How Nurse Leaders Support Ethical Decision-Making During Values Conflicts and Moral Distress
Nurse leaders must establish open communication channels for staff to discuss moral distress, provide peer support structures, and facilitate interprofessional collaboration to address ethical conflicts—while actively advocating for patients when resource constraints or competing values threaten care quality. 1
Addressing Moral Distress Through Leadership
Moral distress arises when constraints prevent nurses from doing what they believe is morally right, leading to unresolved grief and burnout. 1 Nurse leaders must:
Create safe spaces for nursing staff to engage in open communication with interprofessional colleagues and families about their experiences of distress. 1 This prevents the accumulation of unresolved moral injury that leads to burnout.
Provide peer support mechanisms and facilitate self-reflection through peer-to-peer coaching. 1 Nurses often place patient wellbeing above their own emotional needs, making structured support essential.
Stimulate self-care and increase self-awareness among staff about negative emotions and thoughts during ethically challenging situations. 1 This requires active leadership intervention, not passive availability.
Implementing Shared Decision-Making Frameworks
Nurse leaders should train staff in shared decision-making (SDM) processes that include three core elements: information exchange, deliberation, and making treatment decisions. 1, 2 This structured approach helps navigate values conflicts by:
Ensuring decisions incorporate the best scientific evidence alongside patient values, goals, and preferences. 1 This framework provides clarity when clinical teams and families disagree.
Tailoring the decision-making approach based on patient or surrogate preferences—ranging from patient-directed to clinician-directed models, all of which are ethically supportable. 1
Engaging in SDM for defining overall goals of care, including decisions about limiting or withdrawing life-prolonging interventions, and for major treatment decisions affected by personal values. 1
Establishing Nursing Leadership in Care Coordination
Registered nurses should have a recognized leading role in delegation and oversight of care tasks, initiation and evaluation of care plans, and assessment of their effectiveness. 1 This leadership position is critical when ethical conflicts arise because:
Nurses function as mentors and supervisors for other care personnel, providing guidance during morally complex situations. 1
Nursing staff collaborate diligently with families, physicians, and other healthcare professionals to provide timely, adequate care tailored to individual wishes. 1 This interprofessional collaboration is essential for resolving values conflicts.
Nurses advocate for patients to shelter them from negative consequences when organizational or resource constraints threaten dignified care. 1
Training in Communication Skills for Ethical Conflicts
Clinicians, including nurses, should be trained in communication skills specifically designed for ethical decision-making. 1 Effective communication during values conflicts requires:
Documenting who was present during ethical discussions, including patients, family members, and healthcare team members. 2 This creates accountability and transparency.
Recording how patient values and preferences were incorporated into deliberation, and noting any misperceptions that were addressed. 2 This documentation prevents future conflicts and clarifies the ethical reasoning process.
Clearly stating the decision reached and the rationale, linking it to the patient's expressed values. 2 This makes the ethical framework explicit and defensible.
Utilizing Ethics Resources and Committees
When partnerships in decision-making fail to yield mutually acceptable decisions, nurse leaders should enlist clinical ethics consultants or others adept at conflict resolution. 1 Specific strategies include:
Participating on ethics committees to share nursing's unique perspective, including prolonged patient contact, therapeutic communication skills, and goal-oriented approaches. 3 Nurses are well-suited for this role given their continuous presence at the bedside.
Using institutional decision-making committees rather than allowing treating clinicians to make ad hoc decisions when surrogates fundamentally disagree or no appropriate surrogate can be identified. 4
Ensuring the organization's mission, vision, and values demonstrate consistency between what is espoused and what is lived. 5 Nurse leaders must create congruence between caring missions and caring practices.
Common Pitfalls to Avoid
Organization-related ethical problems are both the most frequent and most difficult that nurse managers encounter. 6 Critical mistakes include:
Failing to routinely use ethical consideration and discussion of prioritization in administrative decision-making. 6 This leads to repeated moral distress without resolution.
Allowing resource constraints to dictate care decisions without transparent ethical deliberation. 1 Strained resources require explicit ethical frameworks, not implicit rationing.
Neglecting to provide ethics education and instructions for repetitive ethical situations. 6 Nurse leaders must proactively prepare staff for predictable conflicts.
Assuming blood relation automatically trumps long-term partners in surrogate decision-making—both state law and relationship quality matter. 4 This common error creates unnecessary conflict.
Strengthening Organizational Ethics Infrastructure
The more positively nurse managers assess their work-related background factors, the fewer ethical problems they encounter and the easier they consider them. 6 Nurse leaders should:
Strengthen resources for ethics, including ethics experts and multiprofessional committees. 6 These structures provide support when difficult value clashes appear.
Integrate ethical decision-making templates into electronic health record systems for ease of use. 2 This normalizes ethical documentation and deliberation.
Establish support mechanisms specifically for situations where difficult value clashes appear, rather than expecting individual nurses to manage alone. 6