by Darcy Copeland, RN, PhD*
I have the good fortune to have two professional roles that compliment one another beautifully. As a hospital based nurse scientist I have focused my research on workforce issues including workplace violence, professional quality of life, moral distress, and the spiritual/emotional elements of providing care. I am a member of the ethics committee and participate in educational and consultation activities. I am also an associate professor of nursing and teach master’s, PhD and DNP level nursing theory courses. My days are literally sometimes spent filling the “theory-practice” gap on both sides of that gap.
One “gap”, maybe dissonance is more accurate, I notice is how messy ethical decision making is in practice compared to how clean it seems in academia. Nursing students spend time learning about the ANA Code of Ethics, written specifically to be both aspirational and normative. The nine provisions articulate values, duties, and ideals that are foundational to our discipline. Most students probably also learn principles of bioethics and research ethics and at least have a cursory understanding of these when entering clinical practice. Nursologists have debated whether or not we should develop our own ethical framework or adopt an existing framework. Personally, I oppose both of those ideas and would advocate for a pluralistic approach to addressing ethical issues in practice.
There is no debating that nurses are moral agents who must make decisions and be held accountable for their actions. Those decisions, however, occur in complex, dynamic (I’ll say messy) environments involving multiple stakeholders whose perspectives often conflict with one another. In the grand scheme of things nurses receive very little formal education related to ethics. In my experience, it is rare for a practicing nurse to justify an ethical decision by articulating anything from the code of ethics or principles of bioethics. The first thing I hear is most often something like, “it felt like the right thing to do.” This response alone would lead me to believe that the decision was based on the person’s individual moral awareness or personal value system. With more dialogue, however, it becomes clear that the nurse’s own moral compass is the starting point for ethical decision-making, not the end point. Nurses may justify their actions because it is what the patient wanted, because people have the right to make their own decisions, because it was the best way to use available resources, because it is wrong to with-hold information, because that is our policy, etc. Any and all of these are acceptable justifications to act in one way instead of another. Each of these justifications can be traced back to an ethical framework, but not the ethical framework of nursing.
It was from these experiences in teaching and applying ethics that I developed a model of moral ecology in nursing (see below). It is based on the social ecological model in which behavior is contextualized and understood as occurring within a web of complex social systems in which the individual is placed. It was developed from the perspective of American nursing, but could be modified to include the ICN code of ethics and eastern philosophy for example. I plan to use this model in my own teaching as a way to introduce students to the messiness of ethical decision making in practice.
Copeland, D. (in press). Moral ecology in nursing: A pluralistic approach. Sage Open Nursing DOI: 10.1177/2377960819833899
- Darcy Copeland is an associate professor of nursing at the University of Northern Colorado and a nurse scientist at St Anthony Hospital in Lakewood, CO. She has undergraduate degrees in nursing and psychology from the University of Northern Colorado, a master’s degree in forensic nursing from Fitchburg State College in Massachusetts, a PhD in nursing from UCLA, and is pursuing a master’s degree in health humanities and ethics at the University of Colorado. Her clinical background is in mental health and forensic nursing; her research interests involve the psychosocial work environment including issues of workplace violence, moral distress, professional quality of life, and the spiritual effects of caregiving.