Pym Scott

Public discussion of resourcing in healthcare tends to compound ideas of resource allocation and rationing. Public debate also tends to focus on situations of scarcity such as lack of kidneys or hearts for transplantation, or heated arguments regarding whether the latest very expensive new drug should be made available, regardless of cost, to treat certain condition such as cystic fibrosis or a particular type of cancer. The idea that nursing or medical time is an important healthcare resource that needs to be allocated with care rarely gets an effective airing in public debate.I argue in this chapter that it is important in the healthcare context to differentiate resource allocation from rationing, on the basis that if we assume we are rationing healthcare as our starting point we may miss opportunities to examine more and less effective ways of allocating the healthcare resource. This is particularly important in nursing care where failure to examine carefully how the nursing resource is allocated, and supported, is leading to covert rationing of nursing time and suboptimal patient care in hospitals across Europe.

Nurses are important to patients. Nurses touch people’s lives during some of the peaks and troughs of human existence. Therefore it is important that we think carefully about nurses and nursing. What do our patients require from nurses, and how do we, as a society, as nurses, and as health service leaders, meet patient need? A first step in thinking about nurses and nursing is to observe that nursing is an important health service resource that needs to be recognised, supported, and protected.It is also important to recognise that nursing, as a practice, has moral values at its core. The nurse-patient relationship, which is central to the provision of nursing care, has ethical importance and is of ethical significance.Additionally, it is noted that the context within which nurses practice can shape, and be shaped by, the moral values of nursing. These moral values form what can be termed the ethical dimension of nursing. It is therefore important that we explore and examine these moral values. Codes of conduct are examples of the nursing profession’s collective attempt to express its underlying values. The institutions within which nurses work help, or hinder, the actual expression of these values in nursing practice and patient care.The interplay of these various factors needs to be recognised, in order to ensure that we as nurses, as potential patients, and as members of society understand what good nursing practice means, what it looks like in practice, and how it can be supported. This chapter sets out to identify the ethical dimension of nursing practice and signal its relevance for good nursing care and a safe, supportive patient experience. The chapters which follow provide theoretical and conceptual lenses through which to identify, analyse, and discuss ethical issues in nursing practice, with a view to providing tools for the nurse to practice in an ethically sensitive and appropriate manner.

The idea of moral injury in healthcare attracted much public attention during the recent COVID-19 pandemic. Duty to care, particularly in circumstances such as the pandemic, raised the awareness of the phenomenon of moral injury in nursing among practising nurse and nurse leaders and managers. The concept of moral injury was introduced originally from a military context, mostly identified, and observed among veterans. Some evidence from the early literature on the concept suggests that moral injury, as an experience, was conceptually confused with other existing experiences conceptualised as burnout and/or moral distress. This may have led to an under recognition and lack of awareness of moral injury as a discreet experience.Although the experiences conceptualised as moral injury, moral distress, and burnout have some commonalities in symptoms and outcomes, it is argued that as individual experiences these three differ in humanly and ethically important ways. It is further argued that these different experiences need to be recognised and addressed appropriately. Failing to do so may add to the rising number of nursing professionals leaving their profession.This reality raises significant challenges for both nurse leaders and managers and for healthcare organisations. It is incumbent on leaders and managers in healthcare organisations to be sensitive to the development of moral distress, moral injury, and burnout in staff members and colleagues, and to work to find ways to support the well-being of nurses and other healthcare practitioners, thus enabling them to flourish as persons and as healthcare professionals.In this chapter we will consider the evolving use of the concept of moral injury in the healthcare literature, including attempts to differentiate it from concepts of moral distress and burnout. We will also consider some of the factors identified as contributing to the experience of moral injury in individual practitioners. The chapter will conclude by suggesting some measures that can be taken to help ameliorate and or mitigate the experience of moral injury.

The nurse’s role as an advocate for the patient appears to be a taken-for-granted aspect of nursing in the twenty-first century; in both the nursing literature and in the British, Irish, and international nursing practice contexts. The focus on the advocacy role of the nurse is predominantly located in the context of hospital-based care and at the level of the individual patient, as opposed to the wider sociopolitical context. However, there are some signs that the greater focus on primary care, globalisation, and the implementation of legislation such as the Assisted Decision-Making (Capacity) Act (ADMA) (https://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html. Accessed 11 August 2023) will broaden this focus in future.While many nurse scholars, nursing registration bodies, professional organisations, and practising nurses are comfortable with the rhetoric of “nurse as patient advocate”, this is not an uncontroversial stance. A number of authors have challenged both the basis for the claim that nurses should be patient advocates and the possibility of such a role for nurses.Given that claims to the advocacy role for nurses are continuing to appear both in our literature and in our codes of practice, it seems relevant to ask what the notion of nurse advocacy means and what are the relative strengths and weaknesses of claims for and against an advocacy role for nurses.

Ethical issues permeate the entire research process from the identification of the research question and selection of research participants, to dissemination of findings. This chapter identifies some of the historical influences informing the development of research ethics frameworks internationally. The author then moves to highlight some of the key ethical issues that need to be considered throughout the various elements of the research process. Some of the important principles underlying research ethics frameworks are identified and interpreted within the context of the research process.

This second edition offers updates, new topics, and new short case studies, based on real stories from the health care arena, ensuring that each chapter of this book is rooted in descriptions of nursing practise that are grounded, salient narratives of nursing care. The reader is assisted to explore the ethical dimension of nursing practice: what it is and how it can be portrayed, discussed, and analysed within a variety of practice and theoretical contexts. One of the unique contributions of this book is to consider nursing not only in the context of the individual nurse – patient relationship but also as a social good that is of necessity limited, due to the ultimate limits on the nursing and health care resource. This book will help the reader consider what good nursing looks like, both within the context of limitations on resources, during crises situations, and under conditions of scarcity. Indeed, any discussion of ethical issues in nursing should be well grounded in a conceptualisation of nursing that nursing students and practising nursing can recognise, accept and engage with. Nursing, like medicine, social work and teaching has a clear moral aim – to do good. In the case of nursing to do good for the patient. However it is vital that in the pressurised, constrained, post-COVID-19 pandemic health service of the 21st century, we help nurses explore what this might mean for nursing practice and what can reasonably be expected of the individual nurse, and the nursing profession, in terms of good nursing care.

Are we on the wrong track, in terms of our expectations of a code of practice, professional ethics teaching or the wider field of moral philosophy, in our search for clear answers to the ethical problems that arise in clinical practice; or are we simply wrong in believing that there are always clear answers? This article examines a particular case, an account of which appeared in Nursing Standard at the end of 1996. The conclusion reached is that we are likely to be misguided in assuming that there are always clear, straightforward answers to the ethical problems of clinical practice. However, more than a fleeting acquaintance with the field of ethics may help us to begin to think with greater clarity about what we do and why we do it. The hope is that this might lead to considered, humane practice by design, with the critical understanding and support of our professional peers and employers.

This article draws attention to the nature and importance of public policy. It argues that if nurses are to influence the quality of healthcare effectively, they must be engaged with policymakers to get nursing care issues on the policy agenda. There is an ethical imperative to do so, driven by the advocacy role of the nurse and rooted in the values base of nursing. In addition, it is argued that if one takes the role of patient advocacy seriously, as core to the nursing role, two things are required of nurses: We must (a) broaden the conceptualisation of patient advocacy beyond the individual patient to the system of healthcare resourcing and provision and (b) see systemic change as important as change at the bedside.

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O’Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals’ experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients’ expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

It is frequently claimed that nursing is vital to the safe, humane provision of health care and health service to our populations. It is also recognized however, that nursing is a costly health care resource that must be used effectively and efficiently. There is a growing recognition, from within the nursing profession, health care policy makers and society, of the need to analyse the contribution of nursing to health care and its costs. This becomes increasingly pertinent and urgent in a situation, such as that existing in Ireland, where the current financial crisis has lead to public sector employment moratoria, staff cuts and staffing deficits, combined with increased patient expectation, escalating health care costs, and a health care system restructuring and reform agenda. Such factors, increasingly common internationally, make the identification and effective use of the nursing contribution to health care an issue of international importance. This paper seeks to explore the nature of nursing and the function of the nurse within a 21st century health care system, with a focus on the Irish context. However, this analysis fits into and is relevant to the international context and discussion regarding the nursing workforce. This paper uses recent empirical studies exploring the domains of activity and focus of nursing, together with nurses perceptions of their role and work environment, in order to connect those findings with core conceptual questions about the nature and function of nursing.

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.

The focus of this article is perceptions of elderly patients and nurses regarding patients’ autonomy in nursing practice. Autonomy is empirically defined as having two components: information received/given as a prerequisite and decision making as the action. The results indicated differences between staff and patient perceptions of patient autonomy for both components in all five countries in which this survey was conducted. There were also differences between countries in the perceptions of patients and nurses regarding the frequency with which patients received information from nursing staff or were offered opportunities to make decisions. This is the second of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.

This book is clearly written and well laid out. The short summary at the beginning of each chapter is a useful guide to the reader and also serves as a valuable summary of key issues for revision purposes. The author offers a number of case scenarios for the reader to work through and provides many practical examples of situation analysis and possible steps to ethical decision making. Seedhouse accurately claims that in nursing, as elsewhere, philosophical analysis is useful in helping to clarify ideas. Unfortunately, as he also accurately points out, to date much that has been described as nursing philosophy has not in fact led to the clarification of ideas but rather to …

This is a broad based introductory text suitable, I suggest, for diploma level or first year degree level courses. The fourth edition retains some of the best elements of the third and updates much of the remaining text. The structure of the chapters is useful, providing a list of learning outcomes for the reader and flagging up the material to follow. The summary at the end of each chapter is also very useful for reviewing the key points, as are the discussion questions posed at the end of each chapter. Dealing with a number of the questions posed, …

This paper revisits a 2003 publication in Nursing Philosophy: The need for accurate perception and informed judgement in determining the appropriate use of the nursing resource: hearing the patient's voice. The author suggests that the basic ideas and focus of this 16‐year‐old paper are still topical and relevant in considerations of nursing care. However, it is also suggested that greater attention to the importance of the nurse–patient relationship in considerations of resource allocation, and potential rationing of nursing care, would have strengthened the original paper.

This paper suggests that a consideration of health care practice is a necessary step in gaining insight into the appropriate composition of an ethics course for students in the health care professional. Health care practice, if it responds to the needs of society, is dynamic in nature. In the current climate of change in the health service, the author sug gests that the nursing profession needs to become more proactive in analysing and attempting to determine the future shape of nursing. To protect patient care the nursing profession needs to have its eyes open to the ethical dimensions of changes in role and practice. The author argues that, in attempting to ensure that the education to which nursing students are exposed is of relevance, it is necessary to introduce an element of the ideal into the ethics component of their professional education. From early on in their profes sional development students should be aware of the scope and standards of practice, and the type of role enactment to which the profession requires them to aspire

Even a brief consideration of the nature of nursing will indicate that an ethical dimension underlies much, if not all, of nursing practice. It is therefore important that students and practitioners are facilitated in developing an ethical awareness and sensitivity from early in their professional development. This paper argues that Aristotelian virtue theory provides a practice-based focus for health care ethics for a number of reasons. Also, because of his emphasis on the character of the moral agent, and on the importance of perception and emotion in moral decision-making, Aristotelian virtue theory provides a useful supplement to the traditional duty-based approaches to health care ethics analysis, which are increasingly being identified in the literature as having limits to their application within the health care context

The focus of this article is on elderly patients’ and nursing staff perceptions of privacy in the care of elderly patients/residents in five European countries. Privacy includes physical, social and informational elements. The results show that perceptions of privacy were strongest in the UK (Scotland) and weakest in Greece. Country comparisons revealed statistically significant differences between the perceptions of elderly patients and also between those of nurses working in the same ward or long-term care facility. Perceptions of privacy by patients and their nursing staff were quite similar in Finland, Germany and the UK. In contrast, in Greece and Spain these perceptions were different: nurses believed that they took account of their patients’ privacy needs more often than the patients themselves felt this was the case. Among Spanish and UK patients, an association was found between lower levels of independence and comparatively less positive perceptions of privacy. No associations were established between nurses’ perceptions and their demographic factors. This is the third of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented

The focus of this article is on elderly patients’ and nursing staff perceptions of informed consent in the care of elderly patients/residents in five European countries. The results suggest that patients and nurses differ in their views on how informed consent is implemented. Among elderly patients the highest frequency for securing informed consent was reported in Finland; the lowest was in Germany. In contrast, among nurses, the highest frequency was reported in the UK (Scotland) and the lowest in Finland. In a comparison of patients’ and nurses’ perceptions, nurses had more positive views than patients in all countries except Finland. Patients with less need for nursing interventions in Greece and Spain gave their consent less often. The German and Greek patients were older, and the results also point to an association between this and their lower frequency of giving consent. In Spain, patients who were married or who had a family member or friend to look after their personal affairs were more likely to be included in the group whose consent was sought less often. This is the fourth of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented

This paper situates the moral domain of practice within the context of a particular description of nursing practice – one that sees human interaction at the heart of that practice. Such a description fits not only with professional rhetoric but also with literature from patients and recent empirical work exploring the nature of nursing practice.Martha Levine in her 1977 description of ethics, within the context of nursing practice, indicated that what was important from an ethical perspective was how we interact with each other, with patients and colleagues, on a daily basis. What enables such interaction to display moral sensitivity, insight into patient need, and a focus on the good for the patient? Of relevance when answering this question is the empirical evidence indicating that professional socialization, as a nurse or a doctor, may dull the individual’s moral sense. If this is the case, cognizance needs to be taken of such evidence when identifying theoretical approaches from mainstream ethics that may provide insight and value for nurse education. It is suggested that such insight and value can be gained from a consideration of the work of Aristotle, Murdoch, and Vetlesen.

Many of the activities of clinical practice happen to, with or upon vulnerable human beings. For this reason numerous nursing authors draw attention to or claim a significant moral domain in clinical practice. A number of nursing authors also discuss the emotional involvement and/or emotional labour which is often experienced in clinical practice. In this article I explore the importance of emotion for moral perception and moral agency. I suggest that an aspect of being a good nurse is having an emotional sensitivity to other human beings (patients), because this emotional sensitivity allows the nurse to perceive more accurately the context and perspective of the patient. It is thus important to the moral agency of the nurse and to morally sensitive clinical practice. As such education of the emotions should be a feature of the moral education of the nurse. A useful conception of the role of educated emotion in the moral life can be discovered in Aristotelian ethics.

Ethical issues in the care of elderly people have been identified in many countries. We report the findings of a comparative research project funded by the European Commission, which took place between 1998 and 2001. The project explored the issues of autonomy (part I), privacy (part II) and informed consent (part III) in nursing practice. Data were collected from elderly residents/patients (n = 573) and nursing staff (n = 887) in five European countries: Finland, Spain, Greece, Germany and the UK (Scotland). Questionnaires were used as the data collection tool (self-completion questionnaires for staff, structured interviews for the elderly participants). Four basic nursing interventions in the care of elderly people were targeted: hygiene, fluid intake and nutrition, medication, and elimination. The data were analysed statistically. The results indicated differences within all five countries between staff and patient perceptions of autonomy, privacy and informed consent. There were also similar differences between individual countries. Conclusions were reached concerning practice, education and research. This is the first of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented