“Introduction The Moral Terrain” in “Toward a Moral Horizon”
INTRODUCTION
The Moral Terrain
Rosalie Starzomski, Janet L. Storch, and Patricia Rodney
“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.” (Canadian Nurses Association, 2017, p. 3)
WELCOME TO THE THIRD EDITION of Toward a Moral Horizon: Nursing Ethics for Leadership and Practice. We believe that this enhanced edition will meet the needs of many people, since this text is constructed to help nurses and all health care providers (HCPs) to take up the challenge of embedding ethics in health care policy, practice, education, and research at all levels—from the local to the global. In writing this book, we are working to push boundaries, by providing content to help nurses and other HCPs to influence change in the health care system, and develop strong intra- and interprofessional collaboration, coalitions and, ultimately, strong moral communities. Creating this book is part of providing the knowledge required to continue to build moral communities within nursing and health care systems to enhance health care delivery.
Our purpose in revising this book is to highlight and celebrate the significant progression of nursing ethics in the face of rapidly evolving Canadian and global health care challenges. These challenges have been exacerbated by a worldwide SARs-CoV-2 pandemic, as well as significant resource constraints in Canada and around the globe. Our intent is to enhance the ability of nurses, including advanced practice nurse leaders,1 graduate students, and senior undergraduate students, to fully understand and enact the ethical dimensions of their practice. Overall, our goal is to promote leadership in nursing, in nursing ethics, for nursing and for nursing ethics.
In 2004 and 2013, we developed the first two editions of this book to serve as textbooks for graduate courses in nursing ethics and to provide practicing nurses with content to enhance their roles as leaders within diverse health care settings. We have had the opportunity to use the first two editions to help educate graduate nursing students, practicing nurses, and colleagues in other health care disciplines. We learned a great deal in the development and use of these first two editions. We thank our contributors, reviewers, colleagues, and students past and present for adding to our understanding of what is needed in this new, third edition.
In this edition of our textbook, we take up and continue to address the challenges that informed our 2013 second edition. That is, we “stretch our moral reasoning about the practice of nursing and health care and [also] challenge each nurse’s everyday moral activities, what we value, how we make decisions and behave, and who we are becoming by virtue of our moral choices.” And we continue to “challenge [our] readers to make ethical fitness in service of benefiting others [a] goal and offer incomparable resources to achieve this goal” (Taylor, 2013, p. xi).
It has been our commitment to these collective challenges, together with ongoing feedback from students and other colleagues, that has led to the planning, designing, and delivery of this book. Although the third edition is written for the audience we highlighted above, it is also relevant for other HCPs, as we work together to develop strong moral communities and effective interprofessional practice models that result in quality patient care.
Readers of our previous editions will note that there is considerable new content in this edition of our book, particularly in relation to neoliberalism, social justice and equity in health care, Indigenous ethics and perspectives, decolonization of nursing and health care, ethnocultural contexts, racism, ethical concerns during pandemics, new technological developments, and the future of nursing ethics. Throughout the text, we aim for sequence, continuity, and integration in the diverse content areas that are discussed, in order to enhance understanding of the issues and provide learning opportunities for readers.
Our key goal is to enable nurses and other HCPs to become ethically fit (Kidder, 2009), to maintain ethical fitness, and to continue to push the boundaries of nursing ethics forward. Ethical concerns have continued to change over the decades since 2004 when our first book was published. Nurses have made great strides toward enhancing their ethical practice to uphold their commitment to the people in their care. We know that other HCPs, including physicians, social workers, and many other colleagues, are also concerned about ethical leadership and practice. Nurses have been instrumental in enlarging the focus on improving health and health care practice, and going beyond what has been considered the purview of traditional health care ethics and nursing ethics. Nurses have responded to the rapidly changing context of health care delivery and nursing practice, which includes an aging population, technological change, and a growing emphasis among health care organizations on a neoliberal ideology. These changes in context will be addressed by authors in the various chapters in this book.
Our focus for this text is based on our own research and engagement in ethics work in health care and nursing. We have noted that the moral well-being of nurses, and all HCPs, matters. As Doherty and Purtilo (2016) suggest, professional morality entails a strong commitment to “moral values, duty, and character” (p. 12). When sustained and shared, this commitment can help to create a moral community, where values are made clear, and where nurses can feel safe and heard when engaging in ethical action (CNA, 2017). While the well-being and subsequent practice of nurses is contingent on such a sense of moral community within a positive moral climate overall, the patients for whom nurses provide care also require a sense of safety and community. This is particularly important if patients have been marginalized through negative experiences, such as racialization (Garneau et al., 2017).
Throughout this book, we highlight the need for leadership in health care ethics and nursing ethics. We believe that leadership for ethical policy and practice arises from
nurses in senior leadership positions, from nurses in practice and from academics, all working in collaboration, each contributing within the limitations of their own contexts, but bringing unique knowledge, skills and energy essential to the provision of ethical nursing practice. (Storch et al., 2009, p. 78)
It is our hope that this text, while focusing primarily on nursing and nursing ethics, will also be informative for our colleagues in a variety of health care roles (including, for example, chaplains, dietitians, physicians, rehabilitation therapists, and social workers). We know that these colleagues are also concerned about and committed to fostering ethical leadership and practice. We also know that the expertise of nurses and all HCPs is required in order to promote effective health care delivery within a robust and ethical health care system.
Approach to the Textbook
We are using a new approach for this edited textbook, moving away from a print edition to a digital version of the book that will be accessible to all readers on an open access digital platform and downloadable to devices for offline reading. With the help of our colleagues at the University of Victoria Libraries, we are ensuring that access to this book, and resources related to it, will be available to all who are interested in reading and using the content in their educational programs and practice settings.
We have divided the book into three sections:
1. Section One: Mapping the Moral Climate for Health Care and Nursing Ethics
2. Section Two: Pursuing Equity in Diverse Populations
3. Section Three: Navigating Horizons for Health Care and Nursing Ethics
As described below, the authors of the chapters in each section provide an overview of the current context in specific areas, and also provide recommendations for future changes. A number of chapters are entirely new; however, some authors have drawn on and updated content from their chapters in previous editions of the book. In all of the chapters, the authors use inclusive language to ensure that the diverse populations within communities are represented. In each chapter, “Ethics in Practice” scenarios are provided to illustrate the manner in which ethics is an integral part of practice in all health care settings, as well as in policy development, education, administration, and research. In the case scenarios, authors address ethical challenges, including those faced by Indigenous communities, ethnoculturally diverse communities, and marginalized communities. As mentioned earlier, in each chapter of the book, readers will have an opportunity to consider ethical concerns from local to global levels. “Questions for Reflection” are also provided at the end of each chapter, along with key references for the continued exploration of ethics in leadership and practice.
Section One: Mapping the Moral Climate for Health Care and Nursing Ethics
The first section in the book includes seven chapters, most new to this edition, and others significantly updated and revised. The content of the chapters in this section is related to situating nursing ethics both historically and within the current health care environment, focusing on moral agency and moral climate, along with a rich approach to theory in practice. The authors of the chapters focus on the theoretical development and foundations of nursing ethics, pointing to further developments in the chapters that follow.
In Chapter 1, the authors provide theoretical perspectives about nursing ethics to aid each nurse to develop a moral compass for leadership. The authors acknowledge and discuss a distinct nursing ethic, the importance of relational practice, and the need to use a justice and equity lens in nursing. They provide an historical sketch of the development of nursing ethics in order to describe current philosophical and ethical thinking in nursing; to critically examine ethical principles and theories (including foundational theories such as feminist ethics and relational ethics); and to focus on concepts of ethical practice, specifically moral agency and moral climate. The authors explore two ethical decision-making frameworks and a duty to care guideline. In addition, they provide opportunities to use these resources in Ethics in Practice case scenarios.
Moving to Chapter 2, the authors review research ethics to highlight selected historical research ethics abuses in Canada and worldwide. Many of these situations involved nurses. These human rights abuses led to the development of research ethics guidelines in numerous reports; for example, the Belmont Report from the United States, in which three key principles—respect for persons, beneficence, and justice—were emphasized. In Canada, the Tri-Council Policy Statement (TCPs 2) guidelines for research ethics were developed, focusing on respect for persons, concern for welfare, and justice. The current use of research ethics boards (REBs) and examples of research ethics guidelines and practices for Canadian nurses are highlighted in this chapter.
In Chapter 3, the authors discuss and critique Canadian health care delivery. They begin with a focus on the manner in which health care delivery is structured in Canada, including attention to federal, territorial, and provincial responsibilities. They emphasize that the mode of health care delivery cannot be described as a “health care system” because it is actually thirteen health care systems, located in ten provinces and three territories. They highlight that a former premier of Saskatchewan, Tommy Douglas, led the way for changes in health care delivery with his belief that health care was a right of all citizens. The authors provide both a history of the division of health care roles, as well as a discussion about the challenges of funding health care. Current health care deficiencies are noted, including limitations in long-term care, mental health care, and care for Indigenous people. The authors end the chapter by stressing the need for nurses to practice using a social justice perspective to foster equitable health care delivery.
In Chapter 4, the author builds on an analysis of public health (PH) ethics from previous editions of this textbook in describing its development over recent decades. The author highlights how PH ethics differs from health care ethics and how it has been implemented in nursing. Current PH ethics issues are presented, including a discussion of PH research ethics, as well as environmental and global ethics. Ethical challenges related to pandemics are discussed, and ethical decision-making frameworks for pandemics are reviewed. The author concludes the chapter with a summary of key developments in PH ethics and a discussion about PH issues for the future.
Chapter 5 is a unique contribution to this textbook from a number of Indigenous scholars in nursing. They use circle pedagogy to explore together what nursing ethics means from their own First Nations and Métis perspectives. With their distinction-based approach, they acknowledge the rights and lived experiences of First Nations, Inuit, and Métis people as unique. In order to convey the richness of their dialogue, their circle is provided in video format, and a transcript of the video is also included.
In Chapter 6, the authors provide a definition of moral distress and examine the basic assumptions underlying the definition, differentiating it from other related concepts. They highlight the importance of moral reasoning and moral action of nurses as foundational for the prevention of and responses to moral challenges in their practice. The authors explore situations where nurses and other HCPs experience moral distress. In addition, they provide recommendations for advanced practice nurse leaders at individual (micro), organizational (meso), and larger system (macro) levels of the health care system to improve the moral climate of health care practice environments. They conclude the chapter by highlighting the importance of moral leadership in fostering ethical practice environments.
The authors of Chapter 7 address nursing ethics and leadership for advanced practice nursing. They focus on the interface of the nursing profession with current systems and organizations, noting that this interface is foundational to enacting ethical leadership in any context. Current concepts of ethical leadership are deconstructed and reconceptualized in light of calls to action in current health systems and public policy. Several ethical leadership models and frameworks are presented and critiqued. The authors close the chapter with recommendations to rejuvenate the voices, power, and political influence of nurses.
Section Two: Pursuing Equity in Diverse Populations
The authors of the nine chapters in this section of the text address diverse patient populations and practice arenas. Topics include nursing education, nursing practice, mental health care, childbearing individuals and families, children, home health care, people with disabilities, older adults, and palliative care at the end of life. While the substantive content regarding challenges and practice interventions differs for each chapter, the authors share a common focus on two foundational and interrelated concepts to support ethical practice—equity and diversity.2
In the first chapter in this section, Chapter 8, the focus is on becoming a transformative nurse educator through using a relational pedagogy. This is a perspective which nurse educators use to prioritize relationships over individualism. The authors focus on nursing education as an ethical practice grounded in principles of social justice; safe, competent practice; and relational pedagogy. They include “A Framework for Ethical Decision Making in Nursing Education” that provides guidelines to actualize key principles in higher education. By focusing on nursing education as an ethical practice, and providing a comprehensive ethics resource, the authors have created a chapter for both new and experienced nurse educators.
In Chapter 9, the authors describe the importance of health equity as being crucial across all levels of health care delivery. They provide an argument for why and how equity ought to be promoted in health care practice. They explore foundational concepts such as the social determinants of health, health equity, and critical social justice. The authors claim that health equity is fundamentally an ethical concept, and warn that there is little critical analysis or application of the concept in practice. They point to power imbalances and structural and systemic conditions that create inequities. In closing, they suggest proactive strategies to promote health equity, including fundamentally shifting and redistributing power, and addressing challenges in order to shift organizations and systems toward equity, particularly when racism is involved.
In Chapter 10, the authors begin by addressing the significant prevalence of mental health and substance use issues in Canada, particularly for those in the lowest income groups. They provide a comprehensive account of how stigma, economic challenges, and limited access result in serious inequities in mental health care delivery. Drawing on their own clinical expertise in mental health care, and their comprehensive analyses of historical trends and initiatives, the authors point to how effective advocacy and leadership by nurses can promote more equitable access to mental health care. In an appendix, they provide readers with online resources about mental health care delivery.
The authors of Chapter 11 emphasize the importance of choice and control in the birth experiences of childbearing individuals, including those who identify as gender diverse. They describe how nurses have a social justice mandate to advance reproductive health policy and practice in partnership with childbearing individuals and families. Drawing on a report by a World Health Organization commission on the social determinants of health, the authors argue for a social justice vision to achieve health equity through safe, ethical, and effective nursing care for childbearing individuals and families. They emphasize that advancing equity of access to reproductive health care is a prerequisite to nurses being able to meet their moral obligations and ethical values in various practice settings—including acute care settings and urban and rural community settings.
The author of Chapter 12 builds on insights from clinical practice, and underscores the importance of nurses listening to children, and not just treating them. The chapter begins with a discussion about the need for nurses to attend genuinely to the moral voices of children, while also recognizing limits to how much responsibility can be safely accorded to them. Drawing on seven related practice scenarios that are based on the author’s clinical experiences, illustrations are provided to show how advanced practice nurse leaders and other HCPs can better support the moral agency of children.
The authors of Chapter 13 point to the need for appropriate resources for home health care in Canada and address implications of current home care policy, offering recommendations where they challenge neoliberal values and beliefs to inform the work of nurses in diverse roles. They warn that Indigenous communities are particularly vulnerable to inequities in the quality and availability of home care, especially in rural, remote, and northern locations. Further, they describe the resulting widespread off-loading of responsibilities for care, and the impacts of this on patients, families, and home care workers. The authors conclude by warning that systemic problems in the delivery of home care negatively affect the health and well-being of those receiving care and their caregivers. In addition, they provide suggestions about how advanced practice nurse leaders can be involved in influencing change in home health care.
In Chapter 14, the authors describe the stigma, exclusion, and discrimination that disabled people experience when accessing health care. They explain that how people think about disability affects the way disabled people are treated in the health care system. They summarize conceptual models of disability and provide a comprehensive overview of the language related to disability, explaining why language is critically important. The authors also offer directions for systems-level changes, and emphasize that leadership in nursing practice for the care of disabled people requires both education and knowledge to address biased health care practices.
The authors of Chapter 15 begin by emphasizing how the COVID-19 pandemic shed light on the limitations of Canada’s long-term care system. They provide an account of the health and illness challenges older adults face, including the impacts of the social determinants of health, ageism, and the limitations of current systems of care. In their analyses, they illustrate fault lines in resources for older adults living at home, in the community, and in long-term care settings. They articulate a new vision for healthy aging, and provide content regarding ethical leadership and improving attitudes toward aging. This latter section is focused on ways for nurses and other HCPs to improve the well-being of older adults.
The authors of Chapter 16 begin by asking readers to consider their own potential death. They provide information about suffering in end-of-life care, and challenge readers to critically examine the assumption that the alleviation of suffering is invariably a moral good. The authors stress that justice and dignity are the key principles of a palliative care ethic, and draw attention to the role of these principles when nurses are caring for gender diverse people at the end of life. They subsequently discuss the ethical challenges and leadership implications of medical assistance in dying (MAID) for nurses and their patients. The authors conclude the chapter by noting that advanced practice nurse leaders are key in advocating for policy change to ensure that the appropriate structures and systems are available for quality end-of-life care.
Section Three: Navigating Horizons for Health Care and Nursing Ethics
In section three of the textbook, which includes five chapters, we expand and broaden our horizons to focus discussion on genetics and identity, health informatics, biotechnology, and global health. We conclude this section, and the textbook, with a chapter where the editors imagine the yet-to-be-explored areas of nursing ethics, and provide final reflections about future horizons in nursing ethics and ways to move boldly forward.
In Chapter 17, the authors write about genetics and identity. They begin the chapter with a discussion of a number of genetic and genomic tools used in health care settings. Using a feminist and relational perspective, they discuss the complex ethical concerns that arise when analyzing and interpreting genetic findings. They move on to describe and analyze a number of ethical issues in genetics relevant to nurses and advanced practice nurse leaders, such as informed consent, incidental genetic findings, and access to genetic technologies. They conclude the chapter by highlighting the key role that advanced practice nurse leaders have in contributing to shaping the future of genetic and genomic technologies within health care systems.
As part of Chapter 18, experts in nursing ethics, technology, and health informatics participate in a Zoom discussion about a number of ethical considerations, including privacy, confidentiality, and safety; use of electronic health records; virtual care; and the use of artificial intelligence when providing health care. The speakers emphasize that there is a need for nurses in leadership positions in practice, education, administration, and research settings who can advocate for the suitable use of technology that meets the needs of patients, families, and communities. They articulate a vision for nurses where the profession as a whole can be more purposefully involved in evaluating, responding to, and helping shape the future of the technological and digital world in health care. The Zoom video of the session is included as part of the chapter, as is a transcript of the discussion.
In Chapter 19, the author emphasizes that the twenty-first century is often called the century of biotechnology. In this chapter, xenotransplantation is used as an exemplar of biotechnological development. A number of ethical and societal challenges, often pushed to the margins, are explored as nurses and other HCPs “boldly go where no one has gone before.” Many of the issues, concerns, and troublesome questions that emerge in the debate about whether xenotransplantation is part of the therapeutic armamentarium to treat end-stage organ failure are discussed; a number of these concerns are also evident in other domains of biotechnological development. The author describes approaches to encourage public participation in health care decision making and advances the dialogue about the ethical and societal concerns regarding biotechnology. In concluding the chapter, the author offers strategies to enhance advanced practice nurse leadership in the area of biotechnology.
Global health ethical issues are explored in Chapter 20. The author provides advanced practice nurse leaders with key concepts that are significant in global health, discusses values related to global health, and describes the interface of global health with human rights. One highlight of this chapter is a discussion of SARs-CoV-2, and how this global viral threat has made global interconnectedness so evident. The author challenges readers to consider how to cultivate the moral courage to live together harmoniously. The chapter concludes with an overview of ethical responsibilities for advanced practice nurse leaders in their roles as ethical global citizens.
Conclusion
In this chapter, we provided an overall description of the textbook, as a road map for readers to follow as they engage with the content throughout the book. We highlighted that nurses face a myriad of challenges as they try to uphold the ethical standards of the profession in increasingly constrained practice environments. We also described how nurses are in unique positions to promote social justice and equity in health care due to the level of trust and interaction they have with patients, families, and communities.
We noted that the nursing profession is in urgent need of greater numbers of advanced practice nurse leaders who have expertise in ethics, and who can drive inquiry forward in nursing ethics. We need leadership in ethics throughout every facet of our profession, and we need leaders who can support the ethical practice of our colleagues in other disciplines. This book is meant to provide support for such leadership. We encourage readers, as they engage with the discussions and questions in the chapters, to consider ethical reflection as both a lens and a mirror—that is, we can use ethics not only as a microscope, but also as a telescope, helping us to envision what is needed for the future.
Endnotes
1 We use the term advanced practice nurse leaders throughout the book to include registered nurses who have graduate preparation in nursing. Advanced practice nurse leaders have roles within the health care system where they are involved in supporting and strengthening nursing practice; educating students, nurses, patients, families, and communities; advocating for patients, families and communities; and influencing change in health care systems.
2 As authors and editors of this text, we consider equity to mean supporting persons according to their needs and resources, and treating like situations alike. We understand respecting diversity to mean being open to, learning from, and supporting people equally, regardless of diverse attributes such as age, ethnicity, language fluency, gender identity, and socio-economic status.
References
Canadian Nurses Association. (2017). Code of ethics for registered nurses. https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics
Doherty, R. F., & Purtilo, R. B. (2016). Morality and ethics: What they are and why they matter. In R. F. Doherty & R. B. Purtilo (Eds.), Ethical dimensions in the health care professions (6th ed., pp. 2–26).
Garneau, A. B., Browne, A. J., & Varcoe, C. (2017). Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing. Nursing Inquiry, 25(1), e12211. https://pubmed.ncbi.nlm.nih.gov/28685947/
Kidder, R. M. (2009). How good people make tough choices: Resolving the dilemmas of ethical living. Harper.
Storch, J., Rodney, P., Varcoe, C., Pauly, B., Starzomski, R., Stevenson, L., Best, L., Mass, H., Fulton, T., Mildon, B., Bees, F., Chisholm, A., MacDonald-Rencz, S., McCutcheon, A., Shamian, J., Thompson, C., Schick Makaroff, K., & Newton, L. (2009). Leadership for ethical policy and practice: Participatory action project. Canadian Journal for Nursing Leadership, 22(3), 68–80.
Taylor, C. (2013). Foreword. In J. L. Storch, P. Rodney, & R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed., pp. xi–xiii). Pearson.
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