By Cynda Hylton Rushton, PhD, RN, FAAN

My nursing career began in the Pediatric Intensive Care Unit—a place of high intensity, great promise and profound grief.  One of the cases that kept me up at night involved a young child who was left with irreversible brain damage as a result of an unusual accident. His parents wanted the life-sustaining technology to be discontinued; the medical team unwilling to do so because of legal concerns.

He lived in our unit—tethered to a breathing machine and tube feedings for more than a year until his body finally succumbed to death. Each day I cared for him, I felt the knot in my stomach twinge as I dutifully implemented his daily litany of treatments—all the while wondering, “Why are we doing this? How do I make sense of my role as a nurse—as a protector of life, reliever of suffering and advocate for the interests of this patient and his family? ”

Ethical issues are part of the fabric of nursing. Everyday, nurses working in a variety of settings, roles, and geographic locations, are confronted with vexing questions about how to maintain their integrity when the ethical terrain is uncertain or complex. Many struggle to articulate the issues, their obligations, and how to proceed when there are conflicting paths that can be taken.  When such issues are not recognized or resolved, many nurses experience moral distress in response to threats to their integrity.  Over time, these unresolved issues can accumulate and undermine nurse’s ability to provide high quality and safe care.

The Johns Hopkins University, School of Nursing & Berman Institute of Bioethics are launching a national dialogue with nurses to understand the contours of the ethical challenges that face the nursing profession.

What are the issues and dilemmas that keep you and/or nurses you know up at night?

We invite you to join us in exploring this question. In August, 2014 we will convene a diverse working group comprised of nurse ethicists and leaders from major nursing organizations to begin the process of developing recommendations to address the most pressing ethical challenges faced by nurses today and looking out on the horizon. Ahead of that meeting, we want to hear from you.

In the next few months, we will host conversations on our blog through a series of Nursing Ethics posts. We encourage you to share your insights and experiences.

We will also host a series of #NursingEthics Twitter chats. Starting June 3rd, these will occur on biweekly (June 17, July 1, July 15, July 29, August 12) Tuesdays at 8pm using the hashtag #nursingethics. (Twitter chats will be recorded via Storify and posted on our blog for those who don’t use Twitter or miss a scheduled chat).

Please let your friends and colleagues know about our conversations as well. Hopefully, together we can find a path towards fewer sleepless nights.

More in the #NursingEthics Series:


Rushton_JHU1140_a_squareCynda Hylton Rushton, PhD, RN, FAAN, is the Anne and George L. Bunting Professor of Clinical Ethics. She holds a joint appointment in the Johns Hopkins University schools of Nursing and Medicine – Department of Pediatrics – and is a founding member and core faculty at the Johns Hopkins Berman Institute of Bioethics

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Cynda Rushton
Nursing Ethics

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7 Responses to “What Keeps Nurses Up At Night?”

  1. cathy robichaux says:

    What stops us from speaking up in such circumstances? Lack of knowledge, support, inability to assert our opinion, fear of reprisal?

  2. LW says:

    when nurses know the right thing to do or know that the patient is getting worse and the physicians will not agree or are unwilling to see the perspective of the nurse and initiate or terminate care appropraitely. doctors and nurses should work together and often times that is not the case. the nurses are at the bedside caring for the patient more hours than the doctor ever will be. our perspective is unique and our training rigiorous. we should have just as much say in a patients care and our insights and perspectives should have the same weight as that of the physician.

  3. I think all of the factors you mention contribute to our silence. Increasingly health care environments have become riddled with fear and betrayal. It is time for us to consider what an ethical practice environment would entail and how we can shift from victimization to empowerment and from fear to courageous action. We need to move from talking about our values to living them!

  4. Dara Whalen says:

    To live our values we need to purposefully identify what they are. As a practicing nurse and educator I don’t see my colleagues or my students paying enough attention to how they feel and subsequently how they are perceived. We assume that since we chose nursing as a career we are skilled at interpersonal communication and that the ability to feel and express empathy is a given. In my experience, that just isn’t so. In a world where mixed signals regarding ethical principles and practices are all around us, how can we expect the high level of skill required to navigate through the daily ethical challenges we face to exist without a continuing and purposeful focus on the issues. I believe ethical principals and formation of self evaluative processes need to be concrete threads through every part of every health care related curriculum. This would be a start.

  5. JF says:

    I’ve been thinking about what I can remember of the education I received as a student about ethics and ethical practice. I recall learning a lengthy list of terms with some general examples of each. It was very generic and there was no mention of moral distress. The final paper I wrote for that class was on the topic of allocation of scarce resources (donor organs for transplantation), filled with jargon but little actual ethical dissection. I got an “A” on that paper. Fast-forward 20 years and my mind has been bombarded with morally-distressing situations. There have been times when I’ve spoken my mind on a plan of care I’ve disagreed with and have been told to stick to patient care, to leave the thinking to those with more education. There is always plenty of well-considered discussion in the break room about these situations but no one is willing to speak out in a larger forum, partly from fear of ridicule and partly from frustration with the imbalance of influence we have. I know of a nurse who spoke up publicly about moral distress and found herself suspended from her job, investigated by her regulatory body and punished further for daring to say what no one wants to hear. This example tends to put a chill on others, and the effects of moral distress continue to grow.

  6. Cynda Rushton says:

    The risks of speaking up without fear or reprisal are important issues of personal integrity and organizational ethics. What can we do individually to build the necessary skills to speak up about these violations of ethical values and collectively to create a call to action for organizational change?

  7. At times I stay up at night going over the day and trying to decide how I can do it better the next day. Perhaps the problem was an angry family, or the dressing change was too painful, or perhaps the care I am giving is futile in my eyes. Sometimes the cause is the family who wants “every thing” or the doctor unable or unwilling to stop. I search my heart for the right answer. It is a slippery slop to stop unilaterally. Agreement among the team and the patient and family is important. The patient should lead if at all possible. The young doctors need to be taught the when the family wants everything they really mean to say every thing that would help meaningful survival. So I stay up at night to seek a way to guide the young resident to talk to the family to say I have nothing that will make a meaningful difference. I try to make time to talk to the family about the patient and guide them to alternatives to full code status. I have been a critical care nurse for more than 40 years. It helps when speaking with patients, families and physicians when you have life experiences and confidence behind your words.

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