Ethical Decision-Making in Nursing Practice

Addressing Moral Distress

Nurse leaders must establish open communication channels for staff to discuss moral distress, provide peer support structures, and facilitate interprofessional collaboration to address ethical conflicts, while actively advocating for patients when resource constraints or competing values threaten care quality 1, 2
Moral distress arises when constraints prevent nurses from doing what they believe is morally right, leading to unresolved grief and burnout, and nurse leaders must create safe spaces for nursing staff to engage in open communication with interprofessional colleagues and families about their experiences of distress 1, 2
Nurse leaders should provide peer support mechanisms and facilitate self-reflection through peer-to-peer coaching, as nurses often place patient wellbeing above their own emotional needs, making structured support essential 1, 2
Stimulating self-care and increasing self-awareness among staff about negative emotions and thoughts during ethically challenging situations requires active leadership intervention, not passive availability 1, 2

Nurse leaders should train staff in shared decision-making (SDM) processes that include three core elements: information exchange, deliberation, and making treatment decisions, to navigate values conflicts by ensuring decisions incorporate the best scientific evidence alongside patient values, goals, and preferences 3, 7
The SDM approach should be tailored based on patient or surrogate preferences, ranging from patient-directed to clinician-directed models, all of which are ethically supportable 3, 5, 8
Engaging in SDM is essential for defining overall goals of care, including decisions about limiting or withdrawing life-prolonging interventions, and for major treatment decisions affected by personal values 3, 5, 7

Registered nurses should have a recognized leading role in delegation and oversight of care tasks, initiation and evaluation of care plans, and assessment of their effectiveness, as this leadership position is critical when ethical conflicts arise 1, 2
Nurses function as mentors and supervisors for other care personnel, providing guidance during morally complex situations, and collaborate diligently with families, physicians, and other healthcare professionals to provide timely, adequate care tailored to individual wishes 1, 2
Nurses advocate for patients to shelter them from negative consequences when organizational or resource constraints threaten dignified care 1, 2

Clinicians, including nurses, should be trained in communication skills specifically designed for ethical decision-making, which requires documenting who was present during ethical discussions, including patients, family members, and healthcare team members 3, 4, 5
Recording how patient values and preferences were incorporated into deliberation, and noting any misperceptions that were addressed, prevents future conflicts and clarifies the ethical reasoning process 6
Clearly stating the decision reached and the rationale, linking it to the patient's expressed values, makes the ethical framework explicit and defensible 6

When partnerships in decision-making fail to yield mutually acceptable decisions, nurse leaders should enlist clinical ethics consultants or others adept at conflict resolution, and participate on ethics committees to share nursing's unique perspective 9, 8
Using institutional decision-making committees rather than allowing treating clinicians to make ad hoc decisions when surrogates fundamentally disagree or no appropriate surrogate can be identified, ensures a structured approach to ethical conflicts 10

Allowing resource constraints to dictate care decisions without transparent ethical deliberation, strained resources require explicit ethical frameworks, not implicit rationing 1, 2
Assuming blood relation automatically trumps long-term partners in surrogate decision-making, both state law and relationship quality matter, creates unnecessary conflict 10