limited to these nine participants and their personal work experiences in four different Norwegian nursing homes. This means that the sample is small and context dependent, which may limit the transferability and generalisability of the findings.

A third limitation pertains to the potential influence of the chosen theoretical framework on researchers’ preunderstanding during data analysis. To avoid bias, the theoretical framework was introduced at the end of the data analyses and after the coding process was conducted. The theoretical framework contributed to situating the knowledge from the empirical data into theoretical knowledge and vice versa. However, to be certain about interpretations and knowing that the qualitative nature of the study cannot completely exclude the impact of the preunderstanding on the analysis of the data, both researchers were aware of their theoretical preunderstanding and tried not to make conclusions beforehand.

The ethics of care framework provides opportunities for nurses to analyse their own caring activities during the provision of end-of-life care to nursing home residents. The exploration of the moral dimension of the provision of end-of-life care, utilising Tronto’s theory, revealed that moral qualities, such as attentiveness, responsibility, competence, responsiveness, and solidarity are influenced to a certain extent by nurses’ autonomy. What is crucial for the provision of competent end-of-life care is the nurses’ awareness of acting properly in accordance with the moral qualities to each of the phases of caring. Therefore, to provide competent end-of-life care nurses must be attentive to residents’ care needs, take on the responsibility for the care provided to ensure that residents’ needs are met, provide competent care based on knowledge, skills and values and assess how residents respond to the care provided. In other words, this is the basic nursing process in action, and this problem-solving approach is needed for the provision of competent end-of-life care.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Oslo Metropolitan University.

Abbreviations

Participant in interview [number of the individual interview

Participant [number] in Focus Group interview

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Acknowledgements

We would like to express gratitude to the nurses who participated in this study, thereby contributing to the data collection. Additionally, we extend our thanks to the Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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D.L. contributed to the study conception, data collection, and analysis, and wrote the main manuscript text. R.G. was involved in data collection, analysis, reflection, and manuscript writing. D.L. was responsible for administrative work related to journal submission and was also involved in reviewing and editing the manuscript. R.G. and D.L. have read and approved the manuscript before submission.

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Correspondence to Daniela Lillekroken .

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The Norwegian Agency for Shared Services in Education and Research approved the study protocol (Sikt/Ref. number 360657) and concluded that the study was not subject to the Norwegian Health Research Act (LOV-2008-06-20-44; https://lovdata.no/dokument/NL/lov/2008-06-20-44 ). An English version of the Norwegian Health Research Act can be found at: https://www.uib.no/en/med/81598/norwegian-health-research-act . This study does not aim to get insight into participants’ health status, sexuality, ethnicity, and political affiliation (sensitive information), therefore, no additional approval from a local ethics committee or institutional review board (IRB) was necessary to be obtained to conduct the study. This study was performed according to principles outlined in the Declaration of Helsinki, and in accordance with Oslo Metropolitan University’s guidelines and regulations. Data were kept confidential and used only for this research purpose. The researchers provided verbal and written information about the study. Informed consent was obtained from all participants prior data collection.

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Gilbert, R., Lillekroken, D. Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study. BMC Nurs 23 , 216 (2024). https://doi.org/10.1186/s12912-024-01865-5

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DOI : https://doi.org/10.1186/s12912-024-01865-5

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