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Journal of Christian Nursing:
doi: 10.1097/CNJ.0b013e3181d22fb6

Promoting Ethical Development in Nursing Education and Beyond


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Denise Stagg, MSN, RN, has been a nurse for 16 years, working in multiple areas after starting practice as an LPN in 1994. Currently she is a nursing instructor at the University of Louisiana in Lafayette. She attends a Roman Catholic church in Lafayette, Louisiana.

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Ethical nursing practice can be referred to as doing what is best for those who are the recipient of one's services, according to the recipient. However, clear-cut lines of what is and is not in the best interest of the patient can become blurred. Nurses often encounter situations that require them to use ethical judgment. This article discusses how ethical decision making can be developed in students, new graduates, and nurses in practice.

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Cindy, an RN who graduated from nursing school 6 months ago and is 3 weeks out from orientation, reports to work for the day shift on the rehab floor of a large teaching hospital. One of her assigned patients is a man recovering from a closed head injury who has a consult for pain management. The night shift nurse reports Mr. M is prone to violent muscle spasms upon increased stimulation or movement, and they have been trying to keep him as still and quiet as possible. After report and according to protocol, Cindy calls the anesthesia department for the pain management consult. She is directed to Dr. Jones who tells her, "That's fine, I can see him. But I have six cases in the operating room today. Just bring him down here and I'll have a look at him." Cindy tells Dr. Jones the patient is bed bound from his injuries and does not tolerate movement well. He replies, "Do whatever you need to do. If you want me to see him, then bring him to me." Cindy discusses the situation with the charge nurse who tells her, "I don't know what to tell you but you cannot leave the unit. You and I are the only RNs on duty plus one of the nurse assistants called in sick." Cindy calls the house supervisor looking for assistance and is told, "Well, Dr. Jones is the chief of anesthesiology. Just do what he wants."

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What ethical dilemmas exist in this case study? Do you see opportunity for patient advocacy? For nurse advocacy? What would you do if you were the nurse in this situation? How would you support Cindy?

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The nursing profession has long been considered a caring, compassionate, service-oriented, ethical profession (Saad, 2009). The ideal practice of using ethics to guide decisions can be referred to as doing what is best for those who are the recipient of one's services, according to the recipient. However, clear-cut lines of what is and is not in the best interest of the patient can become blurred. Nurses often encounter situations that require them to use personal and professional ethical judgment. For new graduates entering a practice world where things are not black and white, complex patient situations can be overwhelming. Care decisions are based on a multitude of factors requiring experience and efficacy to provide the best intervention for patients.

Nursing education exposes students to ethical dilemmas and guides them through the process of critical thinking and ethical decision making. The need for this exposure and guidance is very important, not only for the safety of the patients but also for that of the nursing profession. But nurse educators are not the only professionals responsible for increasing ethical awareness. Professional nurses in all levels of practice have a challenge to set the example for ethical practice for students and new nurses. Although new graduates may have achieved licensure requirements for practice, the need for mentors in their place of employment is ever present.

Within the unique relationship that exists between nurse and patient lies the opportunity to advocate for patients through ethical decision making. The American Nurses Association (ANA) promotes ethical practice and patient advocacy for professional nurses. The Code of Ethics for Nurses states, "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (ANA, 2001, p. 12). The responsibility of ethical nursing practice is described as, "concepts of autonomy, accountability, and patient-advocacy, based on a personal and individualized care system" (Esterhuizen, 2006, p. 104). In a study investigating patient advocacy (Seal, 2007), a nurse described advocacy as, "You want to provide comfort, encouragement and education and support your patients through their own process, not your own" (p. 34).

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Psychologist Lawrence Kohlberg's work on the stages of moral development, although criticized by some (Kenyon, 2009), is widely accepted as a description of how people around the world develop ethically. Kohlberg defined six stages of development occurring over three general levels (Table 1). It is the third and final level, Postconventional Morality, that involves questioning of self and societal norms and acting on universal ethical principles of what is right (Crain, 1985; Kenyon). At this level, one develops the ability to decipher right or wrong, just or unjust proponents of a situation, make a decision based on the merits of the situation, and discern the impact on those involved. Such decisions are not based on directives from superiors (someone told me to do it) or on immediate outcomes to self (what's in it for me, will I get in trouble?); these decisions require critical ethical review and insight. Using postconventional morality, a decision is made because it is believed to be right and action is taken because it is the right thing to do, not because it is expected, legal, or previously agreed upon. As nurses progress through their education and experience, they can be assisted to develop the ability to reflect on their beliefs of what is ethical and what is unethical and use postconventional morality in their practice.

TABLE 1: Kohlbergs S...
TABLE 1: Kohlbergs S...
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Ethical nursing practice does not develop overnight. It is developed by experience and understanding the meanings of those experiences. Speaking about "moral education" to promote moral development, Power, Higgins, and Kohlberg (1989) wrote, "Stimulated [moral] development occurs when the intervention sets up the conditions which promote stage progression. These [conditions] involve providing opportunities for cognitive conflict, moral awareness, role taking, and exposure to moral reasoning above one's own stage of reasoning." (pp. 15–16). Nursing students gain knowledge and experience through education about nursing ethics and ethical practice. Nurse educators seek to provide the basic tools to promote ethical decision making through guidance and reflection. But more importantly, nursing students need guidance to develop the confidence to act on their knowledge when they encounter ethical dilemmas. Experienced nurses can provide the knowledge and example for new graduates to develop this confidence.

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How can nurses be prepared for ethical decision making? In a study of ethical problem solving, Cameron, Schaffer, and Park (2001) asked nursing students to describe a case where they experienced ethical turmoil and how they chose to handle it. This "case-specific" assignment provided students a tool by which to evaluate situations for future patient interactions. Researchers Altun and Nermin (2003) administered questionnaires regarding aspects of patient advocacy to baccalaureate nursing students in the beginning and end of their 4-year education where instruction on ethics and decision making was weaved into the program. The researchers found an increase in acknowledgment of ethical situations to which nurses could be patient advocates. Other studies indicate students have shown improvement in their ability to recognize ethical situations and respond accordingly as their exposure to ethical education increases, implying nursing instruction can enhance students' ethical decision-making abilities. If new graduates could have continued guidance after entering practice, more confidence in ethical decision making could be instilled.

Interestingly, differences in ethical decision making have been found from graduation to practice. Ham (2004) compared ethical reasoning of senior baccalaureate nursing students and experienced practicing nurses. The Nursing Dilemma Test was completed by 112 students and 120 registered nurses, the majority of whom had 10 years or more of experience. Results indicated a higher level of ethical reasoning and decision making for the students than the practicing nurses. This suggests that exposure to real-life practice can have a negative impact on nurses. Although ethical reasoning is very high on graduation, once in practice "environmental pressures to conform" (Ham, 2004, p. 70) may be harder to overcome.

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Research also reveals barriers to ethical thinking and practice. Focus group interviews have revealed students' perception of moral obligation as "being guided by one's inner compass....ideals, values, and knowledge were continuously brought together and reflected upon" (Lindh, Severinsson, & Berg, 2007, p. 133). But students sighted conflict between doing what they thought was right and still being able to be part of the social work group. For example, students found it difficult to find the courage to do the right thing such as report a nurse's poor action. In another study, 75 nursing students wrote about their perspectives during clinical encounters (Lemonidou, Papathanassoglou, Giannakopoulou, Patiraki, & Papadatou, 2004). The most common journal entry was related to ethical conflict. Although the students identified ethical situations, they were conflicted by the response of the nursing staff to incidents. The students wrote about feelings of disillusionment such as, "After this was over I felt tired and depressed and really lonely. I never want to be a nurse if I am to become like this" (p. 129).

Limited staffing, burnout, lack of cooperation among healthcare workers, administrative decisions to control budget, and lack of autonomy for nurses are just some of the barriers to promoting high levels of ethical reasoning and decision making. Due to their limited experience, new graduates may find it challenging to maintain the ideals of nursing practice. New nurses possess the knowledge to act ethically but lack the efficacy. They are often fearful of retaliation from other nurses, physicians, or administrators, should they chose to act in accordance with their ethical reasoning. Further research on barriers to ethical practice and how to overcome these barriers would be beneficial to patients and workers alike. Such research also could provide useful information to guide nursing instructors and staff nurses in education of students.

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Nurse educators will continue to research and develop new and inventive ways to provide experience and guidance in ethical decision making. Providing select ethical situations in all levels of education can assist students to learn how to recognize ethical dilemmas and make decisions with the benefit of the patient in mind. Instructors' understanding of barriers to ethical practice and early discussion of these barriers also can be beneficial. Holding open discussion for students to relay impressions and experiences can encourage them to use critical thinking to solve or maneuver around barriers they may encounter. Encouragement and example by instructors in the clinical environment will assist students in developing confidence to act ethically. Continued use of reflection, in the form of journaling, role play, or open discussion, can assist in improving identification of ethical situations to draw upon for future experiences.

Once students graduate, encouragement and example are still needed. Developing and promoting relationships between new and seasoned nurses can benefit ethical development. Mentorship can facilitate confidence in new graduates and professional growth in experienced staff. Table 2 offers suggestions for mentor characteristics that would be helpful in promoting ethical development in new graduates. Nurse managers can work together in recognizing the potential for ethical conflict while promoting staff nurse involvement. Implementation of ethical in-services for staff can redirect nursing interventions and generate ethical consciousness. Listening to nurses' concerns regarding patient care and the work environment should be a top priority for nurse administrators. Nurses are in tune with their patients and inventive in their quest to give the best care possible. They have a wealth of information in nursing and economical practices, having first-hand knowledge of what is required to give exceptional care. Administrators are in a unique position to decrease nurse turnover and patient outcomes by promoting nursing staff involvement. As new nurses are exposed to positive outcomes in practice, confidence in their choice of occupation can increase. This confidence will encourage more people to join the nursing profession.

TABLE 2: Mentor Char...
TABLE 2: Mentor Char...
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The case study discussed earlier is true, except for one major difference. In this real-life experience, the house supervisor displayed postconventional morality and acted as an advocate for the patient, Mr. M, and for the nurse, Cindy. The supervisor told Cindy she would be happy to speak to the physician. The supervisor called Dr. Jones and explained that Mr. M would be unjustly placed at risk for spasms and possible injury should he be transferred to the OR. She encouraged Dr. Jones to come to the unit in between cases and assess the patient in his room. Dr. Jones relented and did go to the patient's room after a long conversation with the supervisor. He also reported the supervisor for insubordination, but no formal grievance was filed by the Director of Nursing. The patient was seen and the nurses were assisted. The supervisor further helped on the unit with various duties to assist with staffing the unit that day.

Ethical dilemmas are a part of nursing practice. Many times, the right choice is not so easily understood. Although indecision exists in experienced nurses, it is even more so for those new to the profession. Literature suggests nursing students are performing well on ethical dilemmas while in class but demonstrate a lack of confidence in clinical practice. Patient comfort, caring, and compassion have long been goals of nursing practice. For decades nurses have respected the rights of others. Now is the time for nurses to extend this comfort, caring, and compassion to the newest members of our profession, the nurse graduates. With support, encouragement, and guidance of one another, nursing will continue to grow and endure as an ethical profession.

Altun, I., & Nermin, E. (2003). Undertaking the role of patient advocate: A longitudinal study of nursing students. Nursing Ethics, 10(5), 462–471.

American Nurses Association [ANA]. (2001). Codes of ethics for nurses with interpretive statements. Silver Springs, MD: Author.

Cameron, M., Schaffer, M., & Park, H. (2001). Nursing students' experience of ethical problems and use of ethical decision-making models. Nursing Ethics, 8(5), 432–447.

Crain, W. C. (1985). Kohlberg's stages of moral development. In Theories of development (2nd rev. ed., pp. 118–136). Upper Saddle River, NJ: Prentice-Hall.

Esterhuizen, P. (2006). Is the professional code still the cornerstone of clinical nursing practice? Journal of Advanced Nursing, 23(1), 25–31.

Ham, K. (2004, March/April). Principled thinking: A comparison of nursing students and experienced nurses. The Journal of Continuing Education in Nursing, 35(2), 66–73.

Kenyon, R. (2009). Stages of moral development by Lawrence Kohlberg. Retrieved December 29, 2009, from

Lemonidou, C., Papathanassoglou, E., Giannakopoulou, M., Patiraki, E., & Papadatou, D. (2004). Moral professional personhood: Ethical reflections during initial clinical encounters in nursing education. Nursing Ethics, 11(2), 122–137.

Lindh, I., Severinsson, E., & Berg, A. (2007). Moral responsibility: A relational way of being. Nursing Ethics, 14(2), 129–140.

Power, F., Higgins, A., & Kohlberg, L. (1989). Lawrence Kohlberg's approach to moral education. New York: Columbia University Press.

Saad, L. (2009, December 9). Honesty and ethics poll finds congress' image tarnished. Retrieved December 29, 2009, from

Seal, M. (2007). Patient advocacy and advance care planning in the acute hospital setting. Australian Journal of Advanced Nursing, 24(4), 29–36.


decision making; Kohlberg; moral development; nursing ethics

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