A significant part of being a nurse is dealing with dilemmas and problem-solving on a daily basis. Nurses are constantly faced with issues that require critical thinking and decision making. One of the most problematic concerns involves ethical dilemmas.

As much as nurses try to avoid it, ethical violations do occur. Breaches in nursing ethics, depending on the incident, can have significant ramifications for nurses. They may face discipline from their state board of nursing, or from their employer. They can also face litigation.

Nurses need to know how to ensure that ethical violations don't occur in the first place, and also what to do in case it happens. Below are common ethical concerns in nursing and how to prevent, as well as remedy, unforeseen violations.

Privacy Violations

HIPAA laws protect healthcare consumers from having their personal health information shared inappropriately. Nurses are trained to protect private health information in nursing school and throughout their career by their employer. Healthcare technology is set up to protect privacy as well. Access to electronic health records is granted and monitored. Privacy screens help reduce the visibility of patient charts, and passwords are required to access integrated systems.

Nurses must keep patient privacy as one of their top priorities. However, breaches can occur even with the best intentions. One common occurrence involves divulging health information to a family member. An example would be when a nurse receives a phone call from a person who asks for an update on their spouse’s test results. The nurse may have met the spouse and knows they are involved in the care of the patient when present in the hospital. The nurse may feel comfortable divulging health information. However, specific private health information cannot be released, except for general statements.

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To avoid inadvertently divulging health information inappropriately, nurses should be familiar with their organization's policies and procedures; some facilities must have written release of information forms or use passwords/other identifying information with family members. Additionally, nurses should be sure to lock or log off their computers when done, ensure PHI is correctly disposed of, discuss patients/patient care privately and discreetly, and even avoid discussing cases on social media. Using a personal cell phone to snap photos at work is also risky – there may be patient identification in the background.

Withholding Information

Nursing care is not just the care of the patient. Most of the time, nurses must care for families as well. A common ethical dilemma nurses face is when the values and beliefs of the patient differ from the family. For example, a family may ask members of the healthcare team to downplay (or even avoid disclosing) the severity of a diagnosis to avoid burdening the patient. However, nurses have a moral and ethical obligation to educate patients on all facets of their health.

An excellent way to approach a dilemma such as this is to establish trust with the patient and assess their readiness to learn as well as their coping skills. Setting time aside to sit with the patient to encourage questions and offer support will help as well. Being open and honest about the prognosis using factual data is also essential, but at the same time, nurses should include the family to educate on pros and cons of treatment and work to inspire hope, encouragement, and positivity.

Allowing Personal Beliefs to Interfere with Patient Care

This one can be a bit dicey. Nurses do have a right to refuse to participate in the care of patients that conflict with religious beliefs (i.e., abortion), but they cannot refuse care of a patient based on discrimination or dislike (for example, a prisoner admitted from a correctional facility, an alcohol or drug abuser, etc.). It can be extremely challenging to care for certain patients who nurses object to morally, but they have an obligation to provide the same level of care as they would any other patient.

This is not to say nurses cannot make arrangements with managers or coworkers if needed. Nurses should verbalize concerns to their supervisor so that assignments can be switched or replacements found. However, when possible, nurses should practice in care areas where they will be less likely to be faced with these dilemmas.

Personal beliefs can also affect how nurses approach patient education. It can be challenging when a nurse does not believe in specific treatments. Examples of this may include certain vaccines, medications, or invasive surgeries or procedures. While it's perfectly acceptable to hold certain beliefs, nurses should present factual, evidenced-based education to patients that align with current standards of care and practice. In other words, nurses should educate patients on what the treatment does, not what they believe.

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A specific example is a nurse who does not personally believe that a particular vaccine is effective or necessary. They are obligated to educate patients on the vaccine and should educate the patient based on CDC guidelines and statistics. Similarly, they should educate patients on side effects and possible adverse reactions. In a nutshell, nurses should always practice informed consent.

Not Speaking Up Regarding Safety – Including Reporting Peers

Nurses have a responsibility to keep patients safe at all times. Failing to report safety concerns in their work areas not only places patients at risk, but nurses and other staff as well. Nurses may feel like they are too busy to take time out to report or may be concerned about retaliation. Nurses must be careful though, as failing to report safety concerns, depending on the situation, may place them at risk for discipline; they may be accused of negligence. Following the proper channels to report is also crucial. Nurses should know how to properly communicate the various types of safety concerns – knowing this process helps the nurse as well in case of a poor outcome.

Speaking up when a peer is not practicing safely is a challenging dilemma. Nurses are a tight-knit bunch. They are often seen as a “family.” However, observing unsafe practices and not speaking up can lead to detrimental patient care outcomes. For example, let's say a nurse witnesses a close coworker administering medications without verifying the patient's identity and doesn't speak up. Later on down the line, a patient codes and it was found they received the wrong medication when under the care of that coworker. The nurse should have spoken up to address the practice.

So how should a nurse approach this difficult situation? In the above example, the nurse should have discreetly addressed it with the coworker when it was first witnessed. Stating the observation in a non-confrontational way may look like this:

"Hey. I noticed when you gave the morning meds, you didn't ask for the patient to state their name and MRN. I'm worried it may lead to an error."

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Sometimes a coworker's practice is on "autopilot"- they don't realize what they are doing incorrectly until it's brought up. Many times, the behavior changes. However, sometimes it does not, and reporting it immediately to a supervisor is vital. In fact, a supervisor should know from the first occurrence when the peer brought it up to the coworker.

Many nurses fear that they may be seen as a “gossip” or “tattle-tale,” and many are afraid of it feeling awkward in the workplace when practices are questioned. However, each party should recognize that the bottom line is patient safety. Nurses have an ethical responsibility to report unsafe practices, including with other nurses, physicians, techs, or any member of the healthcare team.

Nurses face ethical dilemmas frequently, and in any work setting they choose. They must always keep the welfare of patients at the forefront of their minds and practice with integrity. Recruiting support and seeking advice in the face of ethical dilemmas is also paramount to ensure that the right decisions are made. Nurses need to know that they are not alone; ethical dilemmas, and violations, are unfortunately part of nursing. Anticipating them and approaching them objectively is the best way to handle them.

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