DR.

PATRICIA DAVIDSON (Orcid ID : 0000-0003-2050-1534)

PROF. DEBRA JACKSON (Orcid ID : 0000-0001-5252-5325)

Accepted Article
Article type : Discursive Paper

A social - ecological framework: a model for addressing ethical practice in nursing

Davidson PM, PhD, MEd, RN, FAAN

Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
& University of Technology Sydney
pdavidson@jhu.edu

Rushton CH RN PhD FAAN

Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
& Berman Institute of Bioethics
crushto1@jhu.edu

Kurtz M MSN PhD (C)

Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
& University of Technology Sydney
mkurtz4@jhu.edu

Wise B BSN
Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
& University of Technology Sydney
bwise5@jhu.edu

Jackson D RN PhD
Professor Debra Jackson PhD FACN
Director, Oxford Institute of Nursing, Midwifery & Allied Health Research (OxINMAHR)
djackson@brookes.ac.uk

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.14158
This article is protected by copyright. All rights reserved.
 Beaman A MPH PhD (C)
Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
& University of Technology Sydney
Accepted Article
abeaman1@jhu.edu

Broome M PhD, MEd, RN, FAAN

Dean and Professor
Duke School of Nursing
Durham, North Carolina
marion.broome@duke.edu

Address for correspondence

Patricia M. Davidson, PhD, MEd, RN, FAAN

Dean & Professor
Johns Hopkins School of Nursing
525 N. Wolfe Street, Baltimore, MD 21205
P. 410-955-7544 | F. 410-955-4890 | E. pdavidson@jhu.edu
nursing.jhu.edu/dean | LinkedIn |Follow me @nursingdeanI

Funding: Nil

Abstract

Aims and objectives

To develop a framework to enable discussion, debate and the formulation of interventions to

address ethical issues in nursing practice.

Background

Social, cultural, political and economic drivers are rapidly changing the landscape of health
care in our local environments but also in a global context. Increasingly, nurses are faced
with a range of ethical dilemmas in their work. This requires investigation into the culture of
health care systems and organisations to identify the root causes and address the barriers
and enablers of ethical practice. The increased medicalization of health care; pressures for
systemization, efficiency and cost reduction; and an aging population contribute to this
complexity. Often, ethical issues in nursing are considered within the abstract and
philosophical realm until a dilemma is encountered. Such an approach limits the capacity to
tangibly embrace ethical values and frameworks as pathways to equitable, accessible, safe,
and quality health care and as a foundation for strengthening a supportive and enabling
workplace for nurses and other health care workers.

Design

Conceptual framework development

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 Methods

A comprehensive literature review was undertaken using the social ecological framework as
an organizing construct.
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Results

This framework views ethical practice as the outcome of interaction among a range of
factors at eight levels: individual factors (patients and families); individual factors (nurses);
relationships between health care professionals; relationships between patients and nurses;
organizational health care context; professional and education regulation and standards;
community; and social, political and economic.

Conclusions

Considering these elements as discrete, yet interactive and intertwined forces can be useful
in developing interventions to promote ethical practice. We consider this framework to have
utility in policy, practice, education and research.

Relevance to practice

Nurses face ethical challenges on a daily basis, considering these within a social ecological
framework can assist in developing strategies and resolutions.

Summary box

What does this paper contribute to the wider global clinical community?

 Discussion of the increasing complexity of ethical issues in nursing practice globally

 Argument for a social-ecological approach to address ethical issues in nursing and
integration in the discussion of all aspects of nursing
 Articulation of a framework to stimulate discussion, debate and a solution based
focus to ethical issues in nursing.

Introduction

Discussion and debate on ethical conundrums has existed since the early Greek

philosophers, Aristotle (384–323 BC) and Socrates (469–399 BC). This discourse has

focused on human morality and defining what is right and wrong. There are many high

profile examples of ethical abuses such as the Tuskegee Study of Untreated Syphilis in the

Negro Male where right and wrong is not contested but there are also emerging issues in

respect of issues such as stem cell research, assisted dying treatment allocation in natural

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 disasters, where debate is more nuanced and value bound (Ausbrooks et al, 2009; Phalen

2017). This underscores investigating ethical issues in nursing practice within the complex
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ecosystem of healthcare as well as the individual nurse’s knowledge, values and beliefs. As

the world faces a tide of nationalism and anti-globalisation, it is impossible to avoid complex

ethical issues (Crouch 2017). Not only can this positioning assist in understanding the

genesis of ethical dilemmas but importantly assist in developing tangible solutions.

The profession of nursing focusses on the protection, promotion, and optimization of health

and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis

and treatment of human response; and advocacy in the care of individuals, families,

communities, and populations (Rushton 2016a). Registered nurses practice in a range of

healthcare settings including hospitals, medical offices, ambulatory care centers, community

health centers, residential aged care facilities, prisons, schools, and retail clinics. Nurses’

roles are distinct and sometimes multifaceted, serving as clinicians, educators, researchers,

and policymakers, and their roles are inter-related with other disciplines, systems, and local,

national, and global communities. Nurses practice in geographically diverse settings within

which various laws, scopes of practice, policies and health care regulations influence the

culture, ethical decision-making, and the everyday ethical moments that are integral to

nursing practice. Regardless of the setting, nurses must adhere to a set of professional and

philosophical values and behaviors that are reflected in their codes of ethics, although

periodically this can be challenging (Kangasniemi et al 2015). Ethics has long been

imbedded in the profession of nursing and guided practice. Florence Nightingale and others

articulated the ethical foundations of nursing and over the years, the field of nursing ethics

has evolved with an expanded presence in scholarship, research, clinical practice, and

education (Rushton 2016a). Early nurse ethicists pioneered efforts to create the foundation

for nurses to contribute to the field of bioethics and to expand the significance and impact of

ethics within the nursing profession. This foundation has been instrumental as the

profession rises to the challenges of balancing the tensions between individual interests and

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 team, organizational, community and societal interests. Understanding the current ethical

landscape and reflecting upon potential future ethical issues is vital for creating actionable
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strategies for sustaining and strengthening the ethical foundation of nursing and devising

specific strategies for clinical practice, education, policy and research (Hylton Rushton &

Broome 2016). Within the context of global health, these issues are even more pronounced

where there are marked power differentials, geopolitical instability and a range of socio-

cultural issues that contribute to health disparities (IJsselmuiden et al 2009). Developing

models of interaction that move from paternalism to capacity development and sustainability

are issues that many health professionals face (Bourgeois et al 2017).

Nursing occurs in a range of complex and diverse individual, organizational, and societal

cultures and practice environments as well as a range of independent and interdependent

settings (Davidson et al. 2006). As the importance of evidence-based practices in health

care gains increasing recognition, there is a need to expand the lens of evidence beyond

scientific data to include the lived experiences of people in need of health care, those who

provide care, and the people, systems and communities that are affected by the ethical

conflicts and dilemmas that are faced in everyday health care encounters. Issues such as

access and equity have become as important as understanding the scientific basis of health

care (Pratt et al 2017).

Although ethical issues have framed much of nursing education and practice, the discussion

and scholarship is commonly theoretical and esoteric. However, there is some evidence that

nurses have undertaken a much more empirical approach to addressing ethical issues in

nursing practice. Considering the role of ethics in a real world setting and in terms tangible to

practicing nurses is critical to interpreting issues within a broad social, cultural, political and

economic contexts. The use of conceptual frameworks is one approach that can be highly

useful in organizing and providing an explanation for a range of complex factors, and most

importantly in formulating and developing interventions, and clinical, educational, policy and

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 research agendas. As part of the preparation of a national nursing summit, hosted by Johns

Hopkins University, to discuss ethics in contemporary health care (Ruston & et.al. 2015),
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we undertook a comprehensive review of the literature focusing on three key domains:

clinical practice, nursing education, and nursing research. Details of this literature review are

accessible at http://www.bioethicsinstitute.org/nursing-ethics-summit-report/literature-

review#clinicalpractice. The review determined that complex and interfacing elements lead

to ethical issues in nursing practice. A framework provides a structure and organizing

framework for a set of concepts and organizing principles (Davidson et al 2006). We

proposed a social ecological framework to address these issues which was endorsed by 50

conference participants representing peak nursing bodies (Ruston & et.al. 2015). We

consider that this conceptual approach will assist in both documenting the complexity of

ethical issues but also allow a focus on specific dimensions to drive solution-focused

strategies.

Social ecological frameworks

Social ecological frameworks have been widely adapted with the recognition that no single

factor can explain or predict a particular phenomenon (Baron et al. 2014). Given the

complexity of the environments where nurses serve the health of others, an understanding of

the dynamic interplay among the dimensions that influence the culture, work environments

and intimate relationships where ethical issues arise is necessary. Although some may

argue it is folly to consider nursing external to the broader health care system, it is also

incomplete to disregard the unique history and professional, educational, and regulatory

foundations of nursing. Both are needed to have a full spectrum view of the culture and

environments where care is delivered. Achieving an ethical climate is about achieving a

shared purpose and perspective as well as organizational structures that drive decisions that

are considerate and respectful of individuals and a range of perspectives.

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 Distinctions between the various dimensions of culture and environment must be made to

fully appreciate the complexity of nursing practice (Melnyk et al. 2016). At the most local
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level where nurses practice, their “environment” generally refers to the specific

organizational context in which a nurse works. This is the level at which nurses are most

likely to exert direct influence on the parameters of their work, including its conduct

according to ethical values, principles, and frameworks. It is in this context where aligning

individual, professional and organizational values can either enable or undermine the

integrity of nurses.

These organizational environments are situated within a broader “culture” that reflects the

rings of influence outside the organizational context and encompasses larger aspects of the

health care system. These larger influences, if they support ethical behaviors and decision-

making at the individual nurse level, collectively create an ethical culture for nursing practice.

There is an even broader sense of “culture” that is sometimes relevant to nurses, and that is

“societal culture” as a whole, which includes the economy, social policy, and other mega-

influencers. An example of how these aspects affect individual nurses is when structural

inequalities create differences in access to care—that is, issues of social and distributive

justice.

Using these definitions and drawing from the social ecological framework, the levels of the

individual and relationships with patients, families, co-workers, and the organization

represent a nurse’s environment or ecosystem. Professional and educational regulation and

standards, along with public and private health policies, most directly affect the “ethical

culture for nursing,” while the broader social, political, and economic context contributes to

the overall “culture.” The “community” level is in some intermediary position, depending on

the type and size of community meant, or alternatively, the extent of a nurse’s or group of

nurses’ influence within it.

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 While in the immediate future nursing’s influence on ethical practice is most likely to be felt in

nurses’ local environments, it is the long-term goal to strengthen and sustain effects beyond
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individual workplaces to achieve broader cultural changes. Understanding these discrete

elements is crucial in moving forward in ethically grounded person-centered care, inter-

professional interactions, and health care system design that are intentional and congruent

with regulatory scope of practice, ethical standards, and practice guidelines.

Considering ethical issues within a social ecological framework can assist in explaining the

dynamic interaction between dimensions. Within the context of ethical issues in nursing this

can also help illuminate the factors that both help and hinder ethical practice and

environments that not only promote the quality and safety of patient care but also enable

positive practice environments within which nurses can practice ethically. Similarly, they can

help to identify the interrelationships among the elements that impact individual and

collective practice of nursing and the outcomes for the people they serve.

Social ecological framework

Using the social ecological framework, ethical practice is viewed as the outcome of

interaction between discrete but interrelated elements. We have identified eight dimensions

that interface to influence ethical practice in nursing. These are: individual factors (patients

and families); individual factors (nurses); relationships between health care professionals;

relationships between patients and nurses; organizational health care context; professional

and education regulation and standards; community; and social, political and economic.

Considering these elements as discrete, yet interactive and intertwined forces can be useful

in developing interventions to promote ethical practice. (See Figure 1). Below we discuss

these dimensions and although they are described individually their function in the complex

ecosystem are inextricably linked.

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 Society, politics and the economy

Ethical practice in nursing dependent is dependent upon social, political, and economic
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factors. Societal factors include social determinants of health that allow access to health

care and predict the quality of care, as well as societal and cultural norms. For example, in

many countries, particularly the United States (US), the predominate societal value is

individual autonomy: to determine for oneself the balance of benefits and burdens

associated with health care interventions and to preferentially advocate for individual

interests above collective interests. The value of autonomy may be apparent in a number of

health care decisions, including patients’ decisions about which health care interventions to

access or decline. How to balance a society’s value of autonomy with other values is

tenuous, especially when an individual’s choice to decline care leads to negative, costly

outcomes or when patients demand medically ineffective therapies that cause

disproportionate suffering and high cost. Whereas in many countries, there is a much more

collectivist approach to health care decision making and resource allocation.

The political milieu also influences how ethical issues are viewed. The democratic structure

of many Western countries often fuels the diversity, and at times conflict, surrounding

fundamental questions regarding personal responsibility for health, the role of society and

government in creating the conditions for health, and allocation schemes for distributing

scarce resources. Within the US, there is oftentimes a focus on litigation to resolve issues of

conflict, which fuels fearful attitudes and defensive medicine. Issues such as the use of

medical marijuana and assisted dying are controversial globally (Clark et al 2017; Compton

et al 2017).

The economic state of a region impacts the type and number of available resources for

patients, as well as the level of compensation to those who are providing health care

services. Economic instability worldwide creates intensified challenges for balancing the

allocation of the national, state, and local budgets for health and health related services.

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 Embedded in societal, political, and economic understandings are also ethical and moral

worldviews and values that shape the way that ethical issues are identified, named, and
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dealt with. These worldviews influence what is viewed as ethically salient, informs the range

of options for addressing conflicts or uncertainty and guides individual, interpersonal, social,

and political behavior. For example, the recent Ebola outbreak has challenged us not only in

how we care for patients, but also regarding treatment allocation (MacIntyre et al. 2014).

Community

Nursing occurs in a socially defined setting, as well as in a range of community settings,

such as schools, neighborhoods, and workplaces. Within geographic communities, there

are often diverse perspectives about the meanings of health, illness, quality of life, death and

other core values that individually and collectively define the structures, processes and

outcomes of ethical issues. These perspectives are informed by broader culture and

society, and may enhance coherence or exacerbate disagreements surrounding local

deliberation and resolution. It is often within the community where the interface between

ethical values, such as religion and spirituality, emerge.

Persons in need of health care are generally situated within a broad definition of family living

within an increasingly diverse and pluralistic society. Commonly, families are isolated from

their extended families and communities, which contributes to increased stress on the

traditional and non-traditional nuclear family. This factor can exacerbate ethical questions

such as how to determine the appropriate surrogate decision maker for a person who lacks

decision-making capacity, and what values ought to guide decision-making in a specific

case. Such ethical tensions are often intensified when they involve reproductive issues or

populations who are very young, incapacitated or elderly.

The community context also raises questions about how one understands one’s

responsibilities and obligations to self and others, and how ethical issues are defined in the

context of an inter-related web of relationships. Although many cultures prioritize autonomy

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 and an individualized approach to health, questions regarding the interplay between

individuals, their families, and communities are also debated. Communities commonly
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encompass a set of values and may set the standard when a particular decision about an

individual within a community is being made. Therefore this collective perspective has the

potential to influence the way in which community-based individuals interact with nurses and

health care organizations. One recent example of the interaction between the community

and the individual is the decision to place safe injecting room in neighborhoods for treatment

of individuals with histories of substance abuse. Such decisions illustrate the dynamic

interplay and complexity of values and perspectives that nurses must navigate to provide

ethically sound care.

Professional and education regulation and standards

The nursing profession is grounded in the ethical value of trustworthiness and takes

seriously the public trust they have been granted. Professional organizations play an

important role in promoting standards of accountability and strategies for protecting the

public. Organizations also seek to shape professional values and behaviors (Lankshear et

al. 2013). Organizations, such as the International Council of Nursing, the American Nurses

Association and the Nursing and Midwifery Council in the United Kingdom , develop and

promulgate guidelines and standards that provide a framework for ethical practice and

standards for monitoring and benchmarking. Nurses are accountable for cultivating their own

ethical competence and working within their professional organizations to create and sustain

environments that support a culture where ethical practice can thrive.

Practicing within regulatory and professional frameworks (Corey et al. 2014) impacts the way

nurses understand important ethical issues, including: promoting patient dignity (Rapport et

al. 2014); disclosure (Harrison et al. 2014); role development, nursing practice environments

( Lim & Bernstein 2014) and professional boundaries. Within the context of increasing

technological complexity and chronic illness (Redman 2005), many ethical issues have

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 emerged related to: withholding and withdrawing treatment (Albers et al. 2014); treatment

access and allocation (White et al. 2014); organ transplantation (Tanimizu et al. 2014);
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genomics (Badzek et al. 2013); quality and safety (Baily et al. 2006); population aging and

increased diversification of society (Badzek et al. 2013) and assisted suicide (Harris 2014).

Furthermore, promoting patient autonomy, delivering care within legal and ethical

frameworks, inter-professional communication and monitoring of standards and practices

remain prominent ethical considerations (Arries 2014). The above summary of issues

highlights the complexity of contemporary health care and the challenges of preparing

nurses to practice in this complex milieu.

Organizational health care context

As the largest group of health care workers, nurses are directly impacted by the context of

health care organizations and the diverse settings where nurses practice (Hughes 2017).

Many organizations that provide health care services are undergoing unprecedented shifts

as demand increases, workforce diversifies, and fiscal constraints increase. Budgetary

containment can threaten the quality and safety of patient care (Aiken et al 2002). In

hospitals, for example, if nurse-staffing ratios are not preserved and economic pressures

derail efforts to focus on person-centered holistic care, the quality of care delivered will be

compromised. Healthcare organizations have competing obligations to patients, families,

employees, and the community. To address these concerns, many health care organizations

have mechanisms to address individual and organizational ethical concerns. Although the

number of ethics consultation services within U.S. hospitals has increased in recent years,

consultation practices in these facilities vary widely, and many health care organizations still

lack the ethical infrastructure needed to support nurses and other clinicians and to

systematically address ethical issues.

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 The ethical culture of health care organizations has a profound impact on individual nurses’

moral agency and their ability to practice in accordance with their personal and professional
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values (Rushton 2016b, Rushton et al. 2017). Recent evidence suggests that nurses who

are unable to translate their ethical values into action experience moral distress that can lead

to burnout, diminished quality of care, and turnover, and that undermines the well-being of

nurses. When nurses are supported by their organizations to practice ethically, there is an

impact on individual resilience and the collective ethical well-being of the nursing workforce.

Relationships between health care professionals

Nurses most commonly practice in inter-professional settings with other health care

colleagues. Ethical practice in nursing requires inter-professional and collaborative

relationships with all members of the health care team (Zorek & Raehl 2013). However, the

reality is there are often tensions between and amongst different disciplines because of

differing worldviews, roles, and values. Embedded in these relationships are differences in

power, authority and responsibility that can either empower or undermine the team’s

effectiveness and create moral distress. Addressing and resolving these tensions in a

respectful manner that creates space for all voices to be heard and understood, while

preserving integrity, is necessary for ethical practice. Nurses need the knowledge, skills and

supportive structures to engage fully in ethical dialogue with their inter-professional

colleagues and to participate in devising innovative solutions to address gaps in

collaboration and teamwork. Recent standards calling for team work and collaboration has

spurred a movement in academic health centers who educate the majority of health care

professionals. These educational opportunities allow learners to develop a deeper

understanding of each other’s disciplines and unique contributions to team based,

interprofessional care (Hanyok et al. 2013).

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 Relationships between patients and nurses

The International Council of Nursing, Nursing and Midwifery Council in the United Kingdom
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and other national professional bodies, such as the American Nurses Association, Code of

Ethics, for nurses asserts that nurses’ primary obligation is to their patient (defined as a

person, family, or community). The wellbeing and health outcomes of patients are

dependent on the quality of nursing care they receive. The complex interplay of ethical

questions arises in the moment -to -moment interactions with patients and their families.

Nurses often have the most sustained, and sometimes the most intimate, relationships with

their patients and from this vantage point are well-situated to advocate for their interests.

Nurses’ competence in physical, emotional, spiritual and behavioral domains of health care

qualifies them to use their expertise on behalf of both vulnerable populations and

populations of people in need of health care more generally. To fulfill their ethical mandate,

nurses must possess the ethical competence and skills to engage with the people they serve

with authenticity, courage and principled compassion (Rushton & Broome 2015).

The nature of the nurse-patient relationship can sometimes create issues in professional

boundary-setting, as well as feelings of conflict, inadequacy and powerlessness, all of which

can manifest in moral distress. Issues arising from nurse-patient complexities can be

exacerbated when nurses are working in resource poor settings and feel that they are

unable to be responsive to the patient’s needs. These factors are further exacerbated within

health care environments that are unsupportive to ethical practice. Ethical practice requires

that nurses possess the attitudes, knowledge and interpersonal skills to effectively engage

with patients and families to understand their unique needs and perspectives within a

context of their Code of Ethics.

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 Individual factors (patients and families)

Nurses have an ethical mandate to care for every person in need of nursing services without
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regard for their individual differences, diagnosis, prognosis or socioeconomic status. Those

in need of healthcare are vulnerable because of the impact of illness. Furthermore, those

requiring care may have a disability or injury, impacting their ability to communicate, make

decisions, and advocate for their best interests. Power imbalances, inequitable access to

needed resources prescribed to benefit them, and variability in capacities to effectively adopt

preventive and therapeutic regimens impact nursing care and create challenging ethical

tensions. Patients and families that nurses care for are as diverse as in the host population,

which can intensify the ethical conflicts that accompany health care. With this diversity, new

ethical issues arise as nurses attempt to understand and respect cultural practices, religions,

and choices different from their own. Nurses are challenged to create more robust notions

of respect for persons as foundational to their ethical framework. Without a firm ethical

foundation, nurses may consciously or unconsciously disrespect or disregard the “inherent

worth and dignity of every person” (American Nurses Association. 2010). This can contribute

to a team and organizational culture that systematically marginalizes patients that are

viewed as “non-adherent”, difficult or irresponsible. In highly complex health care

environments, relational skills such as listening and being present can be extinguished in

favor of other values such as efficiency and productivity. Moreover, as the focus of health

and health care shifts toward a model of shared responsibility and accountability, new ethical

challenges such as patient health, professional and societal responsibilities and roles in the

health care encounter are likely to emerge.

Individual factors (nurses)

Nurses bring their own diverse histories, experiences, skills, and capacities to their work. In

an increasingly culturally diverse society and within a globalized world, failing to consider

individuals’ knowledge, attitudes, and beliefs can challenge care models and threaten

alignment with ethical values. Nurses must have a sufficient understanding of their own

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 attitudes, beliefs and ethical values that they are able to recognize when ethical issues arise

and occasions for principled action. The cultivation of moral sensitivity, skills in ethical
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discernment and deliberation and skillful ethical enactment are the foundation for nurses to

practice with integrity. These competencies are vital for pre-licensure, graduate, and

doctoral education as well as continuing education for nurses in practice.

Curriculum crowding means that there is a limited focus on ethical issues and concerns. A

likely solution is ensuring horizontal and vertical integration of ethics in the discussion of all

practice, education, research and policy discussions. This is vital as every conversation has

an ethical dimension. Similarly, in health care organizations little time or resources are

allocated to the development and sustainability of these competencies in nurses’ practice.

Summary

The socio-ecological framework considers the interface and interaction between factors at

different levels with equal importance, to the influence of factors within a single level. For

example, legal and regulatory frameworks can influence laws and regulations. Similarly,

codes of practice and scope of practice influence the nursing framework. This model also

helps to explain the interaction between model components. For example, a health care

organization that fails to govern clinical practice, promote autonomy of the individual and

foster strategies such as shared decision making can result in unethical practices (Konn et

al. 2016).

Considering ethical issues within the framework of an ecological system is also useful to

developing and implementing strategies based on the level in which they occur and also

considering unintended consequences of actions. For example, promoting interdisciplinary

practice and models of shared governance may promote the clarity of treatment goals within

clinical teams and among patients and their surrogates. but may also increase role

ambiguity.

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 Moving beyond the problem to the solution.

As the profession of nursing faces unprecedented challenges in a complex and dynamic

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health care society, we need to rise to many ethical challenges, both internal and external to

our profession. This will require some crucial conversations and has implications for policy,

practice, education and research. Questions that are critical for further discussion and

debate are provided in Table 1. Without broad engagement across the ecosystem of health

care, solutions are unlikely to be effective, acceptable or sustainable.

Conclusion

This article has underscored not only the complexity of factors influencing the ethical

practice of nurses but the intertwined and interfacing components of ethical decision making

and practice. Considering discrete elements independently from others elements is less

likely to enable ethical practice or promote solutions to dilemmas. Situating the profession of

nursing in policy, practice, education and research, within the complex and dynamic

ecosystem of healthcare is important in developing environments that support and enable

ethical nursing practice.

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 Table 1

Questions to ask to inform the debate on ethical issues in nursing

Accepted Article
Policy 1. What are the current unit, institutional, state, and national policies that
inhibit nurses from practicing ethically, and how could they be changed to
promote ethical practice?

2. What new policies are needed to protect nurses’ ability to practice

ethically as part of interdisciplinary teams in a wide variety of settings?

3. What new legal protections do nurses need to be empowered to practice

ethically without fear of negative consequences?

Practice 1. What new models, systems, or structures are needed to encourage and
enable nurses to practice with ethical integrity in their various clinical
environments?

2. What needs to be done to encourage every nurse to be aware of the

ethical issues surrounding every patient every day?

3. How can environments be changed to encourage interdisciplinary

collaboration in order to maximize the ethical treatment of patients by the
entire clinical team?

Education 1. How can pre-licensure programs incorporate ethical awareness into all
aspects of clinical education?

2. How can students be equipped with the skills necessary to identify ethical
dilemmas, respond to them with an integrated framework, and develop the
resilience necessary to thrive in environments prone to producing moral
distress?

3. How can nurses be trained to productively engage with situations in

which there is ethical conflict between the various parties involved?

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 Research 1. What is the cost of not enabling nurses to practice ethically (in terms of
its impact on the nurses themselves, the patients and their families, and the
institutions in which nurses work)?
Accepted Article
2. Can an evidence-based intervention be created that will reduce and
mitigate the moral distress experienced by practicing nurses?

3. What is the foundational understanding of the moral agency of nurses

and how does that impact their roles and responsibilities when addressing
morally complex situations?

Figure 1: Social ecological model influencing ethical practice

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