This paper addresses several interconnected ethical and legal dimensions of advanced practice nursing. It distinguishes between moral distress and moral integrity, illustrating each with relevant examples. The paper evaluates ethical decision-making models — including the Rational Model and the Collaborative Model — as tools for nursing leaders to resolve moral distress caused by incivility and other workplace challenges. Three practical recommendations for alleviating moral distress are provided, followed by a discussion of the advanced practice nurse's role in influencing ethics committee decisions. The paper concludes with a personal reflection on how coursework reshaped the author's understanding of nursing ethics, accountability, and professional responsibility.
Moral distress is viewed as a contested and evolving concept and has been identified as a major issue within the nursing profession (Harris, 2002). Rizzo (2005) is credited with first recognizing the concept of moral distress. He described moral distress as feelings that are painful — a mental imbalance or disequilibrium that occurs when nurses find themselves in circumstances where they feel unable to do the right thing. Rizzo further explained that moral distress arises when one knows the right course of action yet institutional constraints make it practically impossible to follow it. Staff educational level and peer support have been found to affect moral distress (Toiviainen, 2007). Moreover, moral distress has been shown to influence nurses' health, their provision of care, job retention, and job satisfaction.
Moral integrity, by contrast, can be understood as both a personal and a social virtue, highlighting that integrity is composed of diverse values. "Acting with the virtue of integrity does not threaten the respect for life, integrity, well-being, and flourishing of others" (Ulrich, 2004). Integrity is considered to mean living up to one's own ethics and having strength of character. "Integrity is considered to be a noun… One acts with integrity; integrity is detached from the act in a way that truthfulness, honesty, courage and so on are not" (Munin, 2012). An example of integrity in practice is observed when a nurse goes beyond what the rules and codes prescribe and recognizes that acting outside those guidelines will better serve patient safety and outcomes — what they consider the "right thing to do" (Toiviainen, 2007).
As a nursing leader, the Rational Model — grounded in principle ethics — is one that can effectively be used to resolve moral distress. This model is important because when a professional faces an ethical problem, they think through the issue carefully, consider diverse ways the dilemma can be addressed, and select the most appropriate course of action. Richards, Tiffany, and Bertolotti (1995) identify seven steps in this model: (a) recognizing the problem; (b) referring to the code of ethics and professional guidelines; (c) determining the dimensions and nature of the problem; (d) considering the potential consequences of each available course of action; (e) evaluating each course of action by weighing its pros and cons; (f) applying the best course of action; and (g) evaluating the outcome (p. 270).
This model was selected because one of its key strengths is that it allows a person to thoroughly examine an ethical issue along with all available options, ultimately enabling them to choose the best one. Additionally, it explicitly incorporates reference to the code of ethics and professional guidelines, which are essential when substantiating a decision. An example of how this model resolves distress is that it involves all relevant parties rather than placing the burden on one individual. In this way, a decision can be reached that all parties can accept. A further strength of the model is that it allows everyone to understand each other's point of view regarding the difficulties and possible solutions being considered.
Incivility is a term used to describe intimidating, rude, disruptive, and undesirable behaviors directed toward another person. One example of incivility in the healthcare setting is the use of racial and ethnic slurs. Some nurses may come from backgrounds that carry racial bias or prejudice toward other groups, and this behavior can manifest on the job in interactions with both staff and patients. A second example is refusing to help others at work, which may stem from interpersonal conflicts with colleagues or even patients. A third example is threatening or intimidating faculty or staff members.
The following steps, drawn from an ethical reasoning tool, lead to a solution for these behaviors:
"Collaborative Model for group-based ethical resolution"
"Liaison psychiatry, group meetings, and extended leave"
"Nurses influencing ethics committees on patient rights"
"Personal growth in nursing ethics and accountability"
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