Nurses Hope to Build on Ethics Blueprint

Fifty leaders in nursing ethics, education, and research from across the nation have created a blueprint for nursing ethics that they hope will allow the profession to adhere to ethical standards in 21st century working environments. In an August 2014 National Nursing Summit meeting on Nursing Ethics for the 21st Century sponsored by the Johns Hopkins School of Nursing and the Johns Hopkins Berman Institute of Bioethics, the leaders discussed ways in which they could change health care environments and, ultimately, health care culture, to allow nurses to practice more ethically. The discussion led to the creation of a blueprint for 21st century ethics that focused on the intersection of nursing and ethics in the domains of clinical practice, education, research, and public policy.

Ethical Challenges

The leaders believe that the day-to-day activities of nurses have a significant impact on improving care experience, reducing health care costs, and improving population health. In filling their important roles, nurses face ethical challenges every day. Summit attendees discussed “What Keeps Nurses Up at Night?,” as well as ethical challenges facing the profession. They discussed disparities in care given among patients, including racial and ethnic groups, and the need for cultural competence to at least ask patients what they need and “listen for the unspoken things.” They mentioned the phenomenon of too much end-of-life care that prolongs the suffering of patients, as well as difficulties that arise when patients express a desire for limited care to their nurses, but are unwilling to express those feelings to their families or other medical team members. Inadequate staffing, as well as a culture that doesn’t support nurses and allow them to provide quality, safe care were also common responses. One nurse opined, “We come to the work prepared to see pain and suffering, and so there are times when, when it seems like too much, it probably is too much.”

The existence of day-to-day ethical challenges was one of eight key assumptions upon which the summit proceeded. Others included the tenet that many ethical pressures arise not from a scarcity of resources, but from “resource allocation decisions and waste,” the urgency of the need to strengthen nursing’s ethical foundation, the existence of moral distress for nurses who are blocked from translating their moral choices into action, and the impact that efforts to improve the ethical environment have on patient care.

Plan for Improvement

Four separate work groups at the summit contributed to the blueprint by suggesting ways to improve ethics in four domains. With respect to the clinical practice domain, the blueprint calls for the development and sustainment of working environments that support ethical practice. As a first step to ultimately shifting the ethics approaches of organizations, their leaders, and individual nurses, the blueprint recommends defining and describing ways that workplaces currently fail to achieve the goal and suggesting improvements. In the nursing education domain, educational programs need to shift their “scope, priority, design, and evaluation.” Information regarding ethics teaching should be gathered and ethical expectations for students should be raised.  The nursing research domain emphasizes the creation of a measurable, evidence-based research agenda. The work group suggested surveying American Nurses Association (ANA) membership and medical center leaders regarding important areas for research and developing tools and metrics to measure ethics-related outcomes.  In the nursing policy domain, the blueprint calls for the promotion of care excellence and civility in working environments, professional integrity, and courage, among other priorities, at an institutional level. The work group recommended the creation of a central resource of existing standards, guidelines, and best practices and the inclusion of ethical concepts in nurse credentialing board activities.

Over the course of the next year, Summit participants will engage in a campaign to disseminate the blueprint and prepare for the launch of the ANA revised code of ethics in June 2015.  They hope that the blueprint will lead to improved working environments and, eventually, to an improved health care culture.  One Summit attendee stated that the greatest ethical challenge facing nurses today “is to speak up and to stay.  There are a lot of nurses who leave, and there are a lot of nurses who stay physically, but they have checked out of their purpose and their passion and their idea of what it means to be a nurse.”  Time will tell whether the blueprint can offer them support and reignite their fire.