Translational Research in Nursing Ethics: Evidence-Based Practice Change

Introduction: The Theory–Practice Gap in Nursing

For the last thirty years, emphasis has been placed on shifting nursing curricula out of hospitals and into universities. The education of nurses is now increasingly oriented toward theory. This has led to an obvious gap between what nurses experience in practical healthcare settings and what is taught in lecture halls (Saifan, AbuRuz, & Masa'deh, 2015).

Nursing practice is just one of the areas of healthcare experiencing increased pressure from a dynamic healthcare environment. Each year, as changes in the medical environment become more pronounced, outcomes become harder to forecast, and partnering with other stakeholders becomes essential for success. The pace of change in practical nursing is inevitable and will continually increase as the level of dynamism and interdependence in the profession continues to grow (Jooste, 2011).

Nursing Ethics as an Area Requiring Change

Nursing is practiced by people who have been licensed and registered under the Nursing Act, as it is one of the regulated professions that form part of a multifaceted healthcare system. Its practice encompasses scientific knowledge, expertise, and wisdom within a caring environment, and preserves the coordination and continuity of healthcare provision. Nurses have a two-fold accountability: first, to clients in terms of character and the quality of practice; and second, to society through license laws, by engaging in safe and competent practice (Jooste, 2011). It is generally held that the professional duty of nurses — either directly or through referrals — is to provide non-discriminatory attention to all patients. Nurses are professionally obliged to give excellent, unbiased care to those under their care, even in emergencies, in spite of their personal beliefs. Any approaches or convictions that would interrupt important job functions must be communicated to employers at the point of employment as a professional obligation (AWHONN, 2009).

It is generally considered difficult, in the healthcare profession, to acknowledge the fact that sometimes the actions nurses take are not in the best interest of the patient (Moore, 2012). For example, nurses sometimes take action to save a patient's life when the patient may have been better off allowed to die. Nurses are sometimes placed in life-and-death situations in which life is saved, but with regrets afterward. Ethics in nursing thus comes into play (Moore, 2012).

The area of nursing ethics is one that clearly needs change. In order for healthcare professionals to provide improved and enhanced services to patients, ethical codes must evolve at the same pace as the rapidly evolving nursing practice.

For human development, care is vital and is aimed first at the physical needs of people. In order for infants to survive, nurturing care is needed, just as it is needed for a dependent patient at the end of life. Nursing ethics arise from the notion that care is a basic requirement for human existence. Care ties people together into a web of relationships. Choosing to join the nursing profession means accepting a moral duty to tend to all patients. This is not, and should not be, a light decision — as reflected in the nurses' code of ethics (Lachman, 2012).

The American Nurses Association (2001) states that, irrespective of the type of health problem in question, nurses should respect the value and rights of all human beings (Nursing World, 2015).

A nurse, for instance, is required to give care to a patient whose current health condition is the result of refusing to follow a treatment plan aimed at managing his diabetes and alcoholism. However, for a nurse to set aside personal prejudice in such a case and follow the four stages of care is very difficult. Adhering to those four dimensions requires the nurse to go beyond good intention alone. Good care requires a combination of activities, attitudes, and knowledge of the situation at hand (Lachman, 2012).

Nursing can either be considered just like any other duty within the ethics bracket — and hence a difficult task — or it can be viewed as a calling and a passion to be enthusiastically involved in patients' needs (Lachman, 2012).

In providing care to others, there comes a time when the patient and his or her family members, the attending doctor, and the nurse in charge do not agree. Despite such disagreements, none of them is necessarily wrong, as their focus is the same — only the solution is not obvious (Bedrosian, 2015).

Nurses confront ethical challenges every single day, in all departments of various healthcare organizations. These challenges rarely form part of formal discussions in the course of care provision. However, if disregarded, healthcare facilities do not merely end up with burned-out staff — nurses sometimes quit altogether. This has dire consequences for the future of healthcare, as demand for nurses is rapidly increasing (Bedrosian, 2015).

Nurses face unique ethical challenges in their medical work, even though ethical difficulties affect all healthcare workers. Because of the time nurses spend with their patients, they are better positioned to understand what the patient and his or her family feel and want. They are commonly present when patients and their families face important yet often uncomfortable decisions. In most cases, nurses are the ones who are aware when either a patient or a family member is uncomfortable with an ongoing treatment. Nurses have extended contact with patients and their families. They share the experience and the frustrations that come with receiving treatment, being more connected with the prevailing situation. This can greatly affect their own ethics, and it becomes particularly complicated when the nurse's own beliefs are in conflict with those of the patient's family, the hospital, or other caregivers (Bedrosian, 2015).

Nurses should receive training so that they can readily recognize and discuss the ethical dilemmas they encounter each day in their practice.

Key Stakeholders in Nursing Practice

The key stakeholders in nursing practice include nurses, doctors, hospital management, educational institutions, and regulators of the healthcare industry. These parties are among those responsible for drafting and revising ethical codes.

Educational institutions have a vital role to play in ethical education. One such role is to encourage discussions on ethics and create awareness by providing forums in which students can openly speak on ethical issues. One institution that has done this is Johns Hopkins, which has introduced ethical rounds — meetings in which teams are given space to discuss ethical issues emerging from patient care (Bedrosian, 2015). These meetings may include patients and their relatives. Topics discussed can include how the healthcare team feels about the current course of treatment, how the family feels about it, what the family believes the patient would have preferred if he or she were able to express that preference, and whether the patient has previously expressed such preferences (Bedrosian, 2015). Awareness of ethics is thus created among all involved in patient care, and the topic is demystified.

Doctors make decisions regarding patient care and consult with nurses and other medical professionals to ensure that their instructions are carried out (Browne, n.d.). Since doctors are in close contact with nurses, it also becomes their responsibility to ensure that ethics is discussed and that they support their colleagues in making sound ethical decisions. McKay and Narasimhan (2012) delineated the roles of doctors and nurses. According to them, doctors should maintain high personal ethical standards and provide leadership and management within their organizations. By acting as leaders, doctors can help nurses develop their ethical judgment and monitor behavior for red flags (McKay & Narasimhan, 2012).

Hospitals also have major functions to fulfill in changing nursing practice. These include designing appropriate safety guidelines and specific codes of conduct. Elements captured in a code of conduct that embraces change include respect for cultural traditions, confidentiality, and patient autonomy. This is reflected in the code of conduct for Johns Hopkins Hospital. The code of conduct should also specifically address how it relates to everyday hospital activities, such as vaccinations, admissions, administering medications, allocation of scarce supplies, staff assignments, and distribution of space. Some safety guidelines are designed to protect the emotional health of nurses. For example, Johns Hopkins Hospital has support systems allowing nurses to speak openly about the ethical issues they face (Bedrosian, 2015). The hospital has made a chaplain available to nurses who wish to discuss their ethical dilemmas.

Nurses also have a role to play in acquiring the ability to ethically care for patients. They should develop the knowledge and skills necessary to offer rounded, consistent, and excellent care. Nurses can fulfill this role by diligently reading available professional literature, sharing evidence-based research with colleagues, and influencing others through their knowledge and expertise — thus strengthening the practice of nursing (Bedrosian, 2015; Parker, 2007).

Regulators play a vital role in instituting policies and guidelines that the profession must adopt, and they create awareness through various initiatives and campaigns. One such regulator is the American Nurses Association, which has revised the Code of Ethics for Nurses through interpretive statements that serve as standards for the ethical practice of all nurses. The association has been incorporating incremental changes in thought and focus by accounting for how the healthcare landscape and technology have evolved. One way the ANA has raised awareness of ethics is by designating 2015 as "The Year of Ethics" (Bedrosian, 2015). This title served to raise questions and initiate discussions, helping to elevate awareness of this key issue.