Ethical Leadership in Nursing

Ethics are moral beliefs and rules about what is right and wrong. Ethical leadership is defined as behaving appropriately at work and outside work, respecting ethical values and ideas, and being motivated by the dignity and rights of others.

Ethics are moral beliefs and rules about what is right and wrong. Ethical leadership is defined as behaving appropriately at work and outside work, respecting ethical values and ideas, and being motivated by the dignity and rights of others.

Nurses are held to ethical principles that relate to all aspects of nursing care. They must incorporate ethical values into nursing practice and will face situations where they must decide if something is right or wrong. These decisions are based on a system of ethical behavior.

All nurses are leaders in their roles as healthcare providers and advocates. Nurses communicate and work in partnership with the patient, family and healthcare team to deliver quality care. Nurse managers involve nurses in decision-making about patient flow and staffing, quality improvement and professional development to improve care delivery. These nurse leaders aim to ensure appropriate staffing and other resources are in place for safe care and optimal patient outcomes.

Nurses perform many critical, health-related tasks every day; in some cases, the decisions they make test their professional and personal morals. Ethical guidelines remind nurses to treat all patients equally and individually and to protect their privacy. The nursing code of ethics helps consider patient needs from different viewpoints and establish a safe environment.

An accelerated nursing program will equip students with the skills of a clinical nurse leader and to provide direct patient care. Elmhurst’s entry level master’s in nursing is an online program designed for students with bachelor’s degrees in other subjects who want to enter the nursing profession.

Florence Nightingale

Ethics in nursing has played a critical role since the inception of the profession. Florence Nightingale, the founder of modern nursing, served as a nurse and nurse trainer during the Crimean War of 1853-1856. In her book Notes and Nursing, she gave ethical instructions to nursing leaders. She believed nurse leaders should be fair and honest and lead by justice rather than personal preferences. She wrote that the nurse leader must cultivate an atmosphere where their staff can do the right thing. They must also be aware of the wants of their staff and have a realistic but generous insight into their characters. The team must know that their leader cares about them even while overseeing them.

Nightingale believed moral formation to be at the heart of nursing education and that moral character was essential to have the values, ideals and conduct required for nursing. This was the start of the nursing ethical tradition, which continues to be critical in nursing today.

Possible scenarios

There are many possible ethical dilemmas in nursing; this scenario is one example. Mrs. Richards has metastatic lung cancer. Her doctor has explained the treatment options that could prolong her life by six months to a year. Her family is dismayed that she wants no more treatment. Mrs. Richards has made a living will that includes signing a DNR (do not resuscitate).

The ethical dilemma here concerns end-of-life care and is one of many examples you will face in nursing. Nurses can find it hard to meet the family’s requests while also fulfilling the patient’s wishes.

If Mrs. Douglas is mentally sound and understands her prognosis, then she has the right to decide against treatment. Although this situation may be difficult, the nurse’s primary responsibility is to the patient, and they must advocate for the patient’s autonomy and rights. As the patient in this case has made a living will, this will make following her wishes easier.

Nursing leadership

Leadership is about determining what needs to be done, collaborating to achieve this goal and ensuring sure it is accomplished. As leaders in diverse roles, nurse managers direct and motivate others through credibility, trust and strong relationships. Effective leadership at management levels also contributes to a positive workplace, improved patient care and better nurse retention rates. 

Nursing training includes the development of leadership skills. There is an emphasis on ethical and critical decision-making, productive working relationships and conflict-resolution methods. Nurses understand moral reasoning and use leadership to encourage advocacy, collaboration and social justice. Newly graduated nurses will be future leaders in practice, administration, education and research. The industry will rely on these nurses to provide leadership and encourage the continued delivery of quality healthcare.

There are many leadership theories, but popular models in nursing education are transactional, transformational and authentic leadership. A transactional nurse leader focuses on the monitoring and managing of daily functions and provides effective, stable leadership. A transformational nurse leader encourages other staff to collaborate and nurtures a belief in working together for a higher purpose. An authentic nurse leader speaks the truth, is open about their actions and mentors others to improve performance. Transformational and authentic leadership may be needed in times of organizational change, growth and crisis. These leadership styles do overlap, with characteristics of one often being used by another.

Ethical behavior is a feature of transactional, transformative and authentic leadership. Nurses make ethical decisions and are role models for other staff. They influence others through communication, expectations and conduct. Ethical leaders focus on moral obligations and expect others to do the same. They encourage critical thinking in situations where morals come into play and influence conduct and accountability. The behavior and expectations of ethical leaders can result in greater trust from other staff, which means an increase in positive attitudes and improved job performance.

The terms macro, meso and micro reflect the environment of practice for the ethical nurse leader. At the macro level, nurse leaders are spokespersons, campaigners, researchers and advocates for social justice and healthcare reform. These leaders ensure nurses’ views and experiences are heard and represented in national and international forums. At the meso level, the nurse leader acts as the conscience of the healthcare team by not allowing compromises that could affect standards of care.  These leaders understand nursing concerns and support research and guidance for ethical work practices and quality healthcare. They make sure that ethics resources are accessible and used by nurses. The micro level relates to day-to-day practice and processes. Nurse and patient interactions are a micro factor that influences patient health because communication contributes to a secure environment for patients.

Nursing directors and nurse managers are leaders who are responsible for creating healthy work environments with a climate of caring and support. These frontline leaders must recognize the value of meeting nurses’ needs in order to meet patient needs and allow participation in decision making. These management positions are essential to organizational success, positive patient outcomes and nurse empowerment. However, with responsibility for budgets, staffing and regulatory compliance, there can be tension between ethics and the organization’s needs.

Code of ethics

A nurse’s code of ethics is a collection of guidelines on acceptable behavior. The code states the morals, values and priorities that all nurses are expected to uphold. The code of ethics consists of the following principles:

  • Nurses must practice compassion and respect for the dignity and worth of patients.
  • Nurses’ primary commitment is to the patient.
  • Nurses should promote, protect and advocate for patients’ rights, safety and health.
  • Nurses have authority, responsibility and accountability for nursing practice, making decisions and acting according to their obligations.
  • Nurses have the same obligations to themselves as to others.
  • Through their own and others’ efforts, nurses should maintain and improve the ethical environment at work and employment conditions.
  • Nurses should advance the profession through research, professional development and policy generation.
  • Nurses should collaborate with the public and other healthcare professionals to protect human rights and help reduce health inequality.
  • The nursing profession must express nursing values, maintain integrity and include principles of social justice in policy.

The code of ethics can be a reminder that each patient has a unique background and needs. Nurses will treat patients from different cultures who speak different languages and hold beliefs different from their own. Nurses must make culturally ethical decisions about their care. They should understand how social and cultural differences influence a patient’s beliefs and attitudes to healthcare. Nurses can improve their cultural knowledge by communicating well, being non-judgmental, accepting cultural differences and being aware of their own biases. Being culturally aware can help nurses when they face ethical dilemmas regarding patients with diverse backgrounds.

Nurses are patient advocates, ensuring individual needs and preferences are recognized in their care. The nursing code of ethics puts forward the principle that patients have the right to be fully informed about their treatment and to make decisions. The patient must be mentally fit to do this and, if not, then their nurse will support them in making decisions. 

Nurses promote a well-rounded approach to healthcare, considering patients’ physical, mental and spiritual well-being. They network with other healthcare staff and stand against public health initiatives that do not meet community health needs.

Ethical dilemmas

Despite having guidelines for ethical practice, nurses will still encounter situations where they face difficult choices between two or more options. Some of the more common ethical dilemmas that nurses encounter include patients refusing treatment, tasks clashing with their personal beliefs, needing parental consent for a child’s treatment, involving minors in decision making, differing values between nurses and patients, and confidentiality issues that are in conflict with ethical principles.

Nurses may find themselves working in situations where a patient’s religious beliefs hinder providing medical treatment that is right for their health. This ethical dilemma can occur when the patient is a Jehovah’s Witness and their religious beliefs do not allow blood transfusions. If the patient refuses a blood transfusion, all the nurse can do is make sure they are fully aware of the medical consequences and keep detailed documentation of their decision.

Nurses are responsible for recognizing ethical issues that affect staff and patients. For example, providing healthcare for patients having abortions could raise ethical and moral concerns for some nurses. The principle of autonomy must be followed with the patient having the right to make decisions about their healthcare.

Most hospitals and healthcare facilities have multidisciplinary ethics committees that meet to resolve ethical dilemmas and conflicts. Nurses can approach committee members for support in resolving ethical issues.

The pandemic

The coronavirus pandemic raised numerous ethical issues for the nursing profession. Healthcare providers faced many challenges in coping with the pandemic and trying to provide quality healthcare while placing themselves at great risk. Regardless of disasters or pandemics, nursing staff are expected to apply the four main principles of ethics in healthcare, which are autonomy, justice, beneficence and non-maleficence.

The code of ethics states that the nurse’s primary commitment is to the patient while also owing the same duty of care to themselves. During the pandemic, these two obligations could conflict when nurses must care for critically ill and infectious patients, often with inadequate resources and uncontained infection. Nurses needed to decide how much care they could give patients while also looking after themselves.

Clear communication and strong leadership were essential in supporting nurses during such a high-impact, stressful time. Moral decisions had to be made in a rapidly changing and complex environment. Keeping to the code of ethics, nurses had to assess and reflect on their intentions, consider all options and formulate a moral justification for their actions.

In nursing, human rights concerns are only placed below other considerations in extreme and exceptional circumstances. Efforts to stop the spread of COVID-19 included hospitals tightening restrictions on visits, including to those patients at the end of their lives. Some hospitals supplied smartphones and computer tablets to help loved ones say their last goodbyes. Most health authorities suspended all visits with some exceptions for compassionate reasons decided by the nurse in charge. The ethical principles of palliative care were challenged at this time, with nurse leaders having to make decisions they would not usually make for the greater good of the population.

There is a proud tradition of ethics in nursing that contributes to the professionalism of nurses. Ethics change over time but remain connected to the patients’ and nurses’ human rights. Strong ethical leadership creates an environment of respect and dignity for all and helps to ensure that quality healthcare is provided.

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About the Author: Barry Lachey

Barry Lachey is a Professional Editor at Zobuz. Previously He has also worked for Moxly Sports and Network Resources "Joe Joe." he is a graduate of the Kings College at the University of Thames Valley London. You can reach Barry via email or by phone.