By Stacey Kusterbeck
While directing the nurse residency program at a large midwestern academic teaching hospital, Rebecca West, MSN, RN, NPD-BC, observed that many recent graduates were highly distressed over ethical issues.
“The moral distress they experienced caused mental and physical symptoms. It also caused early burnout,” recalls West, now a senior clinical education specialist at Community Hospital North in Indianapolis.
One new nurse was intensely uncomfortable with completing orders for aggressive treatment for a patient clearly in the process of dying. The nurse did not think to request an ethics consultation.
“His lack of clinical experience and low level of moral agency, directly related to his tenure as a nurse, caused him to fulfill medical orders that were medically inappropriate,” says West.
West led a discussion about the troubling case. Other new nurses reported similar experiences, feeling compelled to complete medical orders they viewed as medically inappropriate. The nurses felt as though they were harming patients, resulting in insomnia for some. “As a result of these stories, I debriefed nurses on how to identify an ethical dilemma, and how to increase their personal moral agency by utilizing available resources,” says West.
West and colleagues authored a recent paper on the benefits of embedding ethics content in nurse residency programs.1
In addition to affecting physical and mental health, nurses being unprepared to manage ethically complex cases also could have a negative effect on clinical care, the authors assert. For instance, nurses may not push back against inappropriate treatment pathways.
Code status is another area that inexperienced nurses struggle with. “Several times, new graduate nurses told me that physicians new to practicing medicine thought that a DNR (do-not-resuscitate) code status implied that no aggressive treatment should be given to a patient,” says West. In reality, patients can be DNR after they stop breathing or lose a pulse, but they may want aggressive care provided when appropriate.
“New graduate nurses with limited clinical judgment would not advocate appropriately, and the patient would decompensate as a result,” says West.
Nurses need to be able to identify ethical dilemmas, such as inappropriate treatment, identifying the correct surrogate decision-maker, or determining a patient’s code status. Nurses also need to know the available resources to manage ethical conflicts. Ethics training during nurse residency programs can help improve both these skills, the authors noted.
“Ethicists could support this process by creating unit-based ethics conversations that allow space for nurses to debrief,” suggests West.
The problem of inadequate ethics preparation is widespread in the nursing field, according to Pamela J. Grace, RN, PhD, FAAN, HEC-C, associate professor emeritus at Boston College. Grace and colleagues developed a framework for ethics education in nursing.2
“This is a very complex issue with many contributing factors. In part, this is probably due to a turn away from the humanities and toward the physical sciences in many universities, and at the graduate level. Those who become nurse educators often do not get a course in ethics or how to teach it,” says Grace.
Currently, Grace is teaching nursing ethics to the first cohort of nurses obtaining a baccalaureate nursing degree in Armenia.
“Interestingly, other countries are recognizing the importance of ethics education for nurses at a time when it is falling out of nursing curricula in the United States,” observes Grace.
After nurses are able to discuss ethical issues with colleagues, patients, and families, it reduces their moral distress, says Grace. Ethics expertise also can help nurses to not feel alone when the problem has a system cause (such as inadequate staffing). “For new nurses, it is even more important. Many senior nurses left after experiencing the horror of working through COVID. Thus, new nurses have fewer seasoned nurses to draw upon,” says Grace. Clinical ethicists can help those nurses to address ethically complex cases. These unique ethics issues that nurses face often fall “under the radar,” in Grace’s experience:
• Nurses observe family members pressuring a patient to get certain treatments that the patient does not want.
• Nurses see that pain medications are inadequate but are unable to get ahold of the doctor to change the order.
“Nurses tend to be in more sustained contact with patients and their families. They, perhaps more frequently than others, face such problems,” says Grace.
- West RS, Axel-Adams RM, Wocial LD. Embedding nursing ethics within teaching strategies in nurse residency programs. J Nurses Prof Dev 2024;40:167-171.
- Robichaux C, Grace P, Bartlett J, et al. Ethics education for nurses: Foundations for an integrated curriculum. J Nurs Educ 2022;61:123-130.
