Lesson 8: Qualities

of Ethical Nurses
“Watch your thoughts; they become
words,
Watch your words; they become actions.”

Virtue Based Nursing Model

INTELLECTUAL VIRTUES:

• Awareness & knowledge of the

moral nature of nurses’ day-to-day
Insight work.
• Knowledge that moral suffering
can be transformed.

Phronesis or • Using deliberative reason to direct

one’s actions.
Practical
Wisdom
 MORAL VIRTUES
• Refraining from deception through false
Truthfulness communication and self deception.

• Mildness in verbal & non-verbal communication.

Gentleness
• Desire to separate others from suffering.
Compassion
• Desire to bring happiness and well-being to self &
Loving Kindness others.

• Giving & receiving based on need.

Just Generosity
• Putting fear aside in difficult circumstances to act
Courage for a purpose that is more important than one’s fear.

• Rejoicing in other’s happiness.

Sympathetic Joy
• Evenness and calmness of being.
Equanimity
Qualities of Ethical
Nurses
https://nursing.lecturio.com/?pc=nl&utm_source=crm&utm_mediu
m=E-
Mail&utm_campaign=21KW11_EN_NC_FundamentalsTheory_RO
W&utm_content=CLC#/lecture/c/45405/45314/191036

Fundamentals: Traits of an RN
 Ethical Formations and Moral
Obligations
Clinical Practice Boundaries
✓Respecting patient’s dignity
✓Right to self-determination
✓Delegating tasks appropriately
✓Practicing good judgment
✓Accepting accountability in practice
✓Alleviating suffering
✓Being attentive to patients’ interests
✓Working within the nurse practice acts and standards
of practice
continuation

Professional Practice Self-Care and Self

Boundaries Development
✓Maintain authenticity in Boundaries and
all relationships Obligations
✓Address issues of ✓Advancing knowledge,
impaired practice- competence
fraternizing, ✓Professional
inappropriate familiarity, collaboration
accepting gifts etc., ✓Promoting healthy
unhealthy, unsafe, practices
illegal environment.
MORAL INTEGRITY
“wholeness of character”

T.G. Plante (2004) No one is mistake free, but

people with moral integrity follow a moral
compass and they do not vary by appeals to act
immorally.
▪Pursue a moral purpose
▪Understand their moral obligation in the
community
▪Committed to follow through
Good character
Good intent
Good performance

Nurses with moral integrity act

consistently with personal and
professional values.
https://www.youtube.com/watch?v=pOakDs41IsI

We asked nurses what keep them up at night and they told us...

The School recently held a Nursing Ethics Summit

(#NursingEthics​), co-sponsored by the Berman Institute of
Bioethics, to develop a comprehensive and strategic agenda for
nursing ethics in the 21st Century in the areas of clinical practice,
education, research and policy.

What Keeps Nurses Up At Night?

“What is firmly established cannot
be uprooted
What is firmly grasped cannot slip
away.
It will be honored from generation
to generation.”
(Lao Tzu on Values, 1972)
 MORAL DISTRESS
Jameton (1984) “When one knows
the right thing to do,
but institutional constraints make it
nearly impossible to pursue the
right course of action.”
https://www.youtube.com/watch?v=kgfX2FhQwTA
Nurses can feel moral distress when they feel they feel their
integrity has been compromised or when they feel powerless to
take actions they know are ethically correct. In this video,
Cynda Rushton, Anne and George L. Bunting Professor of
Clinical Ethics, talks about the roots of moral distress and how
nurses can effectively manage it. This video is part of the Isabel
Hampton Robb Nursing Ethics series.

Same video
https://nursing.jhu.edu/excellence/quality-safety/ethics/ethics-
video-series.html

Nursing Ethics: Moral Distress in

Nursing
When nurses are asked or
pressured to do something that
conflicts with their personal &
professional values

▪Eg. asked to falsify records, deceive

patients, accept verbal abuse from
others.
Four A’s to Rise above Moral Distress
(American Association of Critical-Care Nurses, 2004)

1. ASK appropriate questions to become aware

that moral distress is present.
2. AFFIRM your distress and your commitment
to take care of yourself.
3. ASSESS sources of your moral distress and
prepare an action plan.
4. ACT to implement strategies for change to
preserve integrity.
Ethics Committee
▪Institutional Review Board (IRB) as a
group formally designated to protect the
rights, safety and well-being of humans
involved.
▪Can also be called independent ethics
committees (IECs).
IRB/IEC members should be collectively qualified to review
the scientific, medical and ethical aspects of the given
situation (research/trial).

An IRB/IEC should have:

▪ At least five members
▪ Members with varying backgrounds
▪ At least one member must represent a non-scientific area
(a lay member)
▪ At least one member must not be affiliated with the
institution or the trial site (an independent member)
▪ Competent members who are able to review and evaluate
the science, medical aspect and ethical implication.
 MORAL COURAGE
Overcomes fear by confronting an issue head on.
Having the will to speak out and do
the right thing even when constraints
or forces to do otherwise are
present.
Turns principles into action.
Courage to do what they believe is the right thing to do.
They make a personal sacrifice by possibly standing alone,
but will feel a sense of peace in their decision.
Threats will be in the form of: humiliation,
rejection, ridicule unemployment, and loss of
social standing (Lachman, 2007)

Eg. Confronting or reporting a peer who is

stealing & using drugs.
▪Confronting an MD who ordered a questionable
treatment
▪Confronting a supervisor regarding unsafe
practices or staffing patterns
1st Share personal
story of an
encounter with Dr.
Bailey
2nd Crossing the
picket line
HONESTY

▪2010 Gallup poll for past 11 years

(Jones, 2011)
▪More than just telling the truth.
 TRUTHFULNESS
▪ The mean between imposture (excessiveness) and
self-deprecation (deficiency) – Aristotle, Nicomachean
Ethics
▪ Vitrue : WISDOM or CONTEMPLATION

▪Principle of veracity
What we say and how we say it.
(and our motive)
CONCERN - ADVOCACY
▪Safeguarding patient’s autonomy
▪Acting on behalf of patients
▪Championing social justice in the
provision of healthcare
MORAL COURAGE
Nursing Profession
Nursing continues to be the most trusted of professions
(Norman, 2016, cited in DeSimone 2019).

As a profession, nursing cannot separate itself from

moral/ethical intent and behavior. Nursing educators
therefore have a huge responsibility for building a strong
moral and ethical foundation upon which future nurses
will build their practice.
Moral courage is the…
ability to stand up for and practice that which
one considers ethical, moral behavior when
faced with a dilemma, even if it means going
against countervailing pressure to do otherwise.
Those with moral courage resolve to “do the right thing” even if it puts
them at personal risk of losing employment, isolation from peers and other
negative consequences. One should stand up for what is right even if it
means standing alone (Murray, 2010). According to former Senator from
Maine Margaret Chase Smith: The right way is not always the popular and
easy way. Standing for right when it is unpopular is a true test of moral
character.
One should not confuse moral courage
with moral arrogance or moral certitude.
Individual, social, and cultural values may differ, so it is
important to have open, respectful communication (Murray,
2010) While the values of honesty, integrity, fairness,
compassion and respect seem to be universal, different
cultures might prioritize them differently.
Nurses need moral courage to assure quality care and safety
of patients, to interact with other healthcare professionals and
to advocate for consistent universal care with healthcare and
community organizations (Pajakoski, 2021).

Moral courage is needed to deal with unethical, unsafe or

discriminatory practices (Murray, 2010).
 To clarify the elements of moral
courage…
Numminen et al. (2016) analyzed literature and arrived at
these attributes:
true presence,
moral integrity,
responsibility,
honesty,
advocacy,
commitment and perseverance,
and personal risk.
Antecedents were ethical sensitivity, conscience, and experience.
Consequences included personal and professional development
and empowerment (Numminen et al., 2016)
(Adapted from Kidder, 2005)

Table 2. Critical Checkpoints in using Moral Courage for Ethical

Decision Making
Steps Checkpoint
Evaluate the circumstances to establish whether moral courage
1
is needed in the situation
Determine what moral values and ethical principles are at risk or
2
in question of being compromised

Ascertain what principles need to be expressed and defended in

3
the situation – focus on one or two of the more critical values

Consider the possible adverse consequences/risks associated

4
with taking action
Assess whether or not the adversity can be endured –
5
determine what support/resources are available
Avoid stumbling blocks that might restrain moral courage, such
6 as apprehension or over reflection leading to reasoning oneself
out of being morally courageous in the situation
Continue to develop moral courage through education, training,
7
and practice
1.(Adapted from Kidder, 2005)

He further makes us aware of impediments to exercising moral courage:

Table 3. Inhibitors of Moral Courage

1.Organizational cultures that stifle discussion regarding unethical

behaviors and tolerate unethical acts

2.Willingness to compromise personal and professional standards in

order to avoid social isolation from peers or to secure a
promotion/favoritism within the organization

3.Unwillingness to face the tough challenge of addressing unethical

behaviors
4.Indifference to ethical values

5.Apathy of bystanders who lack the moral courage to take action

6.Group think that supports a united decision to turn the other way when
unethical behaviors are taking place

7.Tendency to redefine unethical behaviors as acceptable

Lachman (2010) has written extensively about the virtue of
moral courage. To bolster the teaching and ability to act with
moral courage, she suggests the following using the acronym
CODE:
•Courage to be moral requires:
•Obligations to honor (What is the right thing to do?)
•Danger management (What do I need to handle my fear?)
•Expression and action (What action do I need to take to
maintain my integrity?)

She discusses strategies for overcoming risk-aversion

and fear in order to speak out and “do what’s
right.”
 Resource:
https://www.aacnnursing.org/5B-Tool-Kit/Themes/Moral-
Courage#:~:text=Moral%20courage%20is%20the%20ability,countervailing
%20pressure%20to%20do%20otherwise.
https://www.youtube.com/watch?v=pOakDs41IsI

We asked nurses what keep them up at night and they told us...

The School recently held a Nursing Ethics Summit

(#NursingEthics​), co-sponsored by the Berman Institute of
Bioethics, to develop a comprehensive and strategic agenda for
nursing ethics in the 21st Century in the areas of clinical practice,
education, research and policy.

What Keeps Nurses Up At Night?

MORAL INJURY
https://www.youtube.com/watch?v=AybMPLVbtvg

Understanding Moral Injury

Moral distress and moral injury

Moral injury may be experienced when a person

perpetrates, witnesses or fails to prevent an act that
conflicts with their moral values and beliefs.

The concept of moral injury has its origins in the context

of military personnel encountering ethically challenging
decisions during armed conflict.

The term has been applied to healthcare and moral

injury is increasingly acknowledged to be a challenge for
healthcare professionals. Nurses across all specialties
and settings are frequently required to make or witness
ethically challenging decisions about patient care.
 Self-care strategies in response to nurses’
moral injury during COVID-19 pandemic
Particularly, nurses face extraordinary challenges in response
to shifting protocols, triage, shortages of resources, and the
astonishing numbers of patients who require care in expedited
time constraints. As most healthcare workers are passionate
nursing professionals, frustration and often a sense of
powerlessness occur when they find themselves unable to
provide needed care to their patients.

Nurs Ethics. 2021 Feb; 28(1): 23–32.

Published online 2020 Oct 30. doi: 10.1177/0969733020961825
PMCID: PMC7604672
PMID: 33124492
Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic
Fahmida Hossain and Ariel Clatty
In this altered landscape, nurses confront choices that
are often morally and ethically challenging, such as:

Fairness and justice

Despite the lack of resources, every nurse continues to
have an obligation and duty to treat the patient at hand.
Nurses find themselves forced to make moment-to-
moment ethical decisions on who should receive
treatment. Who should be seen first, who should be
seen later? How much time to allocate at the bedside?
How to address the grief? All these choices confront
core ethical questions which revolve around preserving
the life and dignity of the individual patient. This situation
is extremely stressful. Such choice-making often falls
outside the realm of nurses’ training and expertise.
Duty to care
Nurses are trained to care for patients with empathy and expertise.
However, due to a lack of resources, patient-centered care is not always
possible. Nurses are asked to make tough ethical decisions, which run
contrary to their training and the core human concern for the other’s well-
being.

Personal safety versus professional integrity

Nurses, like all people, have families and loved ones in their lives. Nurses
find themselves with competing obligations to work, family, and loved
ones. This dilemma is a conflict between professional obligations and
personal responsibilities. How can nurses balance or make peace with this
predicament? On the one hand, there are obligations to virus sickened
patients staring at them for help and assurance. And on the other, the
embodied obligations to those they love and depend on in so many
common ways.
The ethical dilemma nurses confront: nurses face the obligation to care for
patients, but they also have the right and responsibility to care and protect
themselves and their families.
Re-narrated job description

Nurses (and all staff) find themselves as innovators,

problem-solvers, and sometimes mechanics, finding
creative ways to stretch or re-allocate scarce
resources, or re-purposing one thing to do another.
As example, nurses have designed and constructed
low-cost, easily made and mass producible protective
shield to safeguard front liners. Nurses determined to
provide care faced safety challenges.
Self-care strategies

▪ Healthcare professionals are often termed HEROs

(High Expectation and Risk Occupation)
▪ When moral distress is not addressed it can lead
to burnout, feelings of frustration, and chronic
exhaustion. Unattended stressors can lead to
secondary traumatic effects which are identified as
negative feelings, vicariously acquired due to
indirect exposure of trauma-related events.
 Moral resilience
▪ One way to self-care is by building moral resilience. Self-efficacy and
self-control help nurses respond positively to distress they encounter
as nurses.
▪ Moral resilience is the courage and confidence to confront distressful
and uncertain situations by following and trusting values and beliefs.
Being morally resilient allows one to maintain perspective, keep a
situation in context, and understand that some conditions are out of
one’s control.
▪ Nurses can also strengthen their parasympathetic nervous systems to
combat stress through breathing exercises and mindfulness.
 Self-stewardship

▪ Self-stewardship—allowing oneself to be seen—helps nurses to

contextualize the ethical dilemmas they face between patient-centered
care and public health ethics.
▪ Psychological interventions and support provide structured and
profession forums in which care professionals can talk through and
contextualize the ethical and personal challenges and uncertainties
they face.
 Structural support

▪ Coworkers and institutional leaders must recognize the prevalence

and magnitude of moral distress and stand together to view nurses
as individuals in need.
▪ Healthcare staff will continue to put the needs of their patients
before their own, and may not recognize that they too need to be
cared for. It is the duty of the institution to provide the tools that
serve to keep staff safe and protected, including their mental and
emotional components of their health.
 POWER
Lessons from Nursing to the World | Kathleen Bartholomew
https://www.youtube.com/watch?v=Qh4HW3yx00w
Registered Nurse Kathleen Bartholomew dissects the hierarchical
culture within the nursing profession, and examines why nurses who
are devalued and shamed are much more likely to make mistakes
and relay critical patient information to a physician. Kathleen
Bartholomew, RN, MN, has been a national speaker for the past
fourteen years. She was nominated in 2010 by Health Leaders
Media as one of the top 20 people in the U. S. changing the culture
of healthcare - specifically for calling attention to the dangerous
impact on patient care of disruptive behavior by medical
professionals, as well as the critical need for better physician-nurse
communication.

Kathleen is the author of five books and is best known for her
pioneering work, “Ending Nurse to Nurse Hostility” (2006), which
offered the first comprehensive and compassionate look at the
etiology and impact of horizontal violence on both patients and
nurses. As a health care culture expert, Kathleen now speaks about
patient safety, communication, leadership and power to hospital
boards, the military, senior leadership, and front line staff.
 CULTURE-SENSITIVE CARE

▪Nurses must first have a basic knowledge

of culturally diverse customs and then
demonstrate constructive attitudes based
on that knowledge.
 NURSE-PHYSICIAN
RELATIONSHIPS
▪Doctor- nurse game (Stein, 1967)– based
on hierarchical relationship, competency
and quality of care conflicts, lack of
communication.
 NURSE-NURSE RELATIONSHIPS
▪Horizontal violence-
Interpersonal conflict, harassment,
intimidation, harsh criticism, sabotage and
abuse among nurses.
Tall Poppy Syndrome (Aussie slang – to criticize highly
successful people ‘to cut them down’
To describe a social phenomenon in which people of genuine
merit are resented, attacked, cut down, or criticised because
their talents or achievements elevate them above or
distinguish them from their peers. This is similar to
begrudgery, the resentment or envy of the success of a peer.
 MATTERS IN MORAL SPACES
▪Remain devoted to respecting human
beings in all interactions even in social
networking.
▪Principle of Autonomy – respect for
human beings, self-determination,
trustworthiness, confidentiality, and
privacy.
https://www.youtube.com/watch?v=mSnhY5Bb6eI
The Doctor is a 1991 film loosely based on Dr Edward
Rosenbaum’s 1988 book, A Taste Of My Own Medicine.
The film stars William Hurt as Jack MacKee, a doctor who
undergoes a transformation in his views about life, illness and
human relationships following his experience as a patient.
Watch out for a particularly fine performance by Elizabeth
Perkins who plays June Ellis, a fellow cancer patient who has
an inoperable brain tumour.
It is a powerful film that deals with the importance of empathy,
respect and autonomy.

(Excerpt from "The Doctor, 1991)

Class discussion
Wit is a 2001 American television movie directed by
Mike Nichols. The teleplay by Nichols and Emma
Thompson is based on the 1999 Pulitzer Prize winning
play of the same title by Margaret Edson. The film was
shown at the Berlin International Film Festival

https://www.youtube.com/watch?v=2s4ozvI_hzY
(subtitles not in English)

Midterms: Graded Homework

(Film)
Journal Activity
The following questions are based on the film
viewing assignment.

A. In the film, examine the ethical implication of

caring for Dr. Vivian Bearing, a dying patient whose
physician exercised therapeutic privilege by not
exposing the whole truth about the chemotherapy.
What is your ethical stand on this? (5 points)

B. In the film, did you think that Nurse Monahan

showed moral courage? In what situation did she
show this? (5 points).

C. Did you think that Nurse Monahan acted the role

of a patient advocate? Why? (5 points)
D. Give 1 distinct description of any moral /
ethical adherence (positive) or violation
(negative) by each of the following characters
in the film as shown during their encounters
with Vivian Bearing, (main character Ph.D. –
professor English Literature with Stage IV
ovarian CA) (20 points)

a. Dr. Harvey Kelekian -the oncologist

b. Dr. Jason Posner – resident doctor
c. Diagnostic Technician – hospital staff
d. Evelyn Ashford, Ph.D. – graduate professor
& mentor
e. Susie Monahan - Nurse
END.