“Chapter 1 Nursing Ethics: Developing a Moral Compass for Leadership” in “Toward a Moral Horizon”
CHAPTER 1
Nursing Ethics: Developing a Moral Compass for Leadership
Rosalie Starzomski, Janet L. Storch, Patricia Rodney, and Nancy Clark
“Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent, and ethical practice.” (Storch et al., 2002, p. 7)
NURSES HAVE THE RESPONSIBILITY TO ENSURE that their practice is not only technically and clinically competent, but also ethical. At the heart of ethical practice in any field is understanding what is happening, what ought to happen, and how to navigate the difference. Many of these responsibilities are articulated in professional codes of ethics, standards for nursing practice, and health care regulatory guidelines.
The focus of advanced practice nurse leaders on ethics in health care has not been consistently visible. For example, a leading American nursing ethics scholar, Marsha Fowler, (2017) published a philosophical paper called “Why the History of Nursing Ethics Matters,” arguing for the importance of nursing’s unique ethical heritage, and the need for preservation of that history. With Fowler’s insights in mind, our premise throughout this chapter—and this book overall—is that for advanced practice nurse leaders, other nurses, and health care providers (HCPs), ethical action necessitates moving toward “the oughts” of ethical practice. This is true for ethical action that takes place for individuals, families, communities, and larger systems at local, provincial, and national levels.
A key element of ethics for advanced practice nurse leaders is social justice. Drawing on the work of Iris Marion Young (1990), social justice means understanding and addressing how members of communities experience oppression in different ways as a result of structural inequities. A multi-layered approach by nurses can avoid an otherwise narrow focus on individuals when socio-political contexts, such as poverty and immigration experiences, are ignored. Canadian nursing policy expert Michael Villeneuve (2017) warned that “politically, the [nursing] profession punches below its weight,” and that our “country is worse for it” (p. ix). Advanced practice nurse leaders in Canada are well positioned to increase their support for individuals, families, and communities; therefore, we have written this chapter to support the ethical practice of these nurse leaders.
Our intent in this chapter is to foster a relational understanding of persons, whereby we acknowledge that people are located in unique and multi-faceted socio-political and cultural contexts (Hartrick, Doane & Varcoe, 2007). We adopt a relational understanding of social justice for nursing leaders as we consider moral philosophies of social justice and ethics of care. Leading Canadian ethicists describe a relational approach to ethics as including mutual respect, engagement, and embodied knowledge (Bergum & Dossetor, 2005). Relational ethics provides a means of attending to inequities experienced by people related to privilege and discrimination, which impair their health (Baylis et al., 2008). An ethical goal of nurses in advanced practice roles is to understand, and ultimately address, the cumulative effects of inequities at individual (micro), organizational (meso), and larger societal (macro) levels, particularly for those who are marginalized, or who are at risk of being marginalized.
In what follows, we focus on ethical theory and practice in health care and nursing. In doing so, we provide a brief review of the history of health care ethics, relational ethics, and nursing ethics. We commence by summarizing the evolution of health care ethics. We then address the concomitant evolution of nursing ethics, including how nursing ethics is informed by a critical social justice perspective. This perspective includes intraprofessional and interprofessional practice and collaboration, ethical leadership, and relational practice. An exploration of related areas of ethical skill development for advanced practice nurse leaders—specifically in regard to ethical decision making—is included. This review is not meant to be exhaustive, as many theoretical perspectives are expanded and integrated in other chapters of this book.
In the latter part of this chapter, we include ethical decision-making frameworks and four case scenarios to assist readers to apply ethical analyses, develop their ethical decision-making and consultation skills, and generate related recommendations for action at the micro, meso, and macro levels of the health care system. We highlight the importance of promoting social justice for individuals, groups, and communities in the ongoing development and application of nursing ethics in Canada. By focusing on social justice, we join colleagues who have, over time, warned that inequities in access to appropriate resources lead to serious disparities in the lives of many people (Anderson et al., 2009; Clark & O’Mahony, 2021; Fraser, 1999, 2001; Young, 1990).
A Brief Overview of Health Care Ethics1
For nurses and other HCPs to effectively engage in ethical practice that fosters the health and well-being of patients, families, and communities, they need to analyze and apply the beliefs and values that underpin their practice, including the values-based theories they use (Rodney et al., 2013). As Canadian ethicist Michael Yeo (2020a) reminds us, it is important for HCPs to appreciate and understand ethics, where the focus is on theories of right and wrong, and includes normative standards for conduct (Fry & Johnstone, 2008). It is also important for HCPs to appreciate and understand morality, where the focus is more specifically on the moral ideals of individuals and their judgments about what ought to happen in particular circumstances and contexts (Yeo, 2020b). HCPs enact morality in personal, societal, and group practice contexts (Doherty & Purtilo, 2016).
The study and application of ethics and morality have long and multi-faceted histories, which have been influenced over time by societal change and theoretical developments in philosophy and theology. HCPs have incorporated these developments into their practice to help determine their most appropriate moral actions in challenging clinical circumstances (Rodney et al., 2013). The application of ethical theory continues to help HCPs to “systematize moral intuitions, values, and principles in a consistent framework or to root them in a common ground” (Yeo, 2020b, p. 39). In so doing, such theory helps HCPs to enact what Yeo refers to as the “oughtness” of health care practice—that is, to consistently work towards values-based goals.
Some ethical theories that have particularly influenced the development of contemporary health care ethics include deontology—acting in a manner that universally focuses on the well-being of the individuals involved; utilitarianism—focusing on the practical effectiveness and consequences of actions and policies; and contractarianism—promoting fair distribution of goods and services, particularly for those who are in need (Rodney et al., 2013).
Other theoretical perspectives relevant to ethics include virtue theory, natural law, and human rights. Virtue theory was strongly influenced by philosopher Aristotle and theologian Thomas Aquinas. Virtue theory can assist HCPs to reflect on and enact virtues in living a moral life (Rodney et al., 2013). Natural law is an approach society has inherited from theology, and provides moral guidance in accordance with theological approaches to understanding and acting on rationality and nature (Rodney et al.). Human rights are often addressed in Western societal discourse and constrain powerful individuals from overriding certain interests of less powerful individuals. Legal theorists in particular are known for contributing to the articulation and actualization of human rights (Rodney et al.). Further, human rights are foundational to research ethics, where there must be a significant focus on protecting the rights of patients and research subjects (Sherwin, 2011).
Notwithstanding the evolution in the development and application of ethical theory noted above, it is also important for nurses to pay attention to a caution from Fowler (2017), who suggested that the rapid and enthusiastic adoption of ethical theory from other disciplines risked overshadowing the moral identity of nurses. Fowler further warned that as nurses share ethical insights and progress with colleagues in other health care disciplines, they ought to be clear about the unique ethical history and identity of nursing. This history and identity entail a significant focus on social justice, including addressing oppression in society (Clark & O’Mahony, 2021). As authors of this chapter, we believe that advanced practice nurse leaders are well positioned to study, apply, and further develop ethical theory for nurses.
The Development of Nursing Ethics as a Field of Inquiry
As the field of health care ethics has evolved, so too has the field of nursing ethics. In what follows, we highlight the contributions of several of the early nurse theorists in ethics. We acknowledge that this is not an exhaustive review of all the contributors to the field of nursing ethics, in North America or worldwide.
One early contributor to the field of nursing ethics was Virginia Henderson, from the United States (US), who, in her groundbreaking 1966 book, The Nature of Nursing: A Definition and Its Implications for Practice, Research and Education, articulated that human needs were the central focus of nursing practice, and that nurses should care for patients until they could care for themselves. In her words, “patient care should be individualized … the nurse will seek constantly to help the patient meet [their] needs and live as normally as possible” (p. 31). It is our belief that Henderson’s articulation of the nature of nursing helped to create an understanding of what nursing ethics ought to entail.
As nurse theorists continued to explore and write about nursing theory, it became clear that direction for ethical nursing practice was also required. In 1980, a Canadian pioneer in nursing ethics, Sister M. Simone Roach, oversaw the development of the first code of ethics for registered nurses in Canada. Further, she developed an influential theory of caring, and wrote a pivotal book about this concept, The Human Act of Caring: A Blueprint for the Health Professions (1987).
In 1982, Janet Storch, one of the authors of this chapter, wrote a book entitled Patients’ Rights: Ethical and Legal Issues in Health Care and Nursing (1982). This was one of the first books written by a nurse ethicist in Canada. In it, Storch described the role of nurses and other HCPs concerning patients’ rights. She spelled out what the expectations should be for all nurses and people in care, based upon what were envisioned as consumer rights of the day; for example, the rights to be informed, to be respected, to participate in decision making, and to have equal access to care.
Another nurse scholar who led the way in developing nursing ethics was Sara T. Fry from the US. In the early days of nursing ethics as a field of study, she sought to differentiate nursing ethics from the rapidly evolving work in medical ethics and health care ethics, noting that the evolution of nursing ethics was initially too dependent on theories of medical ethics (1989). Fry built on the work of other nurse scholars who were addressing nursing ethics, and included perspectives from feminist theorists, such as Gilligan (1982) and Noddings (1984), as well as the perspectives of physician ethicist Pellegrino and philosopher Thomasma (1988). Fry argued that instead of relying solely on contemporary theories of medical ethics, the nursing profession ought to focus on caring as a core ethical value. In addition, she claimed that caring must be grounded by focusing on people rather than on abstract and idealized notions of moral actions. It is important to note that over time, Fry’s theorizing about nursing has had a significant impact on the evolution of nursing ethics. She inspired nurses, including some of the authors of this chapter, to engage in scholarship regarding nursing ethics.
Another important contributor to the field of nursing ethics was Patricia Benner, from the US, who published a pivotal book titled From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1990), where, based upon dialogue with nurses, she described how nurses acquire nursing knowledge, competence, and skill. Benner noted that too much attention had been given to role relationships and socialization in nursing practice and too little to nursing ethics and actual nursing practice; that is, “the knowledge embedded in actual nursing practice, that accrues over time in the practice of an applied discipline” (p. 1).
Nursing research and scholarship related to nursing ethics have continued to evolve. In 1996, Verena Tschudin, a nurse from the United Kingdom, made a significant contribution to the nursing ethics world by founding the journal Nursing Ethics: An International Journal for Health Care Professionals.2 Tschudin also published the books Deciding Ethically: A Practical Approach to Nursing Challenges (1994) and Nurses Matter: Reclaiming our Professional Identity (1999). In her 1994 book, Tschudin provided ten cases based upon a range of principles, such as truth-telling, justice or fairness, and honesty, demonstrating approaches to their ethical resolution. In her 1999 book, she explicated the link between ethics and power, and how power is used. She used the approach of outlining, then discussing, what should matter in ethical practice.
Another nurse ethicist from the UK, Ann Gallagher, has contributed greatly to the evolution of nursing ethics. She became editor-in-chief of Nursing Ethics: An International Journal for Health Care Professionals, following in the footsteps of Verena Tschudin. Her writing and scholarship in the field of nursing ethics are clearly articulated and influential. For example, she has written about the state of nursing ethics and the role of the International Council of Nurses, and she has also written a number of editorials related to moving the field of nursing ethics forward. In one editorial, she made a major contribution when she focused on providing care during the COVID-19 pandemic, and described the experience of families separated from their loved ones during the pandemic (Gallagher, 2021).
Marsha Fowler, from the US, is another leader in nursing ethics. She has published extensively about ethics in nursing, religion in nursing, health disparities, and health policy in global health. She has written several editions of an important book about nursing ethics titled Ethical Dilemmas in Nursing Practice with co-authors Anne Davis and Mila Aroskar (Davis et al., 2010). She also published a book about religious ethics and nursing with three co-authors, Sheryl Reimer-Kirkham, Richard Sawatsky, and Elizabeth Johnston Taylor (Fowler et al., 2012). Her leadership in nursing ethics has included working with the American Nurses Association (ANA) to develop material such as a Guide to the Code of Ethics for Nursing: With Interpretive Statements: Development, Interpretation, and Application (Fowler, 2015a) and a Guide to Nursing’s Social Policy Statement: Understanding the Profession from Social Contract to Social Covenant (Fowler, 2015b).
Writing by scholars about nursing ethics has proliferated, and nursing ethics texts, focused primarily on the education of undergraduate nursing students, have been developed. For example, in the US, authors such as Davis et al. (2010), Doherty and Purtilo (2016), and Fry and Johnstone (2008) have written textbooks that have been used widely. In Canada, Yeo et al. (2010, 2020c) have written a textbook that has been used extensively in undergraduate nursing programs. For graduate nursing students, Storch et al. (2004, 2013) developed and edited two previous editions of Toward a Moral Horizon: Nursing Ethics for Leadership and Practice.
The development of nursing ethics has been enriched, as well, by colleagues in other professions. Nurse ethicist Vangie Bergum and physician ethicist John Dossetor wrote about relational ethics in their book titled Relational Ethics: The Full Meaning of Respect (2005). This book has had a significant impact on the evolution of relational approaches to ethics. Baylis (a philosopher), Kenny (a physician ethicist), and Sherwin (a philosopher) (Baylis et al., 2008) have individually and collectively written extensively about the theory and application of health care ethics. A particular focus of their collaborative work was on relational ethics, where they addressed ethical theory not just in abstract terms, but in terms of the relationships and power dynamics that constrain or foster individual and collective well-being.
As nursing scholarship about ethics, including the concept of caring, proliferated, thoughtful and constructive analyses of nursing ethics began to emerge. In 2004, nurse scholars Joan Liaschenko (from the US) and Elizabeth Peter (from Canada) co-wrote a paper discussing the limitations of contemporary understandings of nursing and nursing ethics, subsequently arguing for a conceptualization of nursing as work that profiles and analyzes the value of nursing’s intellectual and manual labour. In continuing their focus on what nurses ought to do, and how, Liaschenko and Peter, as well as other nurse scholars such as Storch et al. (2013), focused on nurses as moral agents; that is, as individuals who have the capacity to recognize, deliberate, reflect, and act on moral responsibilities. Peter offered a thoughtful analysis of how nurses could foster social justice by working through a socially connected model of moral agency:
Because social justice concerns primarily social groups and their relative positioning, as opposed to individuals outside of group membership, a conceptualization of moral agency as a social or collective construct is useful in terms of thinking about effecting social change. (2011, p. 13)
Peter’s analysis is insightful and inspiring. Fabienne Peter (2004), a theorist from the United Kingdom writing on social justice, added the complementary insight that justice entails the premise that “to be able to pass a judgement on social inequalities in health, we need an understanding of the underlying causes” (p. 104). In other words, nurses ought to attend to the individuals they encounter in their practice, and pay attention to the wider relational contexts affecting those individuals. This broader view includes, for example, the familial, socio-political, and environmental strengths and challenges affecting all levels of context for individuals, families, and communities. A commitment to social justice is foundational to ethical nursing practice (Anderson et al., 2009), and is supported by a concomitant commitment to relational practice. Integral to these commitments is an understanding of human rights and social justice.
Nursing Ethics: Human Rights and Social Justice
Social justice is a concept that originated in philosophical discourse and is widely used across the social sciences and in ordinary language (Jost et al., 2010). The idea of social justice concerns a moral commitment to ensure that opportunities, resources, and privileges are fairly and equitably distributed between people within a society (Anderson et al., 2009; Cook et al., 2019). Nursing has a long history with roots in social justice work; in fact, the inclusion of broad social contexts and client-centred approaches can be found across nursing’s various communities of practice, from institutional to community settings (Clark et al., 2015).
At the heart of nursing’s ethical commitment to social justice is the client, who is nested in a social and ecological environment. By considering social justice, nurses affirm a moral commitment to redress inequities and provide resources for health and health care access (Rodney et al., 2009). A growing body of research in nursing and the health sciences over the past decades has made it increasingly clear that social determinants of health have a major impact; yet social justice in nursing remains a work in progress (Anderson, 2009; Clark, 2015; Rodney et al.). For example, it is often unclear how codes of ethics can provide direction for nurses about social justice aims when they are making ethical decisions. Given the complexity of health care and structural vulnerabilities associated with systemic social exclusion, nurses need direction about social justice in order to foster a responsive health care system. This system should make space for nurses to take social action to help to redress systemic processes of exclusion directly affecting the health and well-being of communities and populations.
All nurses ought to have a mandate to enact their ethical commitment toward social justice. Advanced practice nurse leaders, including clinical nurse specialists and nurse practitioners, are in leadership roles where they are required to meet the complex health needs of Canadians in a wide variety of settings, and contribute to the development of a sustainable, efficient, and effective health care system (Canadian Nurses Association [CNA], 2017). From an advanced practice nursing perspective, the ethics of everyday practice is not devoid of social justice issues. Young (1990) has argued that oppression “is structural and occurs through systemic constraints on groups that are not necessarily the result of the intentions of a tyrant, rather … its causes are embedded in unquestioned habits, norms and symbols, in the assumptions underlying institutional rules and the collective consequences of those rules” (p. 41). Thus, advanced practice nurse leaders are uniquely positioned to mitigate not only the inequalities and inequities that pertain to their clients, whether they be patients, families, groups, or communities, but also the policies which sustain and underpin the root causes of health and health care inequities. In this sense, social justice can be viewed as an ethical imperative that is not apolitical. It can be defined as a normative practice of “political accountability” (Clark et al., 2015).
Diversity and Complexity
Our world is increasingly divisive, based on longstanding national and international inequalities. These inequalities include increased health disparities and social inequities at the intersections of race/ethnicity, class, gender, (dis)abilities, and sexual identities, as well as systemic processes of social exclusion, racism, and human rights abuses. The people who experience the most health disparities are the structurally vulnerable; that is, people who experience social exclusion and oppression based on, for example, racism and classism. Vulnerable groups also experience more complex care needs and multiple morbidities, such as chronic illness, mental health concerns, addictions, and issues of poverty and homelessness (Stafford et al., 2017; Stajdhuhar et al., 2019). These inequalities have become more apparent as a result of the impact of COVID-19 and the subsequent challenges of accessing and delivering health care. Historically, structural inequalities have excluded access by social groups to resources that support their health and well-being. With input from a variety of stakeholders, there is a growing move in Canada to address such inequalities. This includes continuing to engage in a truth and reconciliation process where nurses and other HCPs can be part of addressing the social injustices experienced by the Indigenous Peoples of Canada.
Equity
One of the goals of social justice is to work towards equity. By equity, we refer to the policies and practices which take into consideration the social determinants of health, so that people who are structurally vulnerable can access and receive appropriate care. Political feminist scholars Iris Marion Young (1990) and Nancy Fraser (1999, 2001) have drawn attention to expanding the notions of justice and equity. They argued for not only a (re)distribution of social goods and services, but also for social justice, including the recognition of difference and the systemic exclusion of non-dominant groups in policy decision making. Fraser highlighted the need to recognize differences between social groups, which is fundamental to the notion of equity.
Jost and colleagues (2010) delineated three broad sets of criteria for social justice as a potential framework for consideration: (a) benefits and burdens in society are dispersed in accordance with some allocation principle (or set of principles); (b) procedures, norms, and rules that govern political and other forms of decision making preserve the basic rights, liberties, and entitlements of individuals and groups; and (c) human beings (and perhaps other species) are treated with dignity and respect, not only by authorities but also by other relevant social actors, including fellow citizens. In order to operationalize nursing leadership in advanced practice settings, a relational approach across micro, meso, and macro levels could strengthen a socially just health care system. As was noted earlier in this chapter, nursing practices across these levels intersect and are interrelated.
Values of equality can be seen in the distribution of benefits and burdens in society. However, Young (1990), Fraser (1999, 2001), and Reimer-Kirkham and Browne (2006) suggested that a broader framework for understanding social justice needs to extend beyond a distributive justice paradigm. This requires an analysis of the root causes of social inequities. Reimer-Kirkham and Browne stated that “with associated marginalization, one begins to see sustained intergenerational patterns of ill health and human suffering not as examples of poor individual choices or flawed social communities, but as the results of diminished life opportunities that have systematically … been denied through complex institutional policies” (p. 335). The challenges with distribution policy are evident when examining access to primary health care services, which are intended to be the first point of contact to the health care system. Under an ideal distribution model, it is assumed that everyone can access health care despite, for example, their education level, language, health literacy, gender, and socio-economic status. However, many communities remain without access to primary health care, based on that complex array of circumstances. Thus, distribution of benefits and burdens must reflect the differences and differential impacts of health experienced within society, particularly the systemic exclusion of non-dominant groups (Clark & O’Mahony, 2021).
Advanced practice nurse leaders ought to consider caring as a moral imperative. Care ethics, as a political and moral philosophy, can provide a lens to examine values and practices associated with social justice and advanced practice nursing. Engster (2014) argued that “care is the other half of health care that has been almost completely ignored in normative discussion of health policy but provides the best reason […] to continue subsidizing comprehensive health-care services” (p. 156–157).
A focus on social justice should be taken up not only by individual nurses, but also by professional nursing associations. Indeed, the CNA (2017) highlighted that
Nursing ethics is concerned with how broad societal issues affect health and well-being. This means that nurses endeavour to maintain an awareness of aspects of social justice that affect the social determinants of health and well-being and to advocate for improvements. Although these elements are not part of nurses’ regulated responsibilities, they are part of ethical practice and are important educational and motivational tools for all nurses. (p. 3, emphasis in original)
The ethics of everyday practice requires a relational and intersectional approach, in which the everyday is not devoid of social determinants of health, and therefore, engaging in political action, advocacy, and reflexivity is also a necessary component of nursing ethics. Given that ethics is an everyday practice, nurses ought to engage in political decision making and action to preserve the basic rights of society and health.
Health care is a human right, and lack of access to it needs to be seen as a serious form of injustice. The CNA (2017) has emphasized that nurses ought to use their individual agency to promote justice. However, this framing is not sufficient for contemporary nursing practice, and may not be useful to address the intersecting social and political dimensions of health and illness in a complex health care system (Pauly & Storch, 2013). In this context, it remains a moral imperative that advanced practice nurse leaders and nurses across all settings engage in collective reflexivity and advocacy. The CNA (2017) stated that
Advocacy refers to the act of supporting or recommending a cause or course of action, undertaken on behalf of persons or issues. It relates to the need to improve systems and societal structures to create greater equity and better health for all. Nurses endeavour, individually and collectively, to advocate for and work toward eliminating social inequities.” (p. 5, emphasis added)
This means that taken-for-granted ideologies, such as historical, political, and social processes, must be problematized or critiqued to develop a socially just set of competencies. Thus, reflexivity and advocacy are used to deepen understanding, and also to promote action toward health care practices that foster socially just health care (Clark et al., 2015).
Promoting justice and fairness and the public good has too often been narrowly constructed through a justice lens, without full integration of social justice, which helps nurses to respect diversity regardless of characteristics such as age, mental or physical (dis)ability, race, gender, gender identity, gender expression, and sexual orientation, in order to uphold the dignity of all. In addition, social justice must also include respect for diverse ways of knowing, doing, and being. There is a need to decolonize ethics to consider respect, reciprocity, and relationality (Wilson, 2008). When nurses use relational approaches to social justice they move beyond mere recognition of difference to understand the impact of social connections on political and social policies, including policies in health care. Further, principles of respect should include acknowledgement of the impact of the social determinants of health on Indigenous Peoples, and moreover, must also include respect for relational ways of being and knowing. Decolonizing nursing ethics requires that nurse leaders develop and use a moral compass that includes these principles of respect.
In order to use such a moral compass, nurses need to have moral courage. Moral courage has been described by Indigenous scholars as a concept originally developed within psychology to mitigate the impacts of colonization amongst Indigenous youth (Brendtro et al., 2019). Moral courage and relational ways of being can be used to promote ethical competencies and virtues for nurses. Advanced practice nurse leaders must be aware of the impacts of colonization on nursing practice and have the courage to change their practice when needed.
In continuing to examine social justice, it is important to consider some of the current ethical challenges in public health—for example, providing nursing care during a pandemic. As we noted at the outset of this chapter, Kenny et al. (2010) challenged a dominant individualistic ethics framework and summarized relational concepts that inform our re-visioning of public health ethics. Public health practitioners address the health needs of communities and populations through actions that are taken at social and political levels, which means there is a need to address the social nature of nursing practice.3 Justice, as defined within the 2017 CNA Code of Ethics for Registered Nurses, is about the rights of others, distribution of resources, and promoting the common good. However, relational social justice involves fair access to social goods such as rights, opportunities, power, and self-respect: “This view of social justice directs us to explore the context in which certain political and social policies and structures are created and maintained” (Kenny et al., 2010, p. 10). Drawing on the work of Powers and Faden (2006), Kenny et al. suggested that social justice is “the foundational moral justification for public health” (p. 10). We believe this foundation can help advanced practice nurse leaders to consider how different social groups are affected by a collective practice that creates and shapes inequalities in health access and opportunity.
Relational theorists have long argued that people are relational beings who exist in a web, and that relationships and networks are structured socially and politically (Sherwin & Stockdale, 2017). Advanced practice nurse leaders ought to be critically reflexive about how relationships are structured by systemic patterns of privilege or disadvantage. They ought not to ignore the ways in which various social and political groups (such as those organized based on gender, race, class, ability status, age, ethnicity, and sexuality) influence moral practices across the profession.
Young (2011) describes social justice as a collective responsibility. In the context of advanced practice nursing, this means that advanced practice nurse leaders have a shared responsibility to critique and ameliorate the social practices that result in unjust actions. They have the knowledge, skills, and ability to transform many structural processes so that health care access and outcomes are morally good and socially just. It is imperative that advanced practice nurse leaders consider dignity, respect, and relational approaches when promoting social justice.
A key moral mandate for nurses in ensuring that health care access is equitable and accessible to all is the duty to provide care. This mandate comes from the obligations and responsibilities of nurses to their clients, and is enshrined in the 2017 CNA Code of Ethics for Registered Nurses. Given this moral mandate, the editors of this book recognized a need during the COVID-19 pandemic to provide additional resources to assist nurses to make decisions about their duty to provide care. In the next section, we describe a resource that was developed by Storch, Starzomski, and Rodney to provide support for nurses as they engage in ethical practice (see Appendix 1-1).
Duty to Provide Care During the COVID-19 Pandemic
Nurses have a moral obligation to support the best interests of the individuals, families, and communities for whom they provide care—an obligation that has been particularly challenging during the COVID-19 pandemic. In the spring of 2020, when the pandemic was beginning, the British Columbia (BC) government embarked on the development of comprehensive documents to guide nurses and other HCPs in caring for people with COVID-19. Although the guidelines were carefully crafted, the editors of this book found that the guidelines did not fully address the complex, profound challenges that registered nurses faced at the frontlines of care. Following a review of the BC provincial documents, as well as related provincial and territorial guidelines and national resources, we developed a resource designed to address the gaps that we noted. Our proposed resource was structured in four quadrants for ease of application, and our goal was to promote equitable and effective health care approaches (see Appendix 1-1).
The four quadrants we proposed focused on the following:
1. What is the nurse’s duty to provide care?
2. How does a pandemic affect or alter the duty to provide care?
3. When is it acceptable for a nurse to withdraw from providing care, or refuse to provide care?
4. How should a nurse withdraw from providing care or refuse to provide care?4
Under quadrant one are items supporting the rationale for the duty to provide care, including the obligation of nurses to provide safe, competent, compassionate, and ethical care. This was founded on the ethical principle of beneficence—to benefit others. Nurses play an essential role in responding to a pandemic and in sustaining a functional and compassionate health care system.
Under quadrant two, where we outline how a pandemic affects and alters the duty to provide care, the reality of the risk of harm to nurses is highlighted, as well as the reality of a nurse’s relational obligations. Also shown are the expectations nurses ought to have of their leaders, such as regular consultations about addressing risks and harms.
In quadrant three, we address the circumstances where it would be justified to withdraw from the provision of care, or refuse to provide care. Nurses have two notable and, at times, conflicting obligations. There is the obligation to provide care, but there is also the obligation to determine the circumstances under which refusing to provide care would be justified if the nurse was being placed at an unacceptable level of risk, such as when there was a lack of personal protective equipment (PPE).
In quadrant four, we provide steps to follow when a nurse judges that they need to refuse to provide care, or withdraw from providing care. These steps include speaking to health care leaders about the need to withdraw from providing care as soon as possible, and in time for alternate arrangements to be made. Reasons should be given for the planned withdrawal of care, with a willingness to weigh and consider new information.
Ethical Decision Making for Advanced Practice Nurse Leaders
Given the earlier discussion about theoretical underpinnings for nursing ethics, in this section we provide opportunities for advanced practice nurse leaders to consider theoretical approaches to develop ethical decision-making skills as they engage in nursing practice. To facilitate this development, we include (a) a guideline for duty to provide care (see Appendix 1-1); (b) two ethical decision-making frameworks (see Appendices 1-2 and 1-3); and four case scenarios. These resources are intended to assist readers to apply ethical analyses, and suggest recommendations for action.
The four scenarios below are composites of real-life situations that the authors of this chapter have been involved in over the course of their careers in nursing ethics. A number of key topics are illustrated in the scenarios, including the following:
• advanced practice nurse leadership
• listening to and valuing diverse perspectives
• relational practice
• a critical social justice perspective
• the duty to provide care
• interprofessional collaboration, and
• duties and responsibilities of individuals, teams, and organizations.
We leave it to readers to consider and address the Reflective Questions we have provided after each scenario. We recommend that, if possible, these scenarios and questions be discussed in collaboration with colleagues in order to promote intraprofessional and interprofessional ethical dialogue.
We begin with the following Ethics in Practice scenario, where we describe the leadership challenges surrounding duty to provide care faced by a clinical nurse specialist during the COVID-19 pandemic.
In the next Ethics in Practice scenario, we address a complex home care situation in an isolated Indigenous community. The community has limited available health care resources, presenting significant challenges to the patient, her daughter, HCPs, and the overall community.
In the following Ethics in Practice scenario, we explore the ethically challenging context of treatment withdrawal when the patient no longer wants to proceed with treatment, but the health care team and the patient’s family believe that there may still be hope for life.
In the last scenario of this chapter, we present an ethically complex case of a refugee who requires end stage renal failure treatment immediately upon arrival in Canada. As the health care team strives for a positive patient outcome, resource allocation questions are raised and different layers of government policies and guidelines are considered.
Conclusion
The development and use of ethical theory in nursing has a rich history which continues to evolve. As we have described in this chapter, this evolution requires nurses to focus on a number of areas, including relational practice and social justice. A broad notion of social justice is necessary for nurses to enact their responsibilities and obligations to address the ethical issues they face in their practice, as well as to be part of resolving complex societal ethical concerns. In order for nurses to do so, effective ethical decision making grounded in nursing ethics is key. The case scenarios in this chapter provide an opportunity for nurses, advanced practice nurse leaders, and other HCPs to use ethical theory and decision-making frameworks to resolve ethical challenges.
As authors of this chapter, we believe that a focus on a socially connected model of moral agency has had, and will continue to have, significant benefits for nurses in practice, especially advanced practice nurse leaders. As our lead-in quote for this chapter indicates, and through our shared research and study over many years, we have come to understand the value of advanced practice nurse leaders as moral compasses within practice settings. We continue to be interested in learning more about how to promote quality practice environments for safe, competent, and ethical practice. Fostering proactive communication and trust within and among HCP groups, and across all levels of health care organizational hierarchies, is foundational to supporting all practicing nurses.
What this means to us now is that all of us in nursing—student nurses, nurse educators, nurses in practice, advanced practice nurses, and nurses in formal health care leadership roles—whether in practice, education, research, or health care planning and delivery—should see ourselves as moral agents charged with the collaborative leadership responsibility of guiding ourselves and others. As we move toward understanding what is happening, what ought to happen, and how to navigate the difference, we need to cultivate wisdom, courage, and humility. We believe that cultivating these three qualities will help all of us, as nurses, to provide and promote ethical nursing practice now and in the future.
QUESTIONS FOR REFLECTION
1. In considering your own values and beliefs, how do you think they influence your approach to ethical concerns/issues/dilemmas? What are the implications for you as a moral agent?
2. How might you initiate discussions about ethics among health team members?
3. What actions can you take to foster a social justice perspective in your health care setting?
4. What actions can individual advanced practice nurse leaders take to strengthen their autonomy as moral agents? As members of organizations? In professional groups?
5. How might advanced practice nurse leaders work with HCPs, governments, and other organizations to decrease moral distress and foster moral resilience in health care settings?
6. How can relational values be fostered in health care organizations so that nurses and other HCPs are better supported in enacting a relational ethic?
7. What are some key initiatives that nurse educators could promote to foster ethical practice across diverse groups of health care providers?
8. How can advanced practice nurse leaders model ethical practice within and across diverse health care groups?
Endnotes
1 In this chapter, we draw on content from: Rodney, P., Burgess, M., Phillips, J. C., McPherson, G., & Brown, Helen. (2013). Our theoretical landscape: A brief history of health care ethics. In J. L. Storch, P. Rodney, & R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed., pp. 59–83). Pearson.
2 Its office was previously located at the University of Surrey, but moved to the University of Exeter with Ann Gallagher as Editor-in-Chief. Many Canadian nurses have served on the editorial board; many more have published within the journal.
3 For further discussion about public health ethics, see Chapter 4.
4 For more information about the duty to provide care and conscientious objection, please see the British Columbia College of Nurses & Midwives (n.d.) Duty to Provide Care and the CNA (2017) Code of Ethics for Registered Nurses.
References
Anderson, J. M., Rodney, P., Reimer-Kirkham, S., Browne, A. J., Khan, K. B., & Lynam, M. J. (2009). Inequities in health and healthcare viewed through the ethical lens of critical social justice: Contextual knowledge for the global priorities ahead. Advances in Nursing Science, 32(4), 282–294.
Baylis, F., Kenny, N. P., & Sherwin, S. (2008). A relational account of public health ethics. Public Health Ethics, 1(3), 196–209.
Benner, P. (1990). From novice to expert: Excellence and power in clinical nursing practice (2nd ed.). Addison Wesley.
Bergum, V., & Dossetor, J. (2005). Relational ethics: The full meaning of respect. University Publishing Group.
Brendtro, L. K., Brokenleg, M., & Van Bockern, S. (2019). Reclaiming youth at risk: Futures of promise (reach alienated youth and break the conflict cycle using the circle of courage). Solution Tree.
British Columbia College of Nurses & Midwives. (n.d.). Duty to provide care. https://www.bccnm.ca/RN/learning/dutytoprovidecare/Pages/Default.aspx
Canadian Nurses Association. (2017). Code of ethics for registered nurses. https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics
Clark, N., Handlovsky, I., & Sinclair, D. (2015). Chapter 9: Using reflexivity to achieve transdisciplinarity in nursing and social work. In L. Greaves, N. Poole, & E. Boyle (Eds.), Transforming addiction: Gender, trauma, transdisciplinarity (pp. 120–136). Routledge.
Clark, N., & O’Mahony, J. (2021). Considering primary health care as a social determinant of refugee health through the lens of social justice and care ethics: Implications for social policy. In B. Sethi, S. Guruge, & R. Csiernik (Eds.), Understanding the refugee experience in the Canadian context (pp. 176–186). Cambridge Scholars.
Cook, T., Brandon, T., Zonouzi, M., & Thomson, L., (2019). Destabilizing equilibriums: Harnessing the power of disruption in participatory action research. Educational Action Research, 27(3), 379–395. https://doi.org/10.1080/09650792.2019.1618721
Davis, A., Fowler, M., & Aroskar, M. A. (2010). Ethical dilemmas and nursing practice (5th ed.). Pearson.
Doherty, R. F., & Purtilo, R. B. (2016). Ethical dimensions in the health professions (6th ed.). Elsevier.
Engster, D. (2014). The social determinants of health, care ethics and just health care. Contemporary Political Theory, 13(2), 149–169.
Fowler, M. D. (2015a). Guide to the code of ethics for nursing: With interpretive statements: Development, interpretation, and application (2nd ed.). American Nurses Association.
Fowler, M. D. (2015b). Guide to nursing’s social policy statement: Understanding the profession from social contract to social covenant. American Nurses Association.
Fowler, M. D. (2017). Why the history of nursing ethics matters. Nursing Ethics, 24(3), 292–304.
Fowler, M. D., Reimer-Kirkham, S., Sawatsky, R., & Johnston Taylor, E. (Eds). (2012). Religion, religious ethics, and nursing. Springer.
Fraser, N. (1999). Social justice in the age of identity politics: Redistribution, recognition, and participation. In L. Ray & A. Sayer (Eds.), Culture and economy after the cultural turn (pp. 25–52). Sage.
Fraser, N. (2001). Recognition without ethics? Theory, Culture & Society, 18(2–3), 21–42. https://doi.org/10.1177/02632760122051760
Fry, S. T. (1989). The role of caring in a theory of nursing ethics. Hypatia, 4(2), 88–103.
Fry, S. T., & Johnstone, M.-J. (2008). Ethics in nursing: A guide to ethical decision making. Wiley-Blackwell.
Gallagher, A. (2021). Reflections on a COVID death: Naming a family’s pain and reparation. Nursing Ethics, 28(5), pp. 587–589. https://doi.org/10.1177/09697330211038795
Gilligan, C. (1982). In a different voice: Psychological theory and woman’s development. Harvard University Press.
Hartrick Doane, G., & Varcoe, C. (2007). Relational practice and nursing obligations. Advances in Nursing Science, 30(3), 192–205.
Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research and education. Macmillan.
Jost, J. T., & Kay, A. C. (2010). Social justice: History, theory, and research. In S. T. Fiske, D. T. Gilbert, & G. Lindzey (Eds.), Handbook of social psychology (pp. 1122–1165). John Wiley & Sons. https://doi.org/10.1002/9780470561119.socpsy002030
Kenny, P., Sherwin, S. B., & Baylis, F. E. (2010). Re-visioning public health ethics: A relational perspective. Canadian Journal of Public Health, 101(1), 9–11. https://doi.org/10.1007/BF03405552
Liaschenko, J., & Peter, E. (2004). Nursing ethics and conceptualizations of nursing: Profession, practice and work. Journal of Advanced Nursing, 46(5), 488–495.
Noddings, N. (1984). Caring: A feminine approach to ethics and moral education. University of California Press.
Pauly, B. M., & Storch, J. L. (2013). Ethics and Canadian health care. In J. L. Storch, P. Rodney, & R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed., pp. 236–263). Pearson.
Pellegrino, E., & Thomasma, D. (1988). For the patient’s good: The restoration of beneficence in health care. Oxford University Press.
Peter, E. (2011). Fostering social justice: The possibilities of a socially connected model of moral agency. Canadian Journal of Nursing Research, 43(2), 11–17.
Peter, F. (2004). Health equity and social justice. In S. Anand, F. Peter, & A. Sen (Eds.), Public health, ethics, and equity (pp. 93–106). Oxford University Press.
Powers, M., & Faden, R. R. (2006). Social justice: The moral foundations of public health and health policy. Oxford University Press.
Reimer-Kirkham, S., & Browne, A. (2006). Toward a critical theoretical interpretation of social justice discourse in nursing. Advances in Nursing Science, 29(4), 324–339.
Roach, M. S. (1987). The human act of caring: A blueprint for the health professions. Canadian Hospital Association.
Rodney, P., Browne, A. J., Basu-Khan, K., & Lynam, M. J. (2009). Inequities in health and healthcare viewed through the ethical lens of critical social justice. Advances in Nursing Science, 32(4), 282–294.
Rodney, P., Buckley, B., Street, A., Serrano, E., & Martin, L. A. (2013). The moral climate of nursing practice: Inquiry and action. In J. L. Storch, P. Rodney, & R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed., pp. 188–214). Pearson.
Sherwin, S. (2011). Looking backwards, looking forward: Hopes for bioethics’ next twenty-five years. Bioethics, 25(2), 75–82. https://doi.org/10.1111/j.1467-8519.2010.01866.x
Sherwin, S., & Stockdale, K. (2017). Whither bioethics now? The promise of relational theory. International Journal of Feminist Approaches to Bioethics, 10(1), 7–29. https://www.jstor.org/stable/90012254
Stafford, A., & Wood, L. (2017). Tackling health disparities for people who are homeless? Start with social determinants. International Journal of Environmental Research and Public Health, 14(12), 1535. https://doi.org/10.3390/ijerph14121535
Stajduhar, K. I., Mollison, A., Giesbrecht, M., McNeil, R., Pauly, B., Reimer-Kirkham, S., Dosani, N., Wallace, B., Showler, G., Meagher, C., Kvakic, K., Gleave, D., Teal, T., Rose, C., Showler, C., & Rounds, K. (2019). “Just too busy living in the moment and surviving”: Barriers to accessing health care for structurally vulnerable populations at end-of-life. BMC Palliative Care, 18 (1), 11. https://doi.org/10.1186/s12904-019-0396-7
Storch, J. L. (1982). Patients’ rights: Ethical and legal issues in health care and nursing. McGraw-Hill.
Storch, J. L., Rodney, P., Pauly, B., Brown, H., & Starzomski, R. (2002). Listening to nurses’ moral voices: Building a quality practice environment. Canadian Journal of Nursing Leadership, 15(4), 7–16.
Storch, J. L., Rodney, P., & Starzomski, R. (2004). Toward a moral horizon: Nursing ethics for leadership and practice (1st ed.). Pearson Prentice Hall.
Storch, J. L., Rodney, P., & Starzomski, R. (2013). Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed.). Pearson.
Tschudin, V. (1994). Deciding ethically: A practical approach to nursing challenges. Bailliere Tindall.
Tschudin, V. (1999). Nurses matter: Reclaiming our professional identity. Macmillan.
Villeneuve, M. J. (2017). Public policy and Canadian nursing. Canadian Scholars.
Yeo, M. (2020a). Introduction. In M. Yeo, A. Moorhouse, P. Khan, & P. Rodney (Eds.), Concepts and cases in nursing ethics (4th ed., pp. 13–31). Broadview.
Yeo, M. (2020b). A primer in ethical theory. In M. Yeo, A. Moorhouse, P. Khan, & P. Rodney (Eds.), Concepts and cases in nursing ethics (4th ed., pp. 33–68). Broadview.
Yeo, M., Moorhouse, A., Kahn, P., & Rodney, P. (2010). Concepts and cases in nursing ethics (3rd ed.). Broadview.
Yeo, M., Moorhouse, A., Khan, P., & Rodney, P. (2020c). Concepts and cases in nursing ethics (4th ed.). Broadview.
Young, I. M. (1990). Justice and the politics of difference. Princeton University Press.
Young, I. M. (2011). Responsibility for justice. Oxford University Press.
Wilson, S. (2008). Research is ceremony: Indigenous research methods. Fernwood Publishing.
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