Ethical nursing practice means being willing to show moral courage – despite the risks

Develop the confidence to have a say in complex decision-making   

Develop the confidence to have a say in complex decision-making

Tafida Raqeeb's parents outside the High Court, where they successfully defended their
right to take their daughter to a hospital in Italy for treatment Picture: Shutterstock

Healthcare professionals are being asked to address increasingly complex ethical dilemmas as a result of advances in medicine and surgery, and the availability of new drugs in clinical practice. Patients and their families are also increasingly aware of their legal right to be fully informed, and to choose which care and treatments they will and will not receive.

People are now able to survive diseases and trauma that would once have been fatal and to live longer with serious conditions. However, healthcare professionals know some survivors experience a poor quality of life as a result of interventions. This creates a tension if a family demands access to all available treatments in order to prolong the life of their loved one.

High-profile cases and potential tensions with families

In October, Tafida Raqeeb’s parents won the right in court to keep their daughter on life support and take her to Italy for treatment. The healthcare team at the Royal London Hospital had decided it was in Tafida’s best interests for treatment to be withdrawn because she had no prospect of recovering, and was not aware.

There have been many other, equally high-profile cases where disagreements between families and healthcare professionals have ended up in court.

‘Too often, nurses still defer to doctors on decisions about patients. This must change’

Competent, fully informed patients sometimes make decisions judged by healthcare professionals not to be in their best interests; for nurses and other healthcare professionals, having to provide care in these situations can be difficult.

Ethical distribution of scarce healthcare resources

Another ethically complex issue is deciding which drugs and treatment should be available on the NHS. We have insufficient healthcare resources and they should be distributed justly. How is this to be achieved? Who should receive treatment and care? Who should wait? Who should not receive treatment and care?

Nurses have a duty to address the many ethical issues they encounter every day. These decisions are often difficult and some nurses may feel inadequately prepared to participate in decision-making.

Nurses should assert their equal status in the multidisciplinary team

An important first step is for nurses to recognise themselves as essential members of the multidisciplinary healthcare decision-making team. Too often, nurses still defer decisions about patients to doctors. This must change.

Nurses are in constant contact with patients, which means they are most likely to have a genuine understanding of their needs and wants.

‘A willingness to face uncomfortable realities, and operate outside your comfort zone, is an important part of ethical practice’

Nurses need to have the confidence to share their insights with other members of the healthcare team, and with policymakers, when patients, relatives and/or carers are unable to do so effectively. It is the nurse who provides most of the treatment prescribed alongside nursing care. Clearly, the nurse must be part of the decision-making process.

Understanding the theory behind ethical decision-making

Nurses can fulfil this important role by equipping themselves with an understanding of ethical decision-making theory. This means becoming familiar with ethical decision-making frameworks such as deontology (an action is right if it adheres to the agreed series of rules), utilitarianism (an action is right if it promotes the greatest happiness for of the greatest number) and the four principles approach (autonomy, beneficence, non-maleficence and justice).

They should actively explore their own values, beliefs and opinions and listen to and reflect on the decisions and opinions of others.

Employers also have a responsibility to provide training to broaden their staff’s knowledge and understanding of ethical dilemmas in practice.

When decisions are made based on sound ethical reasoning, healthcare professionals and patients often arrive at different answers due to their differing personal values, beliefs, cultural influences, religious beliefs, knowledge and experiences. This can be uncomfortable for healthcare professionals but they should recognise that it is normal. Indeed, a willingness to face uncomfortable realities, and operate outside your comfort zone, is an important part of ethical practice.

Ethical practice often requires nurses to have the courage to step outside their comfort zone 
Picture: iStock

Unsafe staffing is an ethical issue

Nurses should be willing to speak out and challenge what they consider to be unethical practice. Sometimes this will mean speaking up for the patient when family members wish treatment to continue that may not be in the patient's best interests. But it can also mean speaking up when staffing shortages mean that patient safety is being put a risk.

‘Moral courage is the pinnacle of ethical behaviour – it requires commitment to fundamental ethical principles despite potential risks’

The first principle of ethical decision-making is and has always been to do no harm. A principle at the core of the NMC Code of Conduct (2015) is that nurses need to exhibit moral courage.

Morally courageous nurses are prepared to face difficult decisions and confront the uncertainties and consequences of their resolve to do the right thing. 

Moral courage in the face of risk to reputation, team cohesion, and even your job

Moral courage is the pinnacle of ethical behaviour; it requires a staunch commitment by the individual to uphold fundamental ethical principles despite potential risks. These risks might include threats to reputation, shame, emotional anxiety, isolation from colleagues, revenge and loss of employment.

The ethical dilemmas in healthcare that attract the most media attention are usually those highly emotive cases involving disagreements between patients or their families and healthcare teams, or controversies about the funding of treatments or drugs. Often patients are on one side of the argument and the professionals are on the other. But ethical practice is about so much more. It is about nurses having the moral courage to ensure patients receive the management and care they deserve and choose.

Karen Sanders is senior lecturer at the School of Health and Social Care, London South Bank University, and chair of HSC ethics committee


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