By Stacey Kusterbeck
Nurses reported significant social and professional barriers to act in response to an ethical violation, a recent study found.1 “Nurses, and other clinicians as well, don’t always understand the ethical implications of their work,” says Lisa Wolf, PhD, RN, an associate professor at the Elaine Marieb College of Nursing at the University of Massachusetts Amherst and the director of the Institute for Emergency Nursing Research.
In a previous study, Wolf and colleagues interviewed emergency nurses in states with abortion bans.2 Many nurses insisted they would do what was necessary to take care of the patient. To learn more about what that really meant, the researchers analyzed 75 emergency nurses who completed The Nurses’ Moral Courage Scale. Nurses eported high perceived levels of moral courage. More than 70% stated that they would speak up about an ethically challenging situation.
“On paper, nurses rank themselves very high, and said they would always act with moral courage. But what that means, in a practical sense, is very different,” says Wolf. The researchers used a mixed methods approach, which allowed them to compare the self-reported data with more nuanced qualitative data from follow-up interviews.
Nurses were asked what actions they took when witnessing an ethical violation. Most (65.8%) nurses said they would bring it up for discussion. Few (21.1%) nurses were willing to report it internally. Only 13.2% of nurses said they would take on a whistleblower role and report the problem externally to trade unions, the media, or outside organizations.
Nurses talked about barriers to acting with moral courage. “Certainly, nurses are one of those very few professions where a single woman can support her family. People are very protective of their financial security, which is understandable,” says Wolf. One nurse stated, “We’re single parents supporting our family, supporting our kids. They’re scared to lose their job. They’re scared of the consequences.”
However, nurses primarily were concerned about social consequences. Nurses worried that making a report would adversely affect their relationships with colleagues. One nurse stated that to report doctors “would be egregious because you would be betraying them.”
Nurses responded that it was “fairly” or “very” easy to defend their professional values to co-workers, ancillary staff, patients, patient families, and authorities outside of the organization. Nurses were less likely to report ease in defending their professional values to physicians, charge nurses, or administrators.
“Nursing is very peculiar in this way — the social environment really dictates how people behave. If I am worried that a nurse will be mad at me, I’m less likely to challenge her on behavior, or patient care, or anything else,” says Wolf. Nurses described a social environment that precludes nurses from speaking out about ethical concerns. Nurses saw doing so as a betrayal of their colleagues. “If a nurse reports a physician for poor care, then the nurse feels they’re betraying their family. Their loyalty is to the unit and not to the patient. This seems like a backwards understanding of how ethics works. Every code of ethics, certainly the American Nurses Association’s (ANA) Code of Ethics for Nurses, speaks to the primacy of the patient,” underscores Wolf.
Notably, nurses’ willingness to take action on an ethical issue hinged on their own personal values, not professional codes of ethics. “Nurses did not understand professional ethics as something they were obliged to follow. Nurses were totally driven by their personal ethics. Nurses said, ‘Well, if it mattered enough to me, I would do something about it,’” says Wolf.
None of the nurses spoke about their professional obligation to take action if something was unethical. “Nurses did not understand the idea of a professional ethical framework that superseded their own feelings about something. The idea of professional ethics did not enter this conversation, which is a little terrifying, frankly,” says Wolf. “Nurses are no different from other people, and will protect their personal interests. But that’s not what nursing is, and what we need is a structure that supports nursing ethics. It is foundational. Otherwise, you are just doing tasks.”
Nurses also qualified that they would take action only in certain circumstances. “What it boiled down to is, the nurse would act if they thought actual patient harm was happening literally in front of them. But the idea of extending the perimeter of who deserves ethical action did not really extend beyond their patient assignment,” says Wolf. “Especially around issues of reproductive justice, nurses were pretty clear that those patients ‘out there’ did not enter into their moral calculus.”
Several nurses identified burnout as a contributing factor to decreased ethical action. One nurse questioned why, if nurses were unsupported with previous complaints, they would expect to get any support from administration for a more serious ethical concern. “Especially if there is no reporting structure, it is challenging for nurses to make ethical concerns known in a way that provokes a response,” acknowledges Wolf.
One challenge is that the amount of ethics education nurses receive varies. At some nursing schools, there is no separate ethics education; instead, the ethics topics are integrated into other course material. “But you need to have somebody who’s trained in ethics to teach it. There’s also the hierarchal structure at a lot of healthcare institutions — and for the new nurse, for the nurse of color, for the nurse who’s part of the LBGTQ community, for anybody who’s not in the dominant group, it’s really hard to speak up. And we’re not giving people the support or the training or the language to be able to do that,” says Wolf.
Ethicists can help by giving nurses the language to use to talk about why something is unethical. Nurses may comment, “This isn’t right,” or “I think this is wrong.” With ethics training, nurses can say instead, “According to the ANA Code of Ethics for Nurses, you are violating the ethical principles of justice and beneficence.” “Training in ethics gives people language, and the ability to have a conversation that’s depersonalized, in a way,” says Wolf.
The authors advocate for nurses to receive ethics education that is specifically targeted toward nursing. “For ethicists, the challenge is to help nurses connect the dots between whatever classroom instruction they’ve had regarding ethics and what’s actually happening in their workspace,” says Wolf.
On nursing units, an everyday ethical issue might be something as basic as not having enough angiocaths. “How does that become an ethical situation? I would offer that any time you are not providing a safe environment for your patients, you are violating ethical principles,” says Wolf.
References
1. Wolf LA, Noblewolf HS. Moral courage of emergency nurses in care-limited environments: A mixed-methods study. Nurs Ethics. 2025;32(2):514-529.
2. Wolf L, Noblewolf HS, Callihan M, Moon MD. What if it were me? A qualitative exploratory study of emergency nurses’ clinical decision making related to obstetrical emergencies in the context of a post-Roe environment. J Emerg Nurs. 2023;49(5):714-723.
Nurses reported significant social and professional barriers to act in response to an ethical violation, a recent study found.
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