CONCLUSION

Going Boldly Forward: Toward a Moral Horizon

Rosalie Starzomski, Janet L. Storch, and Patricia Rodney

“Nursing ethics is philosophically informed and robust. Nursing ethics is relational. Nursing ethics is contextual, rooted in experience. Nursing ethics is about the moral character of the nurse and the instantiation of nursing identity. Nursing ethics, rightly enacted, is an alloy of skilled nursing practice and ethical comportment; they are interfused and inseparable—one does not exist rightly without the other.” (Fowler, 2022, para. 7)

IN REFLECTING ON THE OVER 20 YEARS of working on three editions of this book, we acknowledge that the challenges nurses face in enacting nursing ethics in their practice are rooted in history and the contexts in which they practice. Over these years, while we have been at different stages of our professional careers, we have benefited from the insights of each other, our colleagues and students, and all those who have used our texts as learning and teaching tools. This third edition of our book builds on our cumulative insights from writing the two previous editions, as well as the knowledge we have acquired from our interactions with students and nurses, particularly advanced practice nurse leaders. These interactions, as well as our teaching, graduate supervision, and collaboration with other health care providers (HCPs), have enriched our understandings of the challenges nurses and HCPs face, and the need for nursing ethics to continue to flourish. Our goal in writing the three editions of this text has been—and continues to be—to promote ethical fitness, and to provide hope for all of us in the nursing profession, as well as for our colleagues in other health care fields.

The content of each of our three books has been influenced by specific events that occurred in the health care environment at the time of writing each edition. For example, in our first book, published in 2004, we described and analyzed the moral landscape, the moral climate, and the moral horizon for nurses in the wake of the 2003 severe acute respiratory syndrome (SARs) outbreak, where it became clear that the voices of nurse leaders were essential in order to ensure optimal care for all citizens (Registered Nurses Association of Ontario, 2003). When writing the second book in 2013, we included information about the effects of the aftermath of SARs on public health and noted the importance of the establishment of the Public Health Agency of Canada to coordinate the changes needed in primary health care.

When considering the issues nurses faced during the periods above, and the issues they face today, we are struck by the similarity to situations they faced during a prior pandemic, over a hundred years ago (Fowler & Gallagher, 2019). In 1919, there was evidence of a nursing and nursing student shortage, challenges with workloads for nurses, concerns about working conditions for nurses, concerns about the salaries of nurses, as well as widespread fatigue and exhaustion in the nursing workforce—all concerns that nurses continue to face today (Fowler & Gallagher).

What We Have Offered in This Edition

This third edition of the book has been created in the midst of a prolonged SARs-CoV-2 pandemic that has brought with it unprecedented changes in health care delivery and societal practices. The challenges of both this pandemic, and the many global issues facing society, require the expertise of advanced practice nurse leaders locally, nationally, and internationally. These challenges include the global climate emergency, war and insurrection, escalating health care costs, limited access to health care, racism, social injustice and inequity, poverty, inadequate Indigenous health care, and a growing opioid epidemic. Although developments have been made by advanced practice nurse leaders and others, there continue to be major challenges in all areas of health care. These challenges are exacerbated by an escalating worldwide severe shortage of HCPs, particularly nurses.

A clear vision of nursing ethics is required to ensure that advanced practice nurse leaders, and all nurses and HCPs, are able to provide quality health care. What we offer in this edition of Toward a Moral Horizon: Nursing Ethics for Leadership and Practice is a wide view of nursing ethics. We trust that the content of this textbook will closely match the current needs of advanced practice nurse leaders, all nurses, and other HCPs. We are confident that the approach taken in the chapters in this text will be useful to readers.

There is considerable new content in this edition, particularly in relation to social justice and equity in health care. We explore Indigenous ethics and perspectives,¹ decolonization of nursing and health care, ethnocultural contexts, racism, ethical concerns during pandemics, and the promises and perils of technological developments.

Ethical responsibilities in specific areas of practice are described throughout the book, including in mental health care, in the care of childbearing individuals and families, in supporting the moral agency of children, and in the care of older adults. Other critical areas of practice include attention to Indigenous health care, genetics and identity, the ethical challenges of home health care, caring for people with disabilities, and biotechnological developments in health care. There are variations on many other topics, some covered in previous editions of the book, which are enlarged upon and updated in this edition. These topics include ethical concerns in nursing education and nursing research, a palliative care ethic for nursing at the end of life, ethical issues in public health nursing, and global ethical challenges.

Throughout this text, ethical leadership is promoted, with a particular emphasis on widening the understanding of nurses about the nursing profession itself, and its fit with organizations and health care systems. To that end, we stress the importance of enhancing the moral agency of nurses, developing strategies to deal with the moral distress of nurses, fostering the moral resilience of nurses, and promoting greater equity in nursing practice.

Throughout this book, we have pressed for nurses to recognize and maximize their leadership with a goal of boldly moving toward future moral horizons. This requires that they recognize and support the values upon which Canada’s unique health care system is based. Further, since nurses face so many challenges in all aspects of health care, they need to engage in research activities and use research findings to consider revised and new approaches to various areas of practice. Importantly, as advanced practice nurse leaders move into the future, they must address the ethical challenges and opportunities that they will continue to encounter in their practice.

On the Horizon: Challenges and Opportunities

In 2013, in the closing chapter of the second edition of our book, we began with a quote from a nurse participant in our research study about the quality of practice environments (Rodney et al., 2002). The nurse participant emphasized the importance of having hope to improve nursing practice and patient care, telling us that “we have to have some hope. And so that’s how I look at it … I am in no way thinking that there’s not more work to be done. There definitely is. But I have seen successes and so I think it is possible” (p. 91). At that time, citing work done by nursing organizations, as well as findings from research conducted by ourselves and our colleagues, we noted the leadership we saw across many areas of nursing practice. More than 20 years later, as we write the third edition of our book, we continue to see strengths in nursing leadership, and we continue to have hope. We know that nurse leaders have the education and skills to influence change regarding organizational priorities, and to support interprofessional staff, patients, families, and communities. Further, we have been inspired by the commitment and leadership from all nurses that we consistently witness, whether they are advanced practice nurse leaders, nurses on the front lines of patient care, or student nurses.

We also continue to see persistent challenges—challenges that are reflected in various chapters in this text. For example, authors in this book have exposed ethical issues and critiqued systemic failures in Canada’s mental health care delivery system, in long-term care, and in the care of Indigenous people. Further, in a number of places, authors have explored the moral distress that accrues for nurses who are unable to practice according to their professional standards, often because of systemic failures in health care delivery.² Unfortunately, moral distress continues to be a problem for overburdened nurses and other HCPs. In this edition, we underscore the importance of fostering moral resilience, so that nurses and other HCPs are better prepared to understand and address their experiences of moral distress, and hence provide more effective care for individuals, families, and communities. In today’s health care environment, advanced practice nurse leaders are highly skilled in the clinical areas for which they are responsible, and can help to ameliorate moral distress.

Nonetheless, we also continue to be aware of the substantial—and escalating—health care organizational challenges that nurses face. These challenges reflect the major problems that continue to be evident in Canada’s health care system overall. As we note in this text, such challenges include a chronic shortage of nurses and other HCPs in an era of increasingly complex health care requirements and fiscal limitations. In particular, during the SARs-CoV-2 pandemic, the shortage of physicians and nurses, as well as limited access to primary health care, has become alarming, highly publicized, and politicized. Some solutions have been developed, such as increasing the number of university seats for nursing and medical students, and increasing the number of nurse practitioners across Canada, with the goal of providing more nurses and physicians and better access to primary health care for patients.

As a result of nurse, physician, and other HCP shortages, emergency departments in Canadian urban and rural centres often have to “pick up the slack.” Staff in emergency departments are frequently overwhelmed with increased patient loads. These patients often have not had health care from primary HCPs in their communities. Such gaps in health care delivery also threaten Canada’s cherished publicly funded health care system because they open the door for private health care options (Duong, 2023a). While there are some potentially equitable and effective alternatives emerging, such as a rise in virtual health care, multidisciplinary clinics, and hospital-at-home programs (Duong, 2023b), widespread initiatives to better support health care delivery across Canada are clearly needed.

Given the persistent challenges in health care delivery we have noted in this text, it behooves nurses and other HCPs to sharpen their political acumen at all levels of the health care system (micro, meso, and macro) so that they are able to work together to promote greater equity and effectiveness in health care planning and delivery. To actualize a robust, publicly funded health care system in Canada, advanced practice nurse leaders, all nurses, and other HCPs must work collaboratively to influence change, ensure sustainability, and promote equity in the system. The public they care for deserves access to their combined commitment and expertise.

Charting Our Course

Given that the public continues to place nurses at a high level of trust and respect (Canada’s Most Respected, n.d.; National Nurses United, 2023), nurses are well-positioned to take greater leadership roles in order to restore, maintain, and continue to develop what is beneficial in health care. Nursing practice must be grounded in nursing ethics. Therefore, the primary focus of nurses must be to engage in ethical practice in their work. Ethics must be embedded in all aspects of practice, and it must be the lens through which decisions are made and actions are taken. Nurses must continue to shape and adopt changes that need to occur for both present and future improvements. In addition, continued recognition must be given to the development and the increased complexity of professional roles for all nurses, particularly for advanced practice nurses.

At a time when health care needs are outstripping resources for care, governments must undertake urgent action and coordination to attract more nurses to and across Canada. Recruitment of nurses must involve federal, provincial, and territorial governments, as well as nursing associations and organizations. This means that these groups must work together in fulfilling the recruitment of nurses, with an emphasis on striving to make sure that the knowledge and skills of nurses serve the current health care needs of Canadians.

Canada’s unique approach to health care is based on a publicly funded health insurance program. A sound knowledge about how health care is delivered in Canada, and the continuing commitment to provide access to health care for all Canadians, is vital for nurses. Nurses must understand this system and engage in political action to ensure that their voices are influential in effecting positive change in health care planning and delivery.

Some of the most pressing challenges facing Canadians today continue to be rooted in systemic inequities, yet many health care organizations have been unable to change their practices in order to eliminate these inequities. During the SARs-CoV-2 pandemic, the energy for and commitment to addressing inequities in health care delivery faltered. National and regional political action is critical to effect change in health care delivery, and nurses must be involved in helping to lead actions fostering such change. Our hope is that physicians, nurses, other HCPs, health care organizations, assoc­iations, and governments will continue to find ways to collaborate to meet the health care needs of Canadians.

When nurses engage in political action individually and collectively, they need to be very clear about priorities regarding whom they serve—that is, people requiring care, rather than governments and politicians. By keeping this focus in mind, nurses can make a major difference in the lives of Canadians. For example, Bernadette Pauly (a colleague and chapter author in this book from the University of Victoria), in her advocacy and policy development in Victoria for over a decade, has helped to preserve and enhance the lives of many homeless people and people with addictions. As another example, Elizabeth Peter (a chapter author in this book, and a colleague from the University of Toronto), has worked tirelessly to raise the profile about changes needed for home care in Canada. In her research, she describes how home care nurses significantly influence the people in their care through education, role modelling, and restructuring the home environment.

Looking to the future, nurses ought to include a more purposeful linking of ethics with politics in order to promote the well-being of individuals, families, and communities. As cost constraints continue to proliferate in health care delivery, there are serious concomitant challenges to the moral agency of nurses and other HCPs. Therefore, nurses must continue to examine their values and ethics, and consider how to enact them in a Canadian democracy that is founded on an egalitarian ideal and where diversity ought to be respected.

Nurses need to be thoughtful and careful as they chart a course in current and future socio-political climates. This will require policy work at many levels, and political action in communities, workplaces, governments, and professional organizations. Working with provincial and national nursing associations will be foundational to charting the way forward. Nurses will need to consider comprehensive strategies to increase the number of nurses in Canada. Throughout, they must take significant political leadership in working with organizations to promote progressive change.³ Such progressive change requires that nurses come together to commit to a consistent set of values, such as those expressed in the 2017 Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses.

When the CNA revised their Code of Ethics in 2017, they undertook a bold move by preparing a more broadly based code of ethics that also gave greater attention to social inequities. This revised Code of Ethics continues to provide guidance for nurses today. In Part II of the Code of Ethics, the focus is on ethical endeavours, where attention is directed to the social determinants of health and the need for primary health care, health promotion, and greater attention to vulnerable populations and global health. Nurses are encouraged to recognize the broader context of health, as well as the social injustices apparent in many aspects of health care. They are viewed as having responsibility for social injustice because they may contribute through their actions to the social processes and rules which bring about these injustices. Nurses need to accept the responsibility to work individually and collectively to right the wrongs they witness.

Throughout this book, emphasis has been placed on the importance of relational ethics and the moral agency of nurses. From a relational standpoint, moral agency can be conceptualized as a collective good. Nurses need to consider and enact their moral agency to bring about positive changes to health care and to improve the health of the people with whom they work.

Nurses are positioned more effectively than ever before to take leadership roles, maintain what is beneficial in health care, and shape the changes that need to occur in the future. All the authors who have been involved in the writing of this third edition of Toward a Moral Horizon: Nursing Ethics for Leadership and Practice have contributed to nursing’s growing capacity to promote such beneficial changes.

It is our hope that readers will step boldly into shaping the future of health care by becoming more engaged in ethical practice, and by becoming more confident in their leadership roles in health care. We believe that the content of our text can contribute to the knowledge needed for nurses to make ethical and political choices knowingly and wisely.

As a profession, nursing has achieved a great deal in regard to nursing ethics and promoting ethical practice. Yet, a great deal more needs to be done. Nurses must continue to demonstrate moral imagination and moral courage in the face of challenges that confront them at all levels of the health care system. Further, nurses are well positioned to take up the challenge of shaping the future health care system. We are confident that the ethical scholarship, practice, and political action of nurses will promote a future where health becomes an achievable goal for all people on our planet.

Endnotes

1 For example, we include a unique chapter (Chapter 5) where Indigenous nurses provide their perspectives in video format, and discuss the values and perspectives of Indigenous Peoples.

2 Moral distress is the anger, frustration, guilt, and powerlessness that HCPs experience when they believe that they are unable to uphold their values and their practice standards.

3 See Chapter 7 for examples of joint professional leadership.

References

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Duong, D. (2023a). Can Ontario offload surgeries to private clinics without undermining public health care? CMAJ, 195(5), E199–E200. https://doi.org/10.1503/cmaj.1096036

Duong, D. (2023b). Could bringing the hospital home expand acute care capacity? CMAJ, 195(5), E201–E202. https://doi.org/10.1503/cmaj.1096035

Fowler, M. (2022, Oct. 25). A snake in our midst: The constriction of nursing ethics by the serpent bioethics. Nursology. https://nursology.net/2022/10/25/a-snake-in-our-midst-the-constriction-of-nursing-ethics-by-the-serpent-bioethics/

Fowler, M., & Gallagher, A. (2019). One hundred years of ethics in nursing: What’s new? Nursing Ethics, 26(5), 1278–1281. https://doi.org/10.1177/0969733019862471

National Nurses United. (2023, January 10). Nurses named most trusted profession for 21st consecutive year [Press release]. National Nurses United. https://bit.ly/3oI8oJV

Registered Nurses Association of Ontario (RNAO). (2003). SARs unmasked: Celebrating resilience, exposing vulnerability. RNAO.

Rodney, P., Varcoe, C., Storch, J. L., McPherson, G., Mahoney, K., Brown, H., Pauly, B., Hartrick Doane, G., & Starzomski, R. (2002). Navigating toward a moral horizon: A multi-site qualitative study of nurses’ enactment of ethical practice. Canadian Journal of Nursing Research Archive, 34(3), 75–102. https://cjnr.archive.mcgill.ca/article/view/2181