How do nurses balance patient care and ethical dilemmas?

Whether it’s concerns over patient confidentiality or a conflict between a patient’s wishes and giving them a life-saving treatment, nurses will face many ethical challenges in their careers. Sarah Harrop looks at how nurses can best balance patient care and ethical dilemmas while looking after their own wellbeing.

A teenager has tested positive for a sexually transmitted infection but doesn’t want his mum to know - so do you breach his patient confidentiality and tell her anyway?

An elderly man with diabetic ulcers has been advised by the doctor to have his foot amputated but his wife says to you that she thinks her husband has been tricked into losing his foot because the doctor is tired of treating the wounds.

You notice that a nursing colleague with whom you have a close bond has forgotten to do a vital blood test for a patient ordered by the doctor. What do you do?

There are many difficult situations that nurses may face in the course of their nursing career. Having a good grasp of ethics is essential for grappling with these dilemmas and navigating to a solution.

Ethics are the moral principles that dictate how we conduct ourselves. While they’re essential for all healthcare workers, medical ethics in nursing are particularly important because nurses are primary caregivers who have more contact with patients than any other healthcare professionals.

Four principles of biomedical ethics, first outlined by Beauchamp and Childress in their 1979 book Principles of Biomedical Ethics, are the cornerstone of today’s clinical ethics. As such, they have been adopted by the American Nurses Association (ANA) as the ethical principles that every nurse should be aware of in their daily nursing practice in order to provide high quality, safe care for patients. The ethical principles are:

Autonomy - upholding a patient’s right to make decisions about their own care.
Beneficence - doing what is in the patient’s best interests.
Justice - ensuring fairness in all medical and nursing healthcare decisions and care, regardless of a patient’s financial situation, race, religion, gender, and/or sexual orientation.
Non-maleficence - doing no harm, in particular choosing interventions and care that will cause the least amount of harm to achieve a good patient outcome.

Here in the UK, the Nursing and Midwifery Council (NMC)’s ethical framework for nurses and allied healthcare providers has similar themes, but its four main aspects are to:

Ethical issues in nursing

“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 behaviour. It is essential that all nurses develop and implement ethical values into nursing practice,” explains nurse and Allied Health educator Darby Faubian, on NursingProcess.org.

According to Faubian, there are five main reasons why nurses face ethical dilemmas in clinical practice:

1. Patients or family members must make life or death decisions: for example, if a person with terminal cancer has signed an advanced directive including a ‘Do Not Resuscitate’, nurses must balance trying to comfort and counsel loved ones while honouring the patient’s wishes.

The patient refuses medical treatment: eg, a pregnant woman with a life-threatening heart condition is advised by clinicians to terminate her pregnancy because of the risk to her health, but she refuses to do so. This scenario brings the principles of autonomy and the principles of beneficence into conflict with one another.
Nursing assignments may contradict cultural or religious beliefs: for example, a road traffic accident victim who is in urgent need of a blood transfusion, but refuses it because receiving one goes against his religious beliefs as a Jehovah’s Witness. In this bioethics dilemma, the patient’s wishes are in direct conflict with providing the best treatment option to keep them alive.
Nursing peers demonstrate incompetence: perhaps you notice a colleague has forgotten to do a patient’s blood test ordered by the doctor. Nurses often develop close relationships with their peers, which makes deciding to report errors or omissions difficult, however patient wellbeing and safety must always be a nurse’s priority.
Inadequate staffing: for example, when there are far more patients on a ward than each nurse can safely care for, this can pose a considerable risk to patient safety.

Nursing is about patient-centred care; caring for the whole human being while meeting the ethical obligation to preserve and respect the patient’s dignity and human rights. But unfortunately in today’s healthcare systems, the increasingly heavy workloads and time pressures within can challenge nursing healthcare professionals’ ability to act on ethical and moral grounds in individual care situations, says a study published in the Nursing Ethics journal.

Common examples of ethical challenges in nursing

Ethical dilemmas in nursing create a conflict between one course of action and another that are both correct but represent different ethical principles or values. When a situation involves doing something right and wrong at the same time and one action has a negative impact on the other, an ethical dilemma emerges.

One 2019 literature review analysed 15 original, empirical studies of nurses’ experiences of ethical dilemmas in their daily work across 12 different countries. Some of them included:

Being close to the suffering or death of people, eg during palliative care/end-of-life care
Uncertainty as to how to express their feelings
Concerns about patient privacy
Worries about infringing on child patients’ autonomy when providing cancer care or deciding the appropriate treatment level
Dealing with conflicting perspectives on a patient’s care within healthcare teams
Feeling powerless to manage the complex emotional needs of patients and relatives
Providing unequal medical care
Uncertainty over who is the primary carer during the decision-making process
Conflicts with other health professionals and staff members.

Coping mechanisms for difficult ethical situations

So how can nurses manage to take these challenging ethical considerations in their stride while looking after their own wellbeing as well as their patient’s needs?

A qualitative study on how expert nurses in South Korea cope with challenging ethical decision-making by Kim and colleagues, published in BMC Nursing showed that most nurses in the study coped with challenging ethical situations by “being faithful to the nature of caring.” They did this through monitoring and correcting their own ethical insensitivity, being open and maintaining honesty, and actively acting as an advocate.

The paper also concludes that there should be system-wide counselling and interventions for those nurses who have experienced ethical difficulties.

“As a nurse, you probably face ethical dilemmas that challenge your decision-making and leave you feeling stressed and alone. Even worse, there's seldom an easy answer to the many sad or difficult situations you encounter in healthcare,” says registered nurse Alice Blackmore, writing for Shiftmed.

She advises that it is possible to make it easier to navigate these ethical dilemmas in nursing by preparing for different situations mentally and professionally. Blackmore has these tips for nurses to navigate ethical conflict in their work:

Use your moral and ethical values help you recognise and deal with ethical dilemmas and don't wait for a challenging situation to develop before doing an internal audit and analysis.
Know your professional nursing ethics and professional responsibilities by reading and keeping to hand the Nursing and Midwifery council Code of Ethics for Nurses and using it to guide your ethical decisions.
Get familiar with Utilitarianism (sacrificing one person’s health for the health of many) and Deontology (never cause harm to any patient regardless of the consequences) —these are two ethical nursing theories that direct healthcare decision-making and the solution to many ethical dilemmas lies between them.

However, it’s important to note that some ethical concerns are so grave that they must go to ethical committees for further direction and support, Blackmore adds.

Take your nursing career to the next level

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