What advice should be given to new nurses regarding making ethical decisions?

Advice for New Nurses on Making Ethical Decisions

New nurses should master shared decision-making as their primary ethical framework, which requires three core elements: information exchange with patients/families, deliberation about treatment options, and collaborative decision-making that integrates the best scientific evidence with patient values, goals, and preferences. 1

Understand Your Ethical Foundation

The four fundamental ethical principles guide all nursing decisions:

• Autonomy: Respect patients' right to make their own healthcare decisions, even when you disagree with their choices 2
• Beneficence: Act in the patient's best interest to promote their wellbeing 2
• Non-maleficence: Avoid causing harm through action or inaction 2
• Justice: Ensure fair distribution of healthcare resources and equitable treatment 2

The tension between these principles—particularly between doing what you believe is medically best (beneficence) and respecting patient choices (autonomy)—creates most ethical dilemmas you'll face. 3, 4

Implement Shared Decision-Making as Your Default Approach

Use shared decision-making (SDM) for all major treatment decisions, especially those involving goals of care, limiting or withdrawing life-prolonging interventions, and any choices affected by personal values. 1

The Three-Step SDM Process:

1. Information Exchange:

   • Share diagnosis, prognosis, and treatment options in simple language, avoiding medical jargon 1, 5
   • Present risks, benefits, and alternatives for each option, including palliative care when applicable 5
   • Ask patients/families to share their values, goals, and preferences relevant to the decision 1

2. Deliberation:

   • Discuss advantages and disadvantages of each option together 5
   • Explicitly incorporate patient values into the discussion 5
   • Address any misperceptions or misunderstandings 5

3. Making the Decision:

   • Reach agreement on a care plan collaboratively 1
   • Document the decision, rationale, and how it aligns with patient values 5
   • Establish contingency plans and follow-up timelines 5

Adapt Your Approach to Patient Preferences

A wide range of decision-making models are ethically acceptable—from patient-directed to clinician-directed—and you must tailor your approach based on what the patient or surrogate actually wants. 1

When Patients Want More Control:

• Present the range of medically appropriate options 1
• Ensure decisions align with patient values 1
• Let the patient/surrogate choose from these options 1

When Patients Want You to Decide:

• Verify this preference isn't due to inadequate information or support 1
• Explain what decision you're making and why 1
• Explicitly give them opportunity to disagree before implementing 1
• Don't assume all future decisions are also deferred 1

Research shows approximately 5-20% of surrogates want clinicians to make highly value-laden choices, including end-of-life decisions, and this is ethically justifiable when done carefully. 1

Navigate Surrogate Decision-Making

When patients lack capacity, understand the ethical hierarchy for surrogate decisions: 1

1. Previously stated preferences: Use advance directives, living wills, or documented wishes when available 1
2. Substituted judgment: Make decisions the patient would make if they could speak for themselves 1
3. Best interests: For patients who never had capacity or never expressed clear values, decide what serves their best interests 1

For pediatric patients, decisions should be based on the child's best interests, though considering family impact is also appropriate. 1

Address Moral Distress Proactively

Moral distress occurs when constraints prevent you from doing what you believe is morally right, leading to unresolved grief and burnout—you must actively seek support rather than suffering silently. 6

Practical Steps:

• Use established communication channels to discuss moral distress with leadership 6
• Participate in peer support structures when facing ethical conflicts 6
• Engage in self-reflection through peer-to-peer coaching 6
• Advocate for patients when resource constraints or competing values threaten care quality 6

Nurses often place patient wellbeing above their own emotional needs, making structured support essential rather than optional. 6

Recognize Your Leadership Role

As a registered nurse, you have a recognized leading role in care coordination, delegation, and advocacy during ethical conflicts. 6

Your responsibilities include:

• Initiating and evaluating care plans when ethical issues arise 6
• Mentoring other care personnel through morally complex situations 6
• Collaborating with families, physicians, and healthcare professionals to provide care tailored to individual wishes 6
• Sheltering patients from negative consequences when organizational constraints threaten dignified care 6

Document Ethical Decisions Thoroughly

Record who was present during ethical discussions, how patient values were incorporated, any misperceptions addressed, the decision reached, and the rationale linking it to patient values. 6, 5

This documentation:

• Prevents future conflicts 6
• Clarifies the ethical reasoning process 6
• Makes the ethical framework explicit and defensible 6
• Supports appropriate billing for time spent in shared decision-making 5

Utilize Ethics Resources

When partnerships fail to yield mutually acceptable decisions, enlist clinical ethics consultants or conflict resolution experts rather than making ad hoc decisions. 6

• Participate on ethics committees to share nursing's unique perspective 6
• Use institutional decision-making committees when surrogates fundamentally disagree 6
• Seek structured approaches rather than allowing treating clinicians to decide alone 6

Critical Pitfalls to Avoid

Never allow resource constraints to dictate care decisions without transparent ethical deliberation—strained resources require explicit ethical frameworks, not implicit rationing. 6

Other common mistakes:

• Assuming blood relation automatically trumps long-term partners in surrogate decision-making (both state law and relationship quality matter) 6
• Overemphasizing professional compassion while neglecting authentic shared decision-making 7
• Focusing on tangible tasks rather than communication and information provision 7
• Using medical jargon that prevents true understanding 1

Bridge the Values Gap

Research reveals significant discrepancies between what nurses prioritize and what patients actually value—patients consistently rate comprehensible information, equality in conversations, and shared decision-making higher than nurses expect. 7

Nurses tend to overemphasize uniqueness and compassion while underdelivering on:

• Comprehensible explanations of all treatment options 7
• Conversations based on equality 7
• Making truly shared decisions 7
• Being non-judgmental 7

The first step to patient-centered care is communication and complete unbiased information provision, not focusing on normative constructs or what you think patients need. 7

Respect for Persons in Vulnerable Populations

For unrepresented patients without surrogates, demonstrate respect for persons by making extensive efforts to learn about and treat the patient as a unique individual, incorporating all known values into treatment decisions. 1

These patients face risks of:

• Overtreatment due to clinician fear of liability 1
• Undertreatment when no one objects 1
• Decisions based on clinician preferences rather than patient values 1

Treatment decisions not based on ascertainable patient preferences constitute a serious affront to respect for persons. 1