How does a nurse leader support ethical decision making, especially when conflict arises?

How Nurse Leaders Support Ethical Decision-Making During Conflict

Nurse leaders must establish structured communication systems where staff can openly discuss moral distress without judgment, implement shared decision-making frameworks that balance clinical evidence with patient values, and actively engage ethics consultation when conflicts become intractable. 1

Create Safe Spaces for Addressing Moral Distress

Nurse leaders cannot passively wait for ethical conflicts to surface—they must proactively build infrastructure to prevent and address them. The foundation is establishing open communication channels where nursing staff can voice ethical concerns without fear of judgment or professional repercussion. 2

Key structural elements include:

• Regular staff meetings where all team members can express opinions and feelings about ethically challenging cases, with explicit protection from judgment or retaliation 2
• Peer support mechanisms and peer-to-peer coaching, recognizing that nurses often prioritize patient wellbeing over their own emotional needs, making structured support essential rather than optional 1
• Role clarity within the interprofessional team, as ambiguity about decision-making authority significantly increases stress and conflict during end-of-life situations 2

Common pitfall: Assuming that simply being "available" to staff is sufficient. Moral distress requires active leadership intervention, not passive availability. 1

Implement Shared Decision-Making (SDM) Frameworks

When ethical conflicts arise, nurse leaders must ensure their teams are trained in a systematic approach to decision-making that prevents values-based conflicts from becoming intractable disputes.

The three-element SDM model includes:

1. Information exchange: The patient/surrogate shares values, goals, and preferences; clinicians share treatment options with risks and benefits, including palliative care options 2
2. Deliberation: Clinicians and patient/surrogate discuss together which option aligns best with the patient's values 2
3. Making a treatment decision: Both parties agree on a care plan, with authority shared rather than unilaterally held 2

This model should be the default approach, then modified based on patient/surrogate preferences—ranging from patient-directed to clinician-directed models, all of which are ethically supportable. 1

When to apply SDM:

• Defining overall goals of care, including decisions about limiting or withdrawing life-prolonging interventions 2, 1
• Major treatment decisions affected by personal values, goals, and preferences 2
• Not for routine day-to-day decisions (e.g., choice of vasoactive drips, lab testing frequency), which clinicians make based on agreed-upon goals 2

Train Staff in Conflict-Specific Communication Skills

Generic communication training is insufficient. Nurse leaders must ensure staff receive training specifically designed for ethical decision-making and conflict resolution. 2, 1

Essential communication skills include:

• Listening closely to surrogates and providing emotional support to establish trust 2
• Discussing prognosis in clear, jargon-free language while eliciting patient values and preferences 2
• Explaining principles of surrogate decision-making to prevent misunderstandings about the surrogate's role 2
• Documenting who was present during ethical discussions, how patient values were incorporated, and any misperceptions that were addressed 1

Critical documentation requirement: Clearly state the decision reached and the rationale, explicitly linking it to the patient's expressed values. This makes the ethical framework transparent and defensible if conflicts resurface. 1

Establish Nursing's Leadership Role in Care Coordination

Ethical conflicts often arise from ambiguity about who has authority to make or influence decisions. Registered nurses must have a formally recognized leading role in delegation, oversight, care plan initiation and evaluation—this leadership position is critical when ethical conflicts emerge. 1

Nurse leaders should ensure:

• Nurses function as mentors and supervisors for other care personnel during morally complex situations 1
• Nurses actively advocate for patients when organizational or resource constraints threaten dignified care 1
• Collaborative structures exist where nurses work diligently with families, physicians, and other healthcare professionals to provide timely, adequate care tailored to individual wishes 1

Common pitfall: Allowing resource constraints to dictate care decisions without transparent ethical deliberation. Strained resources require explicit ethical frameworks, not implicit rationing. 1

Engage Ethics Resources When Conflicts Become Intractable

Despite best efforts, some conflicts cannot be resolved through communication alone. When partnerships in decision-making fail to yield mutually acceptable decisions, nurse leaders must enlist clinical ethics consultants or others adept at conflict resolution. 2, 1

Escalation pathway:

• Implement proactive communication strategies first, including early involvement of expert consultation to prevent conflicts from becoming intractable 2
• Use 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 1, 3
• Ensure nurses participate on ethics committees to share nursing's unique perspective, given their prolonged patient contact, therapeutic communication skills, and goal-oriented approach 1, 4

The European Society of Intensive Care Medicine guidelines suggest implementing formal protocols to prevent and mitigate conflict situations among healthcare professionals or with family members, though they acknowledge insufficient evidence for a formal recommendation. 2

Promote Multidisciplinary Communication and Prevent Burnout

Ethical conflicts exact a significant toll on nursing staff. Nurse leaders must promote multi-disciplinary communication in ethically challenging situations and implement strategies preventing mental distress, including regular ethical discussions. 2

Prevention strategies include:

• Discussing goals of care with all parties involved: patient, family members, and all professionals 2
• Implementing self-care and mindfulness programs to promote wellness among nursing staff 2
• Recognizing that moral distress from perceived inappropriate care interacts with burnout, leading to anxiety, depression, and lower quality of care 2

The evidence is clear: Conflicts are common in ICUs, usually occur between nurses and physicians or among nurses, and are particularly frequent in end-of-life situations. 2 Lack of effective involvement of healthcare professionals causes significant moral distress and within-team conflict associated with mental ill-being. 2

Understand the Ethical Principles Framework

While implementing these structural approaches, nurse leaders must ensure staff understand the four main principles underpinning ethical care: autonomy, beneficence, non-maleficence, and justice. 5 This theoretical framework helps nurses treat patients with dignity and respect when their own views conflict with patient decisions. 5