Working through an ethical dilemma: while on a clinical placement, a second-year nursing student faced a complex ethical dilemma. She explains how she worked through the issues involved.
Ethics is the study of good conduct, character and motives, and is concerned with determining what is good or valuable for all people. (1) Nurses regularly face ethical challenges in their practice. (2) This exemplar identifies an ethical dilemma T faced and the steps I took to deal with it. The ethical principles influencing the decision included beneficence, confidentiality, autonomy and non-maleficence.
The Bioethics Council states: "Ethics are moral principles that govern or influence behaviour and the choices we make as individuals and communities" and refers to bioethics as the study of the ethical, social, legal, philosophical and other related issues arising in the biological sciences and in health care. (3) Technology and medical advances have created potential ethical dilemmas unheard of a few years ago. (4)
An ethical dilemma has been described as "... an ethical problem in which the ethical choice involves ignoring a powerful non-ethical consideration ..." (6) or as occuring when there are conflicting moral claims. (7)
Morals are modes of conduct taught and accepted as embodying principles of right and good. (6) The Nursing Council's competencies for registered nurses" scope of practice and the Council's Code of Conduct for Nurses require nurses to practise ethically. (8,9)
Conflicting ethical principles
Nursing ethicists Margaret Burkhardt and Alvita Nathaniel explain how a nurse may perceive a conflict, when trying to adhere to more than one ethical principle. (7) For example, a nurse may wish to avoid the suffering a patient may experience on hearing the news of a bad prognosis, white at the same time needing to respect the patient's fight to know this information. Such a situation involves a conflict between the ethical principles of nonmaleficence and autonomy. (7)
Courses in the bachelor of nursing programme address the importance of understanding ethics and endeavour to prepare students with the skills and knowledge required to manage the ethically challenging situations they wilt inevitably face.
White on placement as a second-year student nurse in a hospital, I was involved in caring for a young woman who was admitted for an appendectomy due to appendicitis. Clare (*) was a keen cyclist, fit and healthy. She lived with her boyfriend, who she had been seeing for the past year. He and Clare's mother regularly visited her and appeared supportive. Before moving in with her boyfriend three months earlier, Clare had lived with her mother and stepfather. She had never met her biological father.
As I cared for Clare, I gained an understanding of her situation and she of my role as a student. We were a similar age, it was easy to talk together and I felt I had established a rapport with her and gained her trust. One day I was helping Clare change her clothes when I noticed some bad bruising on her back and right shoulder. I was also aware Clare tried to dress quickly and avoided exposing her right side. Before this, I had not helped her undress or wash, so had not seen the bruising. I commented on it and Clare said it was quite sore. I asked her how she got the bruises. She asked if I could shut the door and then said she would like to confide in me. "You're a student so you won't tell anyone will you? l just need to tell someone to make myself feel better," she said. I was eager for Clare to continue talking so automatically promised to keep the conversation to myself.
Clare then told me the bruising was the result of a fight between her and her boyfriend about a week before, not from a cycling accident as she had previously told the registered nurse (RN). During the argument, Clare's boyfriend had hit her and slammed her against a wall Clare asked me to tell no one, as this had never happened before and she believed it would not happen again. Clare said her boyfriend was very sorry and initially frightened by what he had done.
I felt overwhelmed by the situation and out of my depth. I felt hounoured that Clare had felt comfortable talking to me. My head was spinning as I weighed up how to handle this. I responded by explaining her safety was very important and her well-being was the first priority for the nurses and myself. Clare explained she did not get on with her stepfather and therefore did not want to have to move back home. This relationship difficulty had caused problems in her relationship with her mother; these problems had now resolved and Clare did not want any troubles to resurface.
The importance of confidentiality
I thanked Clare for confiding in me and asked if she was sure she did not want to let someone know, in case her safety was be at risk. Clare made it very dear she only told me because she needed to get it off her chest; she did not want help and she hoped I would understand. Clare said she loved her boyfriend, did not want to get him into trouble and that family dynamics would be far worse if she had to move back home. She reminded me of the importance of confidentiality.
I was facing an ethical dilemma. I wanted to do what was best for Clare, but I was unable to see clearly what that was. I needed to tell the RN I was working with of the conversation but, after listening to Clare, I found myself taking into account what she had told me about her family situation and her need for confidentiality. I didn't know what would be best. I kept my knowledge of the cause of the bruising to myself for the next two days. I eventually did tell the RN, before Clare was discharged. After reflecting on the situation and analysing my responsibilities as a student nurse, I decided this was the best course of action.
My decision was guided by ethical principles. Beneficence is a general ethical principle and refers to taking positive action to help others. In nursing, beneficence is a principle which promotes actions or decisions in the best interest of the client. (10) At first I found it hard to determine what, in fact, was best for Clare.
Clare had her own set ideas about what was best for her, ie tell no-one the truth about her injuries. Clare's ideas about what was best can be linked to the utilitarianism theory of ethics. which states that whether an action is good or bad is determined solely by the outcome the action or decision produces. (7) This theory focuses on doing good for as many as possible; "harm can be done to individuals or minority groups in the name of overall good". (7) In Clare's case, keeping the abuse quiet would benefit the rest of her family, as opposed to causing more stress and worries for others. Clare tried to get me to understand this. I felt the most important thing was to remain focused on what was best for Clare. As Clare's safety was involved, it was the principle of beneficence which guided me to notify the RN of what had been disclosed.
Non-maleficence is an ethical principle related to preventing harm and can be Linked to beneficence. (10) This principle requires us to act in such a manner as to avoid causing harm to patients. (7) This includes deliberate harm and any risk of harm. Using this principle as a guide, I felt it was my responsibility to have some input into making sure Clare was at no risk of being harmed once discharged. Non-maleficence has been described as a moral professional responsibility that requires deliberate or thoughtful professional action. (11) In Clare's case, intervening to promote non-maleficence required deliberate professional action.
Domestic violence screening
The hospital I was working in screened for domestic violence by asking patients the routine question for family violence (RQFV). Clare reported no incidences of violence. Domestic violence is an issue for health professionals and that fact contributed to my decision to notify the RN of Clare's experience. Nurses are legally obliged to intervene when domestic violence is detected or suspected. (12)
Accountability is an ethical principle guiding nurses. (12) Being accountable for one's practice is a mark of a profession, thus nurses are accountable to clients and their families, fellow health practitioners, society and the profession. (12) Accountability means the nurse is responsible for her actions and decisions and able to justify these as appropriate.
When making my decision, I considered what could happen if I didn't notify an appropriate person. Clare could have been at risk of further injury or abuse and I couldn't be sure Clare was the only victim. Therefore I considered it part of being accountable for my practice, for Clare's safety and to society, to seek RN guidance. The fact I was a student and feeling indecisive also encouraged me to seek this guidance.
Conflicting moral claims
Factors contributing to this ethical dilemma involved additional ethical principles. If I had considered the principles of autonomy and confidentiality more important than beneficence and non-maleficence and not taken into account legal responsibilities, my ethical position would have changed and my decision would have been very different. An ethical dilemma occurs when there are conflicting moral claims. (7) When the correct answer is clear, there is no dilemma; a dilemma occurs when there is choice between more than one outcome. (12)
In this situation, I felt the principles of non-maleficence and beneficence conflicted with the principles of autonomy and the patient's right to confidentiality. The Nursing Council defines practising ethically as practising in accord with values and moral principles which promote client interest and acknowledge the client's individuality, abilities, culture and choice. (8) This describes exactly what I wanted to achieve, but conflicting ethical principles made this challenging.
Autonomy literally means self-governing and denotes having the freedom to make choices about issues that affect one's life. (7) In relation to autonomy, the Nursing Council's RN competencies require nurses to recognise the patient's right to choices and to provide them with opportunities for self-determination. While I wanted to respect Clare's choice, I also wanted to do what was best for her and I feet the need to notify the RN under whose guidance I was practising. Nurses work as part of a team and have a duty to participate in ethical decision making and to share the responsibility for these decisions. (11)
Confidentiality is an ethical principle that requires nondisclosure of private or secret information with which one is entrusted. (7) The Nursing Council requires a nurse to ensure all I clients' privacy and to safeguard confidentiality of information obtained within the professional relationship. (9) Clare had shared the information with me in confidence and trusted me to keep it in confidence. As confidentiality is not only an ethical principle but also a requirement of nursing's code of conduct, I found this a major issue in my decision making. There may be times when the benefits of confidentiality may be questioned, usually when conflicting with principles of preventing harm, such as non-maleficence and beneficence. (7)
The ethical principles of beneficence, non-maleficence and accountability, as well as the professional and legal responsibilities of nursing, guided how I handled the ethical dilemma. The dilemma was due to the fact there were contradicting or conflicting ethical principles involved. If the principles of confidentiality and client autonomy alone were to have influenced my decision, the ethical decision might have beendifferent. The fact I was a student and needed to seek guidance may have also influenced the final decision and actions.
Resolution of this ethical dilemma required thoughtful consideration of what was best for the client and involved weighing up the significance and appropriateness of certain ethical principles to come to a decision as to what was ethically and morally right. The situation provided me with immensely important learning, which I will carry with me throughout my nursing career.
(1) Potter, P.A., & Perry, A. (2004) Fundamentals of Nursing. (5th ed.). St. Louis, MO: Mosby. Inc.
(2) O'Connor, T. (2006) Dealing with ethical dilemmas. Kai Tiaki Nursing New Zealand; 12: 6, 21.
(3)The Bioethics Council Toi te Taiao. Defining Bioethics. http://www.bioethics.org.nz/about-bioethics/defining.html. Accessed 20/09/06.
(4) Plante, T. G. (2004) Do the Right Thing; Living Ethically in on Unethical World. Oakland, CA: New Harbinger Publications, Inc.
(6) Ethics Scoreboard. (2004) Definitions and Concepts for Ethical Analysis. http://www.ethicsscoreboard.com/rb definitions.html. Accessed 20/09/06.
(7) Burkhardt, M. A., & Nathaniel, A. K. (2002) Ethics and issues in contemporary nursing. Albany NY: Delmar.
(8) Nursing Council of New Zealand. (1996) Competencies the registered nurses scope of practice. Wellington: Author
(9) Nursing Council. or New Zealand. (2006) Code of Conduct for Nurses. Wellington: Author
(10) Davis, A. J., Aroskar, M. A., Liaschenko, J. & Drought, T. S. (1997) Ethical Dilemmas end Nursing Practice. (4th ed). New Jersey: Prentice-Hall, Inc.
(11) Rogers, J. & Niven, E. (1990) Ethics: A guide for New Zealand nurses. Auckland: Addison Wesley Longman.
(12) Eastern Institute or Technology. (2006) Family Violence [Handout]. Taradale, New Zealand: Eastern Institute of Technology, Bachelor of Nursing, BN6.240: Nursing Adolescence and Young Adults.
* Clare is a pseudonym and some details have been changed to protect the patient's confidentiality.
Anneka Voyce, RN, BN, is a staff nurse in the adult operating rooms at Auckland City Hospital. She is participating in a ten-month new-to-operating-rooms programme at the hospital.
This article has been developed from an assignment she wrote as a second-year student at the Eastern Institute of Technology (EIT). She graduated from EIT in July last year.
Mary F. Lawrene (Member):  7/8/2009 12:32 AM
This individual is very, very smart. There are some point in her argument that I would have not considered. Just researching and looking for more refereces and i found this article. It was very impressive to me. I am a first year student at K.U., and took a Medical Law and Bioethics class. I enjoyed reading this article because she gave me other directions in which to follow. Great Job.