Sometimes, the decision to offer nursing care comes at a very high price.

You can read a summary and listen to this piece from NPR, about caring for Ebola victims in the Kenema district of Sierra Leone: “When Holding An Orphaned Baby Can Mean Contracting Ebola

One day, an Ebola-infected mother brought her baby into a hospital, Purfield recalls. The mother died, and the baby was left in a box.

“They tested the baby, and the baby was negative,” says Purfield. “But I think the symptoms in babies and the disease progression in babies is different than adults.

“So the nurses would pick up and cuddle the baby. And they were taking care of the baby in the box,” she continues.

Twelve of those nurses subsequently contracted Ebola, Purfield says. Only one survived.

“They couldn’t just watch a baby sitting alone in a box,” Dynes says….

From Nature:

Moral distress in the neonatal intensive care unit: an Italian study


Objective: The objective of this study was to evaluate the frequency, the intensity and the level of moral distress experienced by nurses working in neonatal intensive care units (NICUs).

Study Design: We conducted a cross-sectional questionnaire survey involving 472 nurses working in 15 level III NICUs. Frequency, intensity and level of moral distress was evaluated using a modified version of Moral Distress Scale Neonatal–Pediatric Version. Socio-demographic data were also collected.

Result: Four hundred six nurses completed the study material indicating a low-to-moderate experience of moral distress. The situations receiving the highest scores for frequency, intensity and level of moral distress related to the initiation of extensive life-saving actions and participation to the care of ventilator-dependent child. No difference in the mean scores of moral distress was found according to the socio-demographic characteristics investigated.

Conclusion: The present study provides further insight into the moral distress experienced by nurses working in Italian NICUs.

From the Discussion section of the paper:

“The results of our study indicate that nurses working in neonatal intensive care experience a low-to-moderate moral distress…”


“The situations that received the highest scores for frequency, intensity and level of moral distress related to the initiation of extensive life-saving actions and participation to the care of ventilator-dependent child.”

From the forthcoming book, “Critical Thinking for Nurses: Cases and Concepts,” by Chris MacDonald and Nancy Walton (Oxford University Press, 2014). Chapter title: “Thinking Critically About Ethics.”

In terms of behaviour, ethics is about deciding what it is right to do. It is about deciding between how we should behave, and what kinds of people we want to be. Ethics as a field of study can be defined as the critical, structured examination of standards of conduct for people and organizations. It is worth pausing for a moment to look at several elements of that definition. First, ethics is a critical field of study, in the same sense of the word “critical” as we see that word used in critical thinking. In other words, ethics is not just a matter of stating our view about right and wrong, or describing the patterns of such beliefs within society. Ethics, instead, is about examining such beliefs with a critical eye in order to determine which beliefs about right and wrong behaviour can be supported by strong arguments.

Second, ethics is a structured examination of right and wrong. It is not, in other words, just a matter of examining one’s own feelings or relying on intuition. It is a matter of looking carefully at the foundations of our ethical beliefs in a systematic way. It is a matter of asking not just, “What do I believe?” but also “Why do I believe that?” and “Can I provide good reasons for other people to adopt my point of view?”

From the forthcoming book, “Critical Thinking for Nurses: Cases and Concepts,” by Chris MacDonald and Nancy Walton (Oxford University Press, 2014)…

Some people may find it surprising to think that we could apply the principles of critical thinking to the world of ethics. After all, ethics touches on moral issues which may be of a deeply personal nature, and when we think of ethics we often think of issues on which different persons simply agree to disagree.

But ethics isn’t just about opinions. Certainly, all of us have intuitions about various ethical issues — everything from reproductive freedom through to gun control to how children ought to be raised. But while such intuitions and opinions are often important to us, and are often central to our conceptions of ourselves as good persons, differences of opinion on such topics can cause conflict. Such conflict can cause problems in our personal lives, as well as making it more difficult for teams and institutions to function. But as we have seen in previous chapters, not all opinions are equally well supported. Some opinions are based on mistakes of fact, and others are the result of faulty reasoning. The very same goes for ethical opinions. While all persons are equally worthy of respect, not all ethical points of view are equally well grounded in good arguments.

Here’s a useful new article on research ethics from Nursing Times, freely available online: Nursing research: ethics, consent and good practice

Here’s the abstract:

Nursing practice must be based on reliable evidence and nurse education must equip practitioners with the skills to challenge existing practices, read published research critically and evaluate its role in clinical practice. Health professionals are likely to come into contact with patients taking part in clinical trials, and have a role to play in maintaining a culture of improving care using a strong evidence base.

This article explains the responsibilities of research nurses in clinical trials and how patient safety is maintained. It outlines the role of nurses in clinical research and the regulatory frameworks that underpin it, and explores the consent process and ethical principles.

The article discusses both the significance of research (including clinical trials) for developing nursing practice, as well as the role of research nurses in clinical trials more generally.

The webpage is here, and the PDF version of the article is here.

(For more about Research Ethics, check out the Research Ethics Blog).

Once again, nurses have come out atop the results of a Gallup poll that “asked Americans to rate the honesty and ethical standards of members of various professions.” This year’s poll suggested that 82% of Americans rate nurses as ranking “high” or “very high” in terms of their honesty and ethical standards. The next most highly ranked were pharmacists and grade school teachers (both at 70%), followed by medical doctors (69%). Farther down the list: police officers (54%), clergy (47%), bankers (27%), lawyers (20%), and members of congress (just 8%).

Of course, this raises as many questions as it answers. For a start, what contexts do people have in mind when they answer such questions? It’s worth considering that individuals have very different relationships with nurses than they do with (say) lawyers, and those two professions have very different rules about things like honesty. There are situations in which both nurses and lawyers are required by confidentiality rules not to be “honest” (or at least not candid).

It also raises questions about just how well-informed are these opinions, and what are they based on? How, for example, is each of these professions portrayed on TV, and how accurate are those portrayals?

None of this is to cast doubt on nurses being at #1, but rather to promote another essential nursing skill, namely critical thinking!

Here’s another in the Globe & Mail’s series on understanding the healthcare system. This one’s a short video, called: How do hospitals decide who gets a bed?. The voiceover is by a “patient flow specialist,” an RN whose

A couple of quotes from the video:

“It’s constant juggling. We’re constantly playing with missing pieces of a puzzle, we’re trying to make the best to make it work and make everyone get the care that they need…”

“What we’re often doing is speaking to the charge nurses, speaking to the staff physicians, speaking to the fellows, to say if I only do get one bed, who’s the best to move out at this time? You want to take the best patient, the most stable patient — that way you don’t get anyone bouncing back.”

“A patient flow specialist is a registered nurse who basically triages patients from all areas of the hospital, and brings them according to the skillset of the floor, according to patient need…”

The video also touches on the challenges in getting patients and their families to understand hospital prioritization practices when it comes to beds:

“I think it’s very hard for people to understand, when they themselves or their loved one is sick, to understand that there are other needs outside. It’s very hard to accept that when the immediate person at that time requires help and care.”

Finally, the video also touches on the big picture, and the fact that hospital beds are (or should be) just one option among a range of options including various forms of home- and community care.

Ethics of Triage

The Globe & Mail recently ran an interesting piece called “Nurse, who should see the doctor first?”, which challenged readers to prioritize 4 hypothetical visitors to an ER. The question: who should be seen first by a doctor, and why?

The 4 patients (described in greater detail in the article) were…

A man complaining of chest pains and shortness of breath following a long airplane flight.
A young woman with a painful sprained ankle.
A middle-aged man with a headache, blurred vision and an inability to use his right arm.
A senior man who’d shot himself in the hand with a nail gun.

The follow-up piece, featuring the wisdom of an experienced ER nurse, is here: “What would a nurse do?”

Here’s the order recommended:

#1 The middle-aged man with a headache, blurred vision and an inability to use his right arm.
#2 The man complaining of chest pains and shortness of breath following a long airplane flight.
#3 The young woman with a painful sprained ankle.
#4 The senior who’d shot himself in the hand with a nail gun.

It would be easy — and useful — to add details to each patient’s story to make this into a good exercise for an ethics class.

Questions for disucussion:

    Should it matter if one of the patients is homeless?
    Should it matter if one of the patients is a “whiner”?
    Should it matter if one of the patients is a verbally abusive?
    Should it matter if the nail gun injury is the man’s “own ‘fault”?
    Should it matter if one of the patients is a local celebrity?
    Should it matter if the girl with the sprained ankle is the daughter of a major donor to the hospital?
    Should it matter if the patient is a “frequent flyer” (i.e., someone who visits the ER quite often, perhaps seeking attention)?

This is a great example of the close interconnection between nursing skills and ethical decision making.

What’s the connection between manners and ethics?

A recent piece in Time discusses worries about rudeness on the part of physicians: It’s Not You, Doctors Are Just Rude. The piece discusses “a new study from Johns Hopkins University showing that young doctors in their first year out of medical school are unlikely to take the time to introduce themselves to hospitalized patients, or to sit and have an eye-to-eye conversation with patients.”

The point of posting this here is not to promote doctor-bashing. All professions can be susceptible to problems of rudeness; there are rude nurses just as surely as there are rude doctors.

Several years ago, I wrote a short commentary on the topic, for the Newsletter of the College of Physicians and Surgeons of Saskatchewan, called Manners and Ethics: Is it Wrong to be Rude? The key point in that article is that the link between manners and ethics is respect. Manners are a sign of respect, and respect is a fundamental element of ethical behaviour. Individual instances of rudeness might not amount to something unethical, but a pattern of rudeness signals a worrisome level of disrespect that is both unproductive and unprofessional.

p.s. this is of course closely related to the problem of bullying, which is a significant one in some nursing contexts.

We at the Nursing Ethics Blog are big fans of critical thinking. In fact, we’re working on a new textbook (under contract to Oxford University Press) on critical thinking for nurses.

Critical thinking is “the systematic evaluation or formulation of beliefs, or statements, by rational standards.”* It involves thinking outside of the box, and a willingness to ask hard questions when the need arises. We’ve blogged a bit about the significance of critical thinking in nursing ethics in particular here and here.

But critical thinking is a tricky concept to apply within the context of nursing. After all, nurses simply cannot question every practice and assumption. Sometimes immediate action is needed, and now is not the time to sit back and ask probing questions. Being part of a self-regulating profession means that RNs need to stick closely to established technical and ethical standards. And most nurses work in more-or-less hierarchical teams and institutional settings that involve a huge number of rules, policies, and procedures that simply must be followed.

What is really required, then, is a critical approach to critical thinking: a responsible nurse needs to systematically about when and where to question established rules. The key, of course, is to develop the attitude and skills of a critical thinker, and to be ready to apply them in appropriate circumstances.

This is just one way of illustrating this general point about ethics: while individual judgment and critical thinking are essential to good ethical reasoning, it needs to be balanced against the collective wisdom that is often embodied in laws, rules, and social conventions.

*Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 3rd Canadian Edition, Oxford University Press, 2013.