Chapter 7: Implications of professional values and ethics for nursing

Introduction

Previous chapters have provided a detailed overview of the professional, legal and ethical demands of the nursing profession. All of these demands influence the way you manage patients and will influence your attitudes towards patients throughout your career. However, these demands may also influence other aspects of your nursing career. Ethical dilemmas may cause stress and moral distress, while excessive professional demands and role development in nursing may be a source of burnout. The aim of this chapter is to provide some insight into how these professional and ethical values impact on the modern nurse and what can be done to lessen the negative impact of these demands.

The positive impact of professional and ethical values

The wide range of values discussed in the previous chapter illustrates how diverse and demanding the nursing profession has become and the importance of the nurse in contemporary healthcare settings. These values are designed to guide the way nurses interact with patients, work with other professionals and coordinate practice development or personal improvement. These values therefore have a multitude of benefits for the contemporary nurse and patients alike.

One of the most significant benefits of professional values in nursing is that nurses are able to act autonomously in determining patient care, by virtue of knowledge and skills development throughout their career. Nurses have a wide range of skills that are developed in accordance with their professional framework and values. These skills enable nurses to meet the needs of patients in diverse ways, providing a more complete therapeutic experience and avoiding delays in care provision. Similarly, as the professional values of nursing demand extensive knowledge of therapies and care processes, nurses can become experts in their field, benefiting their profession and patient care. Therefore, the fact that the professional values of nursing practice demand excellence in these areas provides motivation for nurses to become care experts and deliver the best possible level of care to their patients.

Professional values in nursing also allow you to advance your career and pioneer new treatment approaches by engaging in research and clinical leadership. Nurses are a vital component of the healthcare system and their contribution to research and leadership is promoted by the Nursing and Midwifery Council (2015) not only as means of advancing personal practice, but also potentially influencing practice for others as well. Professional values provide a clear set of directives for how nurses can integrate research, teaching and leadership into their daily lives, providing an impetus for achieving skills in these areas.

For instance, nursing leadership is a concept that has gained increasing popularity in research and practice, reflecting the knowledge and experience of nurses in addition to their role in the centre of many healthcare processes (Blais, 2015). By promoting leadership among nurses, these values encourage nurses to take control of patient care and promote advocacy of patients. Leadership also allows nurses to contribute to the development of their profession, while representing their profession within multidisciplinary care contexts. Therefore, leadership skills can be considered a beneficial professional value of the nursing profession that facilitates knowledge and skill development in addition to better patient care.

Teaching and research are also being increasingly recognised as roles where nurses should be able to make important contributions (NMC, 2015). Although nurses are expected to manage patients in a practical manner on a daily basis, taking these experiences and applying them to the research setting allows for the design of studies and exploration of gaps in knowledge that have been observed in practice. Similarly, when nurses engage in teaching others, they provide the opportunity to solidify their own knowledge on a subject, as well as disseminating knowledge within the team, for the greater good of patient care. Both research and teaching are academic pursuits that not all nurses may wish to participate in, although informal teaching on the ward is expected of all nurses as a key part of continual staff training and development. However, awareness of research, engagement with teaching practices and appreciation of the value of evidence-based nursing in practice should be traits common to all nurses who wish to be successful in their careers.

The ethical values of nursing are considered beneficial in a number of ways, not only by providing a set of guidelines for practice, but also by ensuring the wellbeing of patients. Ethics extend to all parts of the decision-making and care delivery process and influence nurses on a daily basis. Instilling nurses with ethical values allows them to engage in care that is fair, evidence-based and designed to look after the best interests of the patient - particularly when the patient is unable to make their own decisions. Thus, the ethical values of the nurse act to safeguard the most vulnerable members of society while providing nurses with guidance during difficult decision-making processes. For instance, patients with learning disabilities or mental health problems may lack the capacity to make even basic clinical care decisions. For these patients, the risk of violating the rights of the patient is increased during clinical care unless nurses act as professional and ethical advocates for these patients.

The negative impact of professional and ethical issues

Although the values of ethics and professionalism are a major factor in ensuring the safety of patients and protection of their rights, there may be negative consequences of these values when applied in practice. These negative aspects typically relate to the pressures placed on nurses to achieve high standards of care for every patient and to engage in individualised, evidence-based practice, with an ever-increasing level of responsibility and accountability.

As noted previously, technological and care advances have been responsible for improvements in patient care over the past few decades. These advances have the potential to reduce the ethical uncertainty regarding certain types of intervention -  particularly as therapies become safer and more specific to the needs of the patient. As a result, patients may be prone to fewer side effects and complications from therapy, reducing the need to consider net clinical benefits or harm-risk profiles of interventions. However, these advances are also potentially challenging for nurses in a professional and ethical sense. As new advances emerge, nurses are obligated to keep up-to-date with their use and side effects, leading to an increased knowledge burden. Furthermore, these advances do not necessarily remove ethical challenges, but may further complicate ethical decision-making (Benner et al., 2009). As interventions become more sophisticated and the ability of nurses and doctors to treat illness becomes more pronounced, the views of patients may be side-lined and jeopardised as a consequence. Indeed, there is a perception that nurses may struggle to maintain ethical practice in the face of an increasingly technological or medical approach to patient care (Benner et al., 2009). It can be a challenge to act as a technician or expert, while maintaining compassionate and personal approach to care.

The following sections will consider the specific consequences of professional and ethical demands placed on nurses with regards to the development of stress. These areas are important to consider for all nurses and nursing students, as coping with stress will form a major part of your practice.

Stress and moral distress

One of the most significant negative influences of professional and ethical pressures on nurses is the potential for stress and moral distress. When professional standards need to be met in every instance of a patient interaction, this can be overwhelming for some, particularly when faced with time pressures, complex patient management scenarios, and a physically and mentally challenging shift pattern. Furthermore, ethical dilemmas can have a significant impact on nurses on a personal level, leading to uncertainty over decisions that are made and personal moral conflicts when courses of action may cause discomfort in patients, or where patient’s rights may be violated for the greater good.

Stress can be a mental or physical experience, depending on the severity of the stressful situation and the vulnerability of the individual. Stressful situations affect people in different ways and it is important to recognise that different people need different types of support. Nurses who are more experienced have often encountered a number of stressful situations and may be more immune the effects of these situations, having developed coping strategies. Younger nurses, or those with less experience, may be more vulnerable to the acute effects of stress. Therefore, older or more experienced staff members may provide valuable informal support to less experienced colleagues when encountering stressful clinical situations. However, individuals may respond completely differently to stress, so it is important that you are able to recognise when you experience stress and are able to access support when needed.

As well as the professional demands of the job, the ethical and moral nature of nursing is a major cause for stress in contemporary practice. As noted in previous chapters, ethical dilemmas can be encountered in many aspects of the job and may require difficult decisions to be made. These decisions may conflict with your own personal moral values or may lead to moral distress - even when they are in the best interests of the patient. It is important that, no matter what your personal view, you do not allow your personal feelings of a care situation in influence patient decisions, or to compromise treatment of the patient in relation to their best interests. However, when you do feel conflicted, you should be supported in your ability to discuss this with colleagues or to seek support in other ways, as you see fit.

Overall, stress and moral distress are important consequences of the professional and ethical demands placed on nurses. The following section will consider how these stressful events can lead to negative outcomes for nurses and what should be done to prevent these circumstances from developing.

Job dissatisfaction and burnout

When stress levels are too much to cope with on a daily basis, there is a risk that you may not be able to function effectively in your role. This is particularly true when nurses are dissatisfied with their job, as a result of the demands of the job or because of specific stressful events. Stress can manifest in many ways, but the effect that it may have on your ability to carry out patent care every day is extremely important.

Dissatisfaction with your role as a nurse is a potentially serious situation, as it suggests that you may have encountered experiences that were largely negative, or that aspects of the job are taking their toll on your wellbeing. When protecting the rights of patients, dissatisfaction may arise over time if the organisation or department in which you work does not adhere to best practice principles, or you are unable to institute change consistent with respecting the rights of patients. Often, when nurses feel powerless to help patients or staff, they may feel as though they cannot fulfil the duties of their role to the best of their abilities. This may be due to management constraints on working practice, poor resource availability on the ward, or a demanding time schedule, all of which can impact on how satisfying the job of a nurse can be when managing complex ethical dilemmas or professional situations.

Burnout is a situation when nurses are no longer able to cope with the demands of their work due to stress and may have to have time off as a result of this stress. Nurses who experience burnout often have multiple reasons for feeling stressed and may lack effective support mechanisms to cope with that stress. The impact of burnout on the profession as a whole can be significant, as nurses may leave the profession altogether or extended periods of absence may be required, affecting staffing levels and morale.

Support and coping strategies

Based on the impact that stress might have on nurses, it is essential to consider how nurses can cope with stress, reduce the occurrence of stressful situations, and utilise available support mechanisms appropriately. The ways in which individuals manage issues of stress vary significantly, depending on factors such as personality, experience, confidence and available support mechanisms (including social support). However, all nurses should have support available to them and should be able to apply strategies to minimise the impact of stress on their daily lives, thereby preventing burnout and deterioration of job satisfaction.

Support can come in multiple forms in the ward environment; it may be as simple as discussing concerns with a colleague, or may involve more formal processes such as counselling or structured reflection (e.g. in a group session). The way you access support and the specific type of support that you feel you need varies considerably - you should always consider what would work best for you, but keep an open mind about the value of counselling and other coping strategies for when situations are difficult. However, for most nurses, counselling is only necessary when dealing with ethical dilemmas in situations where decision-making is leading to undue levels of stress, or to a reduction in job satisfaction or job performance. Most of the time, simple strategies and coping mechanisms can be used to avoid these situations and to ensure that you can provide patient care to the best of your abilities.

Firstly, it should always be remembered that knowledge is power, even when managing complex patients. You may not always have the right answer for a particular patient, but someone else may have managed a similar patient, or guidelines may provide clear instructions for that type of patient. Drawing on these resources and using them appropriately is a key skill that can help to reduce pressure on yourself. You should be aware of contemporary guidelines and ward/care setting policy on how to manage complex patient scenarios, including consent assessment and the use of restraint and similar measures. However, these practical guidelines may not cover every eventuality and therefore you should always be ready to discuss care with other colleagues, who can not only provide information when you are in need, but also professional and emotional support. Nursing is a caring process and decision-making cannot be reduced to ‘black or white’ options most of the time - sharing personal experiences and making sure patients are cared for in a manner consistent with evidence-based practice is an invaluable part of the caring process.

In addition to knowledge, you should also ensure that you may the most of any available training courses or opportunities to develop your clinical skills further. One of the most stressful situations that a nurse can be placed in is the need to manage a patient when they lack the appropriate skills to do so, either due to a lack of training or a lack of confidence. This can delay patient care, may aggravate stressful situations and can cause anxiety. Being prepared and expanding your skill set can therefore be helpful in reducing the occurrence of these events. Furthermore, making sure you are aware of your colleagues’ skill sets is important, as an added level of support. Reliance on colleagues and working within a team setting is perhaps the most fundamental strategy that you can use to reduce stress and optimise the potential for patient care that is professional and ethical. Colleagues are there to support your decisions, provide guidance, share the burden of care, and to discuss any issues with care. Using this support network is vital - not only to ensure that you have the support from other professionals when making decisions about patient care, but also in managing your time effectively to facilitate optimal care.

Reflective practice

Among the techniques an individual can use to reduce stress, reflective practice is one of the most common and widely advised for nurses. Reflection typically involves reviewing your own performance in a specific scenario, allowing you to make sense of how decisions were made and the good and bad aspects of those decisions. Typically, a reflective cycle should be used for this purpose, in order to make the reflective process formal in nature. The Gibbs (1988) cycle is commonly used for this purpose, encompassing a description of the event, overview of your thoughts and feelings, an analysis of the situation, an evaluation of the strategies used, and an action plan based on the need to improve care and personal knowledge or skills. By making use of a cycle such as this, you can continually strive to improve your own practice by reflecting on how you have cared for patients.

Reflection is not only about guiding how you develop your knowledge and skills, however; it is also an important process that allows you to stop and take time to consider the issues that arose when managing a specific patient, reflecting on your own feelings and attitudes during the care process. This is a valuable process for many people, as it permits you to identify components of care that caused you the most difficulty or were stressful. By analysing how these situations developed and their impact on your personal wellbeing, you may be able to avoid similarly stressful situations in the future by adopting coping mechanisms or supportive strategies.

In summary, reflection should be considered a support mechanism that all nurses can engage in on a routine basis. By sharing your reflective experiences with others, you can share information and learn from others’ experiences, broadening your ability to manage stress in the workplace.

Conclusion

This chapter has provided an overview of how the professional and ethical values of nurses impact on practice. Both positive and negative factors can arise from these values, and it is important to minimise the potential impact of negative factors on an individual. You need to be aware of situations that can cause moral distress or physical stress and utilise support mechanisms appropriately. This includes the use of effective practice and colleagues’ support whenever possible. This chapter concludes with an example essay focusing on ethical dilemmas in practice, exploring how nurses can be supported to make ethical decisions, preventing harm to the patient and others.

Example essay

Ethical dilemmas are common in nursing practice and require careful consideration of multiple aspects of the care process by definition (Blais, 2015). One study noted that oncology nurses faced as many as 32 distinct types of ethical dilemma over a one-year period, often facing ethical dilemmas on a daily basis (Raines, 2000). Indeed, nursing ethics encompass a broad range of activities and behaviours, designed to maintain the best interests of the patient, advocate on behalf of the patient, and protect the rights of the patient (Burkhardt & Nathaniel, 2013). Furthermore, nurses have a responsibility to make ethical decisions in care on the basis of population health and the protection of the health and wellbeing of others (NMC, 2015). Ethical dilemmas may also involve specific issues such as pain management, resource issues, including cost containment of interventions, and quality of life concerns (Raines, 2000). Therefore, a broad range of ethical considerations are involved in contemporary nursing practice, undoubtedly impacting on nursing training and professional development.

Conflicting ethical priorities and concerns may arise in practice, and the course of action that should be taken is not always obvious or agreed upon among nurses (Blais, 2015). Therefore, nurses need to be broadly supported in practice in order to allow for ethical dilemmas to be resolved in a manner that prevents harm to the patient or others and results in the most ethical process of care. These conflicts may involve instances where the safety or wellbeing of the patient is jeopardised by an advisable treatment course, or where the patient may lack capacity to make their own decisions, and therefore healthcare professionals need to act in a manner that they believe is consistent with the best interests of the patient (Hamric et al., 2013). This may not always be an obvious approach, however, and can cause undue stress and anxiety in patients and staff members, as well as moral distress (Hamric et al., 2013). Therefore, it is worth considering the elements that can be used to facilitate ethical decision-making on an individual nurse basis.

Within the context of ethical care, there is a fundamental issue of protecting the rights of the patient and others who may be affected adversely by patient actions or care processes. There are a number of practical measures that nurses can take in order to protect these rights, as demonstrated in the wider literature base (e.g. McLennon et al., 2013; Park et al., 2014). The individual nurse ultimately has responsibility for protecting the rights of patients and acting in accordance with respect for patient rights (NMC, 2015). Nurses who are aware of the rights of patients and have greater ward experience with complex care scenarios are more likely to express satisfaction with their understanding of ethical care in practice (Park et al., 2014). Therefore, knowledge of the rights of patients and the existing frameworks in place to protect those rights is fundamental in facilitating ethical decision-making (Stein-Parbury, 2013).

It should also be noted that contemporary nurses have a great burden placed on them, as they need to maintain expert knowledge of increasingly sophisticated care processes and intervention techniques (Stein-Parbury, 2013). Regardless of the complexity or technological nature of the technique, all interventions should be grounded in an ethical framework to avoid losing the therapeutic nature of the patient-nurse relationship (Arnold & Boggs, 2015). Nurses need to balance the maintenance of evidence-based skills, cost considerations (particularly in the National Health Service), and ethical patient management. Achieving ethical practice involves nurses not being coerced into actions that they consider ethically ‘wrong’ and having a supportive environment around them, consistent with the advocacy and respect of patient rights (Milliken & Grace, 2015).

The initial responsibility for ethical care rests with the individual nurse who is directing the care process (NMC, 2015). Unless people are willing to act on an individual basis to manage patients ethically, accountability of ethical decision-making can be lost or diluted (White et al., 2015). This is particularly important in instances where patients lack capacity and the nurse needs to advocate on their behalf. It has been shown that patient care may be suboptimal when nurses do not have clear roles in advocating for patients lacking capacity, they are more likely to deny accountability for patient care, which may lead to poor outcomes (Wong et al., 2013). Therefore, individual nurses need to respect their role in the care process and should maintain accountability. Ensuring patient safety in cases where the individual may be aggressive or violent is a particular concern, as this can be stressful for an individual nurse and may be overwhelming (Mohr, 2010). In such situations, it has been noted that more junior or inexperienced staff may express a concern over their ability to manage the situation and may not accept accountability for their actions (Mohr, 2010). Often, they feel forced into the use of restrictive measures or seclusion, rather than planning for the use of these measures only as needed (Wong et al., 2013). Therefore, it is important that inexperienced staff are supported in these examples and that a clear framework is in place to facilitate management of patients that is proactive rather than reactive, in order to prevent forced measures which may have been avoidable (White et al., 2015).

Individual nurses should also take responsibility for their own personal development in practice and should routinely engage in reflective practice (Kalaitzidis & Schmitz, 2012). As noted in this chapter, reflection is a key coping mechanism and means of continuing professional development (NMC, 2015). Nurses who routinely engage in reflective practice often benefit from this process by experiencing a renewed enthusiasm for personal skill development, recognition of errors in practice, and increased knowledge and skills (Ganzer & Zauderer, 2013). Therefore, nurses should be encouraged to reflect on individual episodes of care - particularly when a stressful decision had to be made or the rights of the patient may have had to be compromised for the greater good (Ganzer & Zauderer, 2013). This will allow nurses to maintain their own ethical and moral standards of practice, while facilitating action to be taken where these standards may not have been achieved (NMC, 2015).

As well as the role of the individual nurse, ethical dilemmas and ethical patient care require the input of senior members of staff, organisational leaders, and management (Wong et al., 2013). The ability of an individual to make complex care decisions when the repercussions of those decisions may have implications of the entire organisation is limited. This reflects the need for management and organisation leaders to demonstrate accountability for the broader actions of the healthcare team - particularly when issues of vulnerability and rights emerge in routine patient care (Arnold & Boggs, 2015). Therefore, management staff within an organisation can play an important role in facilitating optimal patient care as well as nursing satisfaction.

An example of the importance of management/senior staff input into the nursing experience can be seen in relation to the way that wider healthcare policy is actually implemented in practice and the culture associated with patient care (Arnold & Boggs, 2015). In a management team with a strong ethos of care, a culture develops that is consistent with the principles of ethical are (Grohar-Murray et al., 2016). Management and senior staff can foster a positive care culture by engaging regularly with nurses and allied healthcare professionals, leading by example and motivating staff members to adhere to wider policy and guidelines (Aitama et al., 2010). This adherence should be facilitated by ensuring that necessary resources and mechanisms are in place to allow nurses to act as autonomous professionals who delivering patient care (Grohar-Murray et al., 2016).

Provided management are focused on the welfare of patients and are responsive to staff concerns over ethical dilemmas, the majority of decisions made in practice can be considered beneficial to the organisation as a whole (NMC, 2015). When management do not achieve these elements, however, patient care may be adversely impacted - particularly if nurses are not able to access appropriate interventions, are coerced into excessive use of restrictive measures, or feel unable to speak out about witnessed deprivation of liberties (Arnold & Boggs, 2015). Indeed, as much as anything, a culture of openness is essential to ensure that staff and management maintain a close relationship and are able to work cooperatively to deliver professional and ethical patient care (Aitama et al., 2010). This openness is a key part of existing guidance (e.g. NMC, 2015) and should be promoted across all healthcare disciplines.

Leadership is a fundamental component of how effective management of healthcare organisations is achieved (NMC, 2015). This includes instances of supporting staff members and promoting patient wellbeing in the care setting (Arnold & Boggs, 2015). Leaders who adopt a transformational approach to staff interaction often achieve the most effective outcomes when implementing policies and changes in practice (Huber, 2013). This leadership style facilitates motivation, self-empowerment and achievement of satisfaction among staff members, all of which are crucial to job satisfaction and confidence in the care setting (Huber, 2013). Leaders who are able to instil key virtues and motivations in members of staff are more likely to create a positive working environment, which is compatible with autonomous nursing practice (Arnold & Boggs, 2015). Hence, leadership skills should be considered an elemental aspect of how management support staff to make decisions and provide professional care.

The final tier of support that should be available for nurses making ethical decision in practice is that of professional bodies and broader healthcare institutions and their representatives. Nurses are a diverse professional group, but their actions and professional values are designated by the Nursing and Midwifery Council (NMC, 2015). This professional body demands that nurses engage in ethical care at all times, and dictates the professional values underpinning these care decisions. Hence, it is a natural extension of the role of the NMC to facilitate ethical decision-making and provide expert guidance to nurses on an individual basis, and organisational basis, as needed.

The ways in which the NMC and the Department of Health contribute towards supporting ethical care and decision-making are varied. Principally, these bodies play an important role in creating and promoting guidance for nurses and associated healthcare staff, standardising frameworks for ethical decision-making (NMC, 2015). These documents are widely available and form an integral aspect of practice on a daily basis, forming the basis for professional values and interprofessional care pathways in many healthcare settings (Polit & Beck, 2013). However, the formulation of these guidelines is not sufficient in supporting the nurse on a daily basis, as not all scenarios can be accounted for in such guidance. Therefore, professional bodies also have a remit to provide opportunities for training, skill extension, and advocacy for nurses in an interprofessional health setting (Arnold & Boggs, 2015). By advocating for nurse skill development and the role of nurses in managing complex patient cases, these bodies raise the level of discourse regarding the needs of nurses when making complex care decisions, thus drawing attention to wider ethical issues suitable for professional and legal discussion (Polit & Beck, 2013).

Furthermore, professional bodies have an obligation to reflect wider social changes and public opinion within care decisions (Tingle & Cribb, 2013). This includes an increasing recognition of and respect for patients’ rights in everyday care and the development of safeguards to protect not only nurse values, but also the experience of the patient (Bowman, 2013). By forging a close link between healthcare professionals and patients in a public forum, these bodies provide a basis for improved communication between the two groups (Bowman, 2013). This is more likely to foster a positive atmosphere where ethical decisions can be discussed openly and where nurses and patients are aware of potential issues before they arise, allowing for care planning and advance decision-making - both of which can assist in complex decision-making (Tingle & Cribb, 2013).

In summary, nurses require a wide degree of support when making professional and ethical decision in practice. These support mechanisms may be internal, reflecting the coping strategies of nurses in routine practice, or may be largely external, including both management and organisational factors. Consideration of the time demands, workload, training and emotional stability of nurses should be recognised in the context of ethical patient care and formal guidelines should be supported with the use of specific staff education and support strategies to avoid job dissatisfaction or burnout.

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