Hospitals depend on nurse leaders to effectively manage unit-based operations in a way that contributes to the success of the whole organization. Nurse leaders serve as a bridge between patients, their families, and staff, while also having the responsibility of managing the details of the workplace environment (Jonasson et al., 2019). In addition, nurse leaders have are ethically and socially responsible to ensure the quality of care and overall well-being of the patients and communities they serve (Orchard et al., 2017). Ethical dilemmas are faced by nurse leaders as they encounter inherent tensions between patient rights and responsibilities and manage sparse resources. Professional development programs for new nurse leaders should include opportunities to explore the types of ethical dilemmas being faced to enhance their ethical reasoning skills needed to deal with these complex ethical issues. We identify commonly encountered dilemmas below.
In an online RN-to-Bachelor of Science in Nursing leadership course, nursing students were asked to interview a practicing nurse leader. One of the interview prompts was: What was an ethical dilemma you have experienced as a nurse leader? Answers from 100 nurse leaders were explored and two major themes emerged: Patient Care Issues, and Managing the Work Environment.
Leading Staff Through Complex Patient Care Issues
Although nurse leaders may or may not provide direct patient care, they are responsible to guide staff nurses in ethical decision-making. Nurse leaders interviewed described many situations where they helped bedside nurses work through dilemmas to accommodate safe, effective, and patient-centered care.
Code status, refusal of treatment due to religious beliefs, families not wanting to disclose terminal diagnoses, and sharing patient information with family members were identified as ethical dilemmas. One leader noted, “My staff had to watch a patient die because they did not want to receive blood products for a condition that [was] entirely treatable with a transfusion and simple procedure.” Another mentioned, “Often, we come across situations where the patient may be terminally ill, but the family does not want to tell the patient. Nurses often struggle with this since they grow so close to the patient and they want to be able to answer the patient's questions and concerns honestly.”
Other concerns identified included elder and child abuse and terminating a patient's care at a clinic for nonpayment. In an elder abuse case, one nurse leader noted, “An ethical dilemma that I have experienced was with a patient who had 30 emergency department visits in one year. The daughter insists that something was wrong with her elderly mother and refused to listen to the providers. The daughter was observed many times force feeding the nonverbal patient and handling the patient roughly.” Another leader noted that sometimes staff are forced to send children home to situations that seemed potentially dangerous: “We have also had to send kids back home with family members that you know are involved with an abuse situation.” A clinic leader described, “One [ethical dilemma] that most frequently plagues me is the decision of which patients the clinic must defer…. Although patients have health care needs, the clinic must be run as a business to remain open and able to care for patients.”
Although the COVID-19 pandemic was not a factor in the early interviews, as it evolved, patient care situations became even more complex. Nursing staff were faced with clinical manifestations of a novel virus previously unknown to them. Diagnosis, treatment, and virus transmission data changed rapidly, often daily, causing devastating levels of distress for staff, patients, and families (Hoffman et al., 2020). Nurse leaders were and are acting as advocates for staff and patients while handling massive amounts of information on how to best care for patients with COVID-19. This requires leaders to arrange evidence-based education not only on managing technical clinical aspects of care, but also the ethical challenges COVID-19 has created. This will prepare direct care nurses to deliver high-quality and safe care to this complex patient population (Hoffman et al., 2020).
Nurse leaders reported using several resources to help resolve issues, realizing that it was not always possible to alleviate the concerns of staff, patients, and families alone. Nurse leaders reported that their ethics committee was a frequently used resource. Other resources included social work, spiritual care teams, patient education, risk management, and in incidences of suspected abuse, local law enforcement.
Managing the Work Environment
Managing the work environment encompasses a wide variety of responsibilities to address staffing, disciplinary actions, and handling complex interpersonal issues. Nurse leaders with the knowledge and ability to identify and resolve ethical issues that may arise in the work environment perform an essential job function. Several exemplars make this point and highlight the need for ethical training.
The most frequently referenced work environment ethical dilemma was staffing. One leader noted, “I am currently facing having to cut staffing due to budget cuts, often leaving the unit short-staffed with sudden rises in census. The understaffing causes a lot of stress and exhaustion for my employees.” Another was concerned that, “Due to the staffing shortage, I felt we weren't able to provide the best patient care.” In another interview a leader said, “My ethical dilemma is not being able to provide my unit with the appropriate staffing, escalating the problem to upper management with no solution.” This leader went on to describe a devastating patient outcome when she was forced to decrease staffing on the night shift. One leader mentioned, “Staffing shortages are an issue that effects every unit in this hospital. Employees are being asked to perform tasks they may not always have to do because of shortages.” When staff are asked to perform tasks outside of their normal practice, patient safety can be compromised.
Since the onset of COVID-19, staffing dilemmas have intensified. Nurse leaders have not only struggled to maintain safe patient–nurse ratios for which there is no precedent, and are tasked with caring for colleagues who have contracted the illness. Shortages of personal protective equipment and employee exposure add to the ethical challenges of balancing staff and patient needs as beds are filled to capacity. This exacerbates the staffing problem and requires leaders to find innovative strategies to maintain a safe working environment. Identifying exposed employees and affording them proper treatment and isolation should be a priority so that they can safely return to work to maintain adequate staffing (Hoffman et al., 2020).
Other ethical issues identified included disciplinary actions and interpersonal issues. In terms of disciplinary actions, one leader stated, “It is not always the corrective action that you want to take, but the one that you need to take. I had an employee that had a clear policy violation, but it was in the best interest of the patient. While you may not agree with the necessity, it is imperative to trust the disciplinary process.” Another mentioned, “A respected colleague of mine had been suspected of drug use at work. I had the nurse removed from duty and followed policy. This impacted the nurse and her career, but ultimately, I put patient safety first.”
The leaders interviewed also described their transition from staff nurse to leader. “The biggest dilemma I've had is separating myself from friends in the workplace. It is hard, but it is the professional thing to do. I just had to make my work life and personal life into two compartments.” Another mentioned a situation where, “I had to fire my long-time friend.” Scenarios like these may cause leaders a personal level of distress and, if unresolved, can form the basis for decisions that place them in the center of an ethical breech. To assist in that process, nurse leaders suggested having a mentor and a close working relationship with upper management for guidance.
The American Organization for Nursing Leadership (2020) competencies state that leaders should apply ethical principles and practice ethical behaviors that support standards and scope of practice. This includes knowing the intricacies of the leader role and engaging in continuing professional development. Nurse leaders interviewed for this project urged that professional development curricula for new nurse leaders include content on identifying and resolving ethical dilemmas. Better preparation and support for new nurse leaders may help decrease attrition in the role and help build a foundation of unit-based leaders that contribute to the success of the organization as a whole.
Advice for Professional Development Educators
The professional development educator can shape learning experiences for emerging leaders. The ethical challenges identified in this article can form the basis of case studies, discussion groups, values clarification exercises, and more. We advise that specific content focusing on applied ethics be present in leadership training and subsequently be reinforced when possible. Using systems thinking, helping leaders process the downstream and upstream sequences of how the dilemma emerged and how decision-making impacted outcomes, builds wisdom and confidence that ethical reasoning does not lead to absolute right or wrong decisions, but rather to the best decision under the circumstance. Leadership is, at times, imprecise and filled with unknown challenges. When educators create learning opportunities for ethical discovery, the outcome is lead with poise, consciousness, advanced communication skills, and reflection.
- American Organization for Nursing Leadership. (2020). AONL nurse manager competencies. https://www.aonl.org/system/files/media/file/2019/06/nurse-manager-competencies.pdf
- Hoffman, R., Battalia, A., Perpetua, Z., Wojtaszek, K. & Campbell, G. (2020). The clinical nurse leader and COVID-19: Leadership and quality at the point of care. Journal of Professional Nursing, 36(4), 178–180 doi:10.1016/j.profnurs.2020.06.008 [CrossRef] PMID:32819541
- Jonasson, L. L., Sandman, L. & Bremer, A. (2019). Managers' experiences of ethical problems in municipal elderly care: A qualitative study of written reflections as part of leadership training. Journal of Healthcare Leadership, 11, 63–74 doi:10.2147/JHL.S199167 [CrossRef] PMID:31213938
- Orchard, C. A., Sonibare, O., Morse, A., Collins, J. & Al-Hamad, A. (2017). Collaborative leadership, part 1: The nurse leader's role within interprofessional teams. Nursing Leadership, 30(2), 14–25 doi:10.12927/cjnl.2017.25258 [CrossRef] PMID:29083290