What types of ethical challenges did Florence Nightingale face over 200 hundred years ago, and how did she respond? What can we learn from her?
These questions are reminders that ethical challenges in nursing are not new. Nightingale, often regarded as the founder of modern nursing, faced complex moral dilemmas, from advocating for sanitation reforms against institutional resistance to calling attention to the extensive role of women in healthcare. Her commitment to improving patient care, integrity, and ethical decision-making continues to serve as a foundation for nursing ethics.
Today, ethical knowing in nursing extends far beyond Nightingale's legacy. In every setting, whether it’s the ICU, a long-term care facility, or a community clinic, nurses must constantly weigh the principles of ethical principles like beneficence and autonomy. Ethical knowing empowers nurses to reflect on their values, understand the broader impact of their actions, and prioritize the dignity and rights of every patient.
What is ethical knowing in nursing?
Ethical knowing is one of the four fundamental patterns of knowing in nursing (empirical, aesthetic, personal, and ethical) described by Barbara Carper, RN, EdD, in her article, “Fundamental Patterns of Knowing in Nursing.”
While some may consider this term interchangeable with “ethical knowledge,” ethical knowing goes beyond clinical skills and scientific knowledge. It involves the moral and ethical reasoning that guides nurses in making decisions that respect patients’ rights, uphold professional integrity, and align with these four central principles:
- Beneficence
- Nonmaleficence
- Autonomy
- Justice
Nurses encounter ethical knowing in everyday practice when they must decide how to advocate for a patient, navigate conflicts between institutional policies and patients’ needs, or manage situations where personal values and professional responsibilities clash.
Common ethical dilemmas nurses face
With the evolution of technology and the healthcare industry, nurses can encounter a wider range of ethical dilemmas that require moral reasoning and ethical knowing.
1. Patient autonomy vs. beneficence
Beneficence in nursing can be defined as doing good or benefiting the people you serve, said Cynda Rushton, PhD, RN, FAAN, the Anne and George Bunting Professor of Clinical Ethics and Nursing at Johns Hopkins University in Baltimore, Maryland, in a Nurse.com blog.
One of the most common ethical tensions in nursing is balancing respect for patient autonomy with the duty to promote well-being. Patients are allowed to make decisions about their care, even when those decisions don’t lead to a full recovery.
For example, a patient with terminal cancer may refuse life-prolonging treatment. Nurses must navigate these situations by educating patients about the consequences of their decisions, ensuring informed consent, and supporting their choices while adhering to ethical and legal guidelines.
2. Resource allocation and staffing shortages
The nursing shortage continues to affect nurses nationwide. When faced with inadequate staffing or limited resources and the need to prioritize care, ethical knowing is critical.
This can lead to moral distress, where nurses feel care is compromised because of factors that aren’t in their control. Ethical knowing helps nurses advocate for systemic changes, such as safe staffing ratios and equitable resource distribution.
3. Truth-telling and informed consent
Informed consent is the “process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention,” according to the National Library of Medicine.
Nurses often serve as the bridge between patients, families, and physicians, which means ensuring patients receive accurate and complete information about conditions and treatments.
Ethical knowing in nursing and the ethical principle of veracity (truthfulness) go hand in hand, as they require communicating information in a compassionate and transparent manner. With this, nurses help navigate difficult or sensitive conversations, especially when patients or families are struggling.
4. End-of-life care decisions
Caring for patients at the end of life presents significant ethical difficulties. Nurses must navigate decisions about do-not-resuscitate (DNR) orders, palliative care, and treatment withdrawal while ensuring that patients' wishes and dignity are respected.
These moments often require sensitive communication with both the patient and their family members, who may have differing views on the best course of action. Ethical knowing helps nurses provide compassionate care that aligns with ethical principles and the patient’s values.
5. Professional boundaries and conflicts of interest
Nurses may face ethical dilemmas related to maintaining professional boundaries, especially when personal values or emotional attachments influence decision-making. These situations can become even more complex in long-term care settings or during emotionally charged clinical scenarios.
For instance, a nurse caring for a patient who lacks family support may feel compelled to go beyond their professional duties, blurring the line between personal and professional roles. Ethical knowing helps nurses recognize and manage these boundaries while maintaining professional integrity.
Developing ethical knowing in nursing practice
To strengthen ethical knowing, consider these strategies for developing ethical competence:
- Ethics education and training: Formal education in nursing ethics provides a foundation for better decision-making. Many hospitals and healthcare organizations offer ethics training to help nurses navigate complex situations.
- Ethical case discussions: Engage in discussions with colleagues about ethical dilemmas to improve moral reasoning and understand multiple perspectives on challenging situations.
- Consult ethics committees: Many healthcare institutions have ethics committees that can offer guidance when nurses face difficult ethical decisions.
- Self-reflection and moral courage: Ethical knowing is strengthened through self-reflection and the courage to advocate for what is right, even in the face of resistance. Taking time to reflect on personal and professional experiences can help develop a deeper understanding of ethical responsibilities.
Ethical knowing is not just a theoretical concept — it’s a necessary part of everyday practice. From advocating for patient rights to addressing systemic healthcare challenges, ethical knowing in nursing helps individuals navigate the complexities of modern healthcare.
Florence Nightingale’s legacy reminds us that ethical dilemmas have always been part of nursing, but with moral courage, critical thinking, and professional integrity, nurses can continue to provide ethical, compassionate care for centuries to come.
