Chapter 6- Values, ethics and advocacy
🧭 STEP 1 – LEARNING OUTCOMES (COVERAGE CHECK ONLY)
Learning Outcome 1
List five common modes of value transmission.
Guiding questions
How are values commonly learned and internalized?
Which sources most strongly shape professional and personal values?
Required content
Family – Primary source; values learned through upbringing, modeling, reinforcement.
Culture – Shared beliefs, traditions, norms influencing perceptions of right/wrong.
Religion – Moral rules, ethical teachings, spiritual beliefs guiding behavior.
Peers – Value reinforcement or modification through social interaction.
Media/Education – Formal and informal messaging that shapes beliefs and priorities.
Learning Outcome 2
Describe three steps in the valuing process.
Guiding questions
How does a person develop and commit to values?
What behaviors indicate a value is internalized?
Required content (in order)
Choosing
Selecting values freely
Considering alternatives and consequences
Prizing
Cherishing and affirming chosen values
Feeling satisfied and proud of the choice
Acting
Consistently behaving in accordance with values
Repeating actions over time
Learning Outcome 3
Use values clarification strategies in clinical practice.
Guiding questions
How do nurses distinguish personal values from patient values?
How are values clarified without imposing beliefs?
Required content
Self-reflection to identify personal beliefs and biases
Open-ended questioning to explore patient values
Nonjudgmental communication
Respect for differing beliefs
Avoidance of value imposition in care decisions
Learning Outcome 4
Compare and contrast the principle-based and care-based approaches to bioethics.
Guiding questions
How do ethical decisions differ by framework?
What priorities guide each approach?
Required comparison
Principle-Based Approach
Focuses on ethical principles
Emphasizes rules, duties, and rights
Applies universal standards
Care-Based Approach
Focuses on relationships and context
Emphasizes compassion, responsiveness, and responsibility
Values individual circumstances
Learning Outcome 5
Describe nursing practice that is consistent with the code of ethics for nursing.
Guiding questions
What behaviors demonstrate ethical nursing practice?
How does the code guide accountability?
Required content
Respect for human dignity
Protection of patient rights
Maintenance of confidentiality
Accountability for nursing actions
Advocacy for patient welfare
Professional integrity and competence
Learning Outcome 6
Describe moral distress and ways to promote moral resilience.
Guiding questions
What causes moral distress in nurses?
How can nurses sustain ethical integrity over time?
Required content
Moral Distress
Occurs when nurses know the ethically appropriate action but cannot act
Results from institutional or hierarchical constraints
Moral Resilience
Capacity to preserve integrity in ethical adversity
Promoted through ethical competence, self-awareness, support systems, and reflection
Learning Outcome 7
Recognize ethical issues as they arise in nursing practice.
Guiding questions
What situations signal an ethical issue?
When is ethical reasoning required?
Required content
Conflicts between values or principles
Threats to patient autonomy or safety
End-of-life decisions
Informed consent concerns
Allocation of resources
Learning Outcome 8
Use an ethical framework and decision-making process to resolve ethical problems.
Guiding questions
How should ethical problems be systematically addressed?
What steps guide ethical decision-making?
Required content
Identify the ethical issue
Gather relevant information
Examine ethical principles and values
Explore options and consequences
Make and justify a decision
Evaluate outcomes
Learning Outcome 9
Identify four functions of institutional ethics committees.
Guiding questions
How do ethics committees support clinical practice?
What roles do they serve within healthcare institutions?
Required content
Case consultation
Policy development and review
Education on ethical issues
Support for staff and patients during ethical conflict
Learning Outcome 10
Describe three typical concerns of the nurse advocate.
Guiding questions
What issues require advocacy by nurses?
Who or what does the nurse advocate protect?
Required content
Patient autonomy and informed decision-making
Protection from harm or unsafe practice
Access to appropriate care and resources
📘 STEP 3 – VOCABULARY (MISREAD-PROTECTION)
advocacy
Definition: Actively supporting and defending patient rights and interests.
Practice use: Speaking up when patient safety or autonomy is threatened.
Exam phrasing: “Nurse advocate,” “protecting patient rights.”
Example: Questioning a treatment that conflicts with a patient’s wishes.
autonomy
Definition: Right of individuals to make their own decisions.
Practice use: Respecting informed consent and refusal.
Exam phrasing: “Patient self-determination.”
Example: Honoring a competent patient’s decision to refuse treatment.
beneficence
Definition: Duty to do good and promote well-being.
Practice use: Acting in the patient’s best interest.
Exam phrasing: “Promoting good.”
Example: Administering pain relief to reduce suffering.
care-based approach
Definition: Ethical approach emphasizing relationships and responsiveness.
Practice use: Individualized, compassionate decision-making.
Exam phrasing: “Contextual ethics.”
Example: Adjusting care based on patient vulnerability.
code of ethics
Definition: Formal statement of ethical standards for nursing.
Practice use: Guides professional conduct.
Exam phrasing: “ANA Code of Ethics.”
Example: Maintaining confidentiality.
conscientious objection
Definition: Refusal to participate in care conflicting with moral beliefs.
Practice use: Must ensure patient care continuity.
Exam phrasing: “Moral objection.”
Example: Declining involvement in a procedure on ethical grounds.
ethical dilemma
Definition: Situation with competing ethical principles and no clear solution.
Practice use: Requires ethical reasoning.
Exam phrasing: “Conflict between principles.”
Example: Life support withdrawal decisions.
ethics
Definition: Study of moral principles guiding behavior.
Practice use: Framework for professional decision-making.
Exam phrasing: “Moral principles.”
feminist ethics
Definition: Ethical approach emphasizing relationships, power, and justice.
Practice use: Attention to marginalized voices.
Exam phrasing: “Relational ethics.”
fidelity
Definition: Faithfulness to commitments and promises.
Practice use: Keeping professional promises.
Exam phrasing: “Keeping commitments.”
Example: Following through on patient education.
justice
Definition: Fair and equitable treatment.
Practice use: Resource allocation.
Exam phrasing: “Fairness.”
Example: Equal access to care.
moral agency
Definition: Capacity to make ethical decisions and act on them.
Practice use: Professional accountability.
Exam phrasing: “Ethical responsibility.”
moral distress
Definition: Knowing the right action but being unable to act.
Practice use: Common in constrained systems.
Exam phrasing: “Ethical constraint.”
moral injury
Definition: Lasting psychological harm from ethical violations.
Practice use: Requires organizational support.
Exam phrasing: “Deep ethical harm.”
moral resilience
Definition: Ability to maintain integrity amid ethical challenges.
Practice use: Sustains ethical practice.
Exam phrasing: “Ethical stamina.”
morals
Definition: Personal beliefs about right and wrong.
Practice use: Influences behavior.
Exam phrasing: “Personal values.”
nonmaleficence
Definition: Duty to do no harm.
Practice use: Avoiding unsafe actions.
Exam phrasing: “Prevent harm.”
nursing ethics
Definition: Ethical standards specific to nursing practice.
Practice use: Guides care delivery.
Exam phrasing: “Professional ethics.”
principle-based approach
Definition: Ethical approach based on universal principles.
Practice use: Policy-driven decisions.
Exam phrasing: “Principlism.”
value system
Definition: Organized set of beliefs guiding behavior.
Practice use: Influences care decisions.
Exam phrasing: “Hierarchy of values.”
values
Definition: Beliefs about what is important.
Practice use: Guides choices.
Exam phrasing: “Personal beliefs.”
values clarification
Definition: Process of identifying and examining values.
Practice use: Prevents value imposition.
Exam phrasing: “Self-awareness strategy.”
virtues
Definition: Character traits that guide ethical behavior.
Practice use: Professional conduct.
Exam phrasing: “Moral character traits.”
Introduction
Nursing practice includes bedside care and participation in interdisciplinary decisions affecting treatment, safety, and resource use.
Ethical focus in practice:
Determining whether an intervention should be done for a specific patient in a specific context.
Managing competing priorities (patient wishes, benefit vs burden, safety, resource limits).
Advocacy obligations increase when patients are vulnerable (e.g., limited finances, unmet health needs) and when workplace conditions threaten safety/quality (e.g., staffing shortages).
Ethical competence is a core nursing competency alongside intellectual, interpersonal, and technical skills.
Ongoing awareness of:
How patient values and nurse values influence nurse–patient interactions.
Ethical dimensions embedded in daily care decisions and communication.
Values
Values
Beliefs about the worth of something; standards that guide behavior.
Values are reflected by how time, energy, attention, and resources are allocated.
Value system
Organized ranking of values along a continuum of importance.
Often forms a personal code of conduct.
Values influence:
Beliefs about human needs, health, illness.
Health behaviors and responses to illness.
Nurse–patient interactions (patient values + nurse values can align or conflict).
Professional expectation:
Nurses monitor whether personal values support safe, respectful, person-centered care.
Development of Values
Values are not innate; they develop over time.
Primary influences:
Environment
Family
Culture
Clinical relevance:
Cultural and family influences affect patient priorities, decision-making preferences, and interpretations of independence, suffering, and acceptable outcomes.
Common Modes of Value Transmission
Modeling
Values learned through observing parents, peers, and significant others.
Can transmit socially acceptable or unacceptable behaviors.
Moralizing
Complete value system taught by parents or institutions (e.g., school, church).
Little opportunity to compare alternatives or weigh consequences.
Laissez-faire
Minimal guidance; individual explores values independently.
Risk: confusion and conflict due to lack of structure.
Rewarding and punishing
Reinforces values through rewards for desired behaviors and punishment for unacceptable behaviors.
Responsible choice
Encourages exploring competing values and weighing consequences.
Includes support and guidance while developing a personal value system.
QSEN – Reflective Practice: Cultivating QSEN Competencies
Challenge to Ethical and Legal Skills
What it shows
A practice situation involving:
Patient/family concerns not addressed by a provider.
Student/novice nurse barriers (lack of confidence/status).
Advocacy obligations despite hierarchical pressure.
What nurses must know
Advocacy includes obtaining needed information and ensuring patient concerns are addressed through appropriate channels.
Response options in advocacy situations typically include:
Direct communication with the responsible provider (professional, respectful escalation).
Seeking support from an experienced nurse/charge nurse/preceptor.
Avoiding actions outside scope (e.g., independently answering complex medical questions beyond competence/authorization).
Avoiding false reassurance or dismissing concerns.
How it’s used in practice
Guides safe escalation and teamwork behaviors:
Identify unmet needs (information, reassurance, decision support).
Use chain of command and interdisciplinary communication.
Maintain respect for all parties while prioritizing patient rights and safety.
Values Essential to the Professional Nurse
Professional values
Foundation for nursing practice.
Guide interactions with patients, colleagues, and the public.
AACN identified five professional values that epitomize the caring professional nurse:
Altruism
Autonomy
Human dignity
Integrity
Social justice
Professional expectation:
Nurses critically examine whether personal values align with professional values.
Professional role requires:
Respecting patient values without assuming nurse values are “more correct.”
Making judgments related to health, safety, and well-being when harm risk exists.
Table 6-1 Professional Values
What it shows
Five professional values and sample behaviors demonstrating each.
What nurses must know
Altruism
Concern for welfare and well-being of others.
Behaviors:
Demonstrate understanding of cultures/beliefs/perspectives.
Advocate for vulnerable patients.
Take appropriate risks on behalf of patients/colleagues.
Mentor other professionals.
Autonomy
Right to self-determination.
Behaviors:
Honor patient/family decisions.
Plan care in partnership with patients.
Provide information for informed choices.
Human dignity
Respect for inherent worth and uniqueness of individuals/populations.
Behaviors:
Provide culturally respectful/sensitive care.
Protect privacy.
Preserve confidentiality.
Design care with sensitivity to individual needs.
Integrity
Acting in accordance with an ethical code and accepted standards.
Behaviors:
Provide honest information.
Document accurately and honestly.
Remedy errors made by self/others.
Demonstrate accountability.
Social justice
Upholding moral, legal, and humanistic principles.
Behaviors:
Support fairness and nondiscrimination.
Promote universal access to health care.
Encourage legislation/policy advancing nursing and health care.
How it’s used in practice
Provides a behavior-based standard for evaluating professional conduct and guiding decisions when values conflict with convenience, bias, or institutional pressures.
Values Clarification
Values clarification
Process of understanding one’s values and value system.
Focuses on discovery through feelings and analysis of behavior.
Clinical purpose for nursing:
Helps nurses understand patient motivations driving decisions and behaviors.
Supports teaching/counseling by linking health behaviors to what the patient values.
The Valuing Process (3 Activities)
Choosing
Choosing freely from alternatives.
Considering consequences of each alternative.
Prizing (treasuring)
Pride/happiness in the value.
Public affirmation of the value.
Acting
Acting on the value with consistency and regularity.
Aligning behavior with the chosen value.
Clinical Applications
Patient places low value on health
Nursing focus: identify patient’s basic values, then connect health behavior change to a value the patient prioritizes.
Methods:
Ask the patient to identify “most important” life priorities.
Use ranking exercises to reveal patterns.
Compare “ideal” vs “likely” choices to identify conflict between goals and behavior.
Values conflict within family
Nursing focus: identify conflicting values contributing to care barriers.
Methods:
Structured statements rated by agreement to reveal value priorities.
Use results to clarify conflict and support joint movement toward health-promoting values.
Ethics
Ethics
Systematic study of principles of right/wrong conduct, virtue/vice, good/evil as related to human conduct and flourishing.
Ethical capacity develops gradually from childhood.
Ethics vs morals
Ethics: systematic, professional or philosophical study; often embedded in professional codes.
Morals: personal or communal standards of right and wrong.
Ethics is distinct from:
Religion
Law
Custom
Institutional practice
Legal/customary does not automatically equal ethical.
Nursing Ethics
Nursing ethics is a subset of bioethics.
Bioethics scope
Life sciences–related ethical concerns.
Paramount human questions central to bioethics:
What kind of person should I be to live morally and make good decisions?
What duties/obligations do I have to others affected by my actions?
What do I owe the common good/public interest?
Nursing ethics
Formal study of ethical issues in nursing practice.
Includes analysis used by nurses to make and evaluate ethical judgments.
Practice expectations (ANA Scope and Standards of Practice, 2021—ethical preparation emphasis):
Continuous appraisal of personal/professional values and their impact on decisions.
Awareness of ethical obligations in the ANA Code of Ethics.
Knowledge of ethical principles and their application in decision-making.
Motivation and skills to implement chosen decisions.
Common ethical issues in daily nursing practice:
Cost-containment that jeopardizes patient welfare
Beginning-of-life and end-of-life decisions
Breaches of confidentiality
Incompetent, unethical, or illegal practices by colleagues
Theories of Ethics
Ethical theories/frameworks explain how people ought to live and why.
Two broad categories:
Action-guiding theories: “What should I do?”
Character-guiding theories: “What kind of person should I be?”
Action-Guiding Theories (2 Categories)
Utilitarian
Right/wrong depends on consequences.
Deontologic
Right/wrong depends on a rule/duty, independent of consequences.
Concept Mastery Alert
Utilitarian focus = “usefulness”:
Actions are right when they promote the greater good.
Deontologic focus:
Actions are right/wrong regardless of consequences.
Principle-Based Approach
Practical approach combining elements of utilitarian and deontologic theories.
Uses action-guiding ethical principles.
Beauchamp & Childress identify four key principles:
Autonomy
Nonmaleficence
Beneficence
Justice
Additional principles commonly included in nursing ethics because of central relevance to practice:
Fidelity
Veracity
Accountability
Privacy
Confidentiality
Ethical dilemmas occur when adhering to principles leads to conflicting actions.
Principles guide action but do not automatically resolve conflicts; outcomes depend on interpretation and context.
Table 6-2 Principles of Bioethics
What it shows
Core ethical principles, moral rules, and implications for nursing practice.
What nurses must know
Autonomy (self-determination)
Moral rule: respect patient/surrogate right to make health care decisions.
Nursing implications:
Provide information/support for informed decisions.
Collaborate with the health care team to advocate for patient decisions.
Nonmaleficence
Moral rule: avoid causing harm.
Nursing implications:
Do not inflict harm.
Prevent harm or risk of harm whenever possible.
Beneficence
Moral rule: benefit the patient; balance benefits against risks/harms.
Nursing implications:
Promote patient benefit (health/well-being or good dying).
Recognize different stakeholders may define benefit/burden differently.
Justice
Moral rule: give each their due; act fairly.
Nursing implications:
Distribute benefits/risks/costs justly.
Identify and address bias/discrimination.
Fidelity
Moral rule: keep promises.
Nursing implications:
Maintain competence and apply it to benefit patients.
Do not abandon patients without ensuring needs are met.
How it’s used in practice
Used to structure ethical deliberation, justify actions, and document rationale in ethically complex cases.
Supports requesting ethics consultation when principles conflict and cannot be resolved within the team.
Care-Based Approach
Developed in response to dissatisfaction with a purely principle-centered focus.
Foundation: care and the nurse–patient relationship.
Central focus:
Specific situations of individual patients within their life context.
Care-based approach characteristics:
Centrality of caring relationship
Promotion of dignity and respect
Attention to particulars of individual patients
Cultivation of responsiveness and professional responsibility
Moral skills include virtues such as:
Kindness
Attentiveness
Empathy
Compassion
Reliability
Feminist Ethics
Ethical approach emphasizing critique of oppression and domination patterns in society.
Focus includes:
Sex-related inequities
Poverty and marginalization
Concerns for the least well off
Nursing alignment:
Promotes social policy supporting marginalized people’s capacity to make legitimate choices.
Supports provision of basic human needs consistent with human dignity and relationality.
Ethical Conduct
Professional nursing ethical conduct is grounded in:
Professional standards of ethical conduct
Professional values
How nurses learn standards for ethical conduct:
Formal education
Peer discussion
Role modeling and adoption of professional behaviors
Minimum expectations:
Cultivate nursing virtues
Understand ethical theories that guide/justify conduct
Be familiar with codes of ethics and standards for professional conduct
Moral Agency
Moral agency
Capacity to be ethical and do the ethically right thing for the right reasons.
For nurses: capacity to meet reasonable public expectations articulated in professional social policy and code of ethics.
Trustworthiness is demonstrated in clinical encounters through actions aligned with professional obligations.
Moral agency is cultivated (not automatic) and requires:
Internal motivation
Professional support rooted in nursing norms/values
Practice environment where ethical action is possible
Tenacity, courage, resilience, perseverance
Nurse Virtues
Virtues
Cultivated dispositions of character and conduct enabling good human and professional action.
Commonly named nursing virtues:
Competence
Compassionate caring
Subordination of self-interest to patient interest
Self-effacement
Trustworthiness
Conscientiousness
Intelligence
Practical wisdom
Humility
Courage
Integrity
Virtues function as stable traits that support consistent ethical action in clinical care.
Civility
Civility is a professional virtue emphasized due to workplace issues such as bullying and lateral violence.
Workplace civility expectations include:
Feeling welcomed and supported
Offering help when needed
Access to adequate resources
Expression of appreciation and concern for staff well-being
Box 6-1 Elements of Moral Agency in Action
What it shows
A clinical situation demonstrating how moral agency components guide ethical recognition and action when patient preferences conflict with provided treatment.
What nurses must know (elements)
Moral sensibility
Noticing discrepancy and experiencing discomfort/distress signaling an ethical problem.
Moral responsiveness
Acknowledging concern and acting (not ignoring) to address it.
Moral reasoning and discernment
Working through options with ethical justification (e.g., burdens vs benefits; ineffective treatment; patient preferences).
Moral accountability
Taking responsibility to investigate system failure and pursue remedy (ethics consult, advocacy).
Moral character
Virtues shaping consistent ethical response (e.g., responsibility, fidelity).
Moral motivation
Primary motivation is patient interests; avoidance of conflict is not an acceptable primary driver.
Moral valuing
High value on patient well-being and advocacy leads to action despite discomfort/inconvenience.
Transformative ethical leadership
Using the case to improve unit culture so ethical action becomes safer and more common.
How it’s used in practice
Serves as a model for recognizing ethical issues, initiating consultation, advocating for patient preferences, and improving ethical climate.
Nursing Codes of Ethics
Nursing codes of ethics include:
ICN Code of Ethics for Nurses
ANA Code of Ethics for Nurses with Interpretive Statements
Canadian Nurses Association Code of Ethics
National Student Nurses’ Association Code of Academic and Clinical Conduct (student focus)
Code of ethics
Set of principles reflecting the profession’s primary goals, values, and obligations.
Professional expectation:
Nurses adhere to and internalize professional moral norms as part of nursing identity.
Box 6-2 American Nurses Association Code for Nurses
What it shows
Nine provisions describing core ethical obligations of nurses.
What nurses must know (provisions)
Practice with compassion and respect for inherent dignity, worth, and unique attributes of every person.
Primary commitment to the patient (individual, family, group, community, population).
Promote, advocate for, and protect patient rights, health, and safety.
Authority, accountability, and responsibility for nursing practice; decisions/actions promote health and optimal care.
Duties to self as to others: promote health/safety, preserve integrity, maintain competence, continue growth.
Establish/maintain/improve ethical work environment and employment conditions conducive to safe, quality care.
Advance profession through research, scholarly inquiry, standards development, and nursing/health policy generation.
Collaborate with health professionals and public to protect human rights, promote health diplomacy, reduce disparities.
Profession collectively articulates values, maintains integrity, integrates social justice into nursing and health policy.
How it’s used in practice
Serves as the profession’s nonnegotiable ethical standard for professional behavior and accountability.
Purposes of the ANA Code of Ethics
Succinct statement of ethical obligations and duties of every nurse.
Profession’s nonnegotiable ethical standard.
Expression of nursing’s commitment to society.
Standards of Professional Nursing Practice
ANA Scope and Standards of Practice:
Standard 7 (Ethics): RN uses the Code of Ethics as moral foundation for practice and decision-making.
Standard 8 (Advocacy): RN demonstrates advocacy in all roles and settings (notable as a newer, explicit standard in the 2021 revision).
Professional implication:
Advocacy is treated as a duty requiring prioritization when patient needs are unmet.
Bill of Rights for Registered Nurses
Created as an advocacy tool addressing issues affecting nursing care quality (e.g., staffing, satisfaction, workplace conditions).
Intended to clarify nonnegotiable workplace expectations supporting safe, quality care.
The Seven Basic Tenets
Right to practice in a manner fulfilling obligations to society and recipients of nursing care.
Right to environments allowing practice consistent with professional standards and legally authorized scopes of practice.
Right to an environment supporting ethical practice consistent with the Code of Ethics and interpretive statements.
Right to freely and openly advocate for self and patients without fear of retribution.
Right to fair compensation consistent with knowledge, experience, and professional responsibilities.
Right to a work environment safe for nurses and patients.
Right to negotiate employment conditions individually or collectively in all practice settings.
Box 6-3 Ethics Inventory
What it shows
A structured approach to identifying and evaluating ethical challenges in practice.
What nurses must know
Ethical issue recognition cues:
Intellectual disconnect
Discomfort/distress signaling something ethically wrong
Decision calibration elements:
Identify applicable moral rules/obligations
Determine duties and priority when obligations conflict
Assess ability and willingness to respond (moral agency elements)
Identify institutional resources and barriers
Criteria used to justify a “good response” may include:
Promotes human dignity and the common good
Maximizes good and minimizes harm
Justly distributes goods and harms
Respects rights
Responds to vulnerabilities
Promotes virtue
Evaluation criteria may include:
Transparency in deliberations and actions
Alignment with professional ethical standards
Ability to justify actions ethically and professionally
How it’s used in practice
Supports consistent ethical reasoning, documentation of rationale, and appropriate escalation to consult resources (e.g., ethics consult, leadership).
Ethical Experience and Decision Making
Ethical experience in nursing occurs in multiple forms during routine and high-stakes practice.
Two common ethical problems:
Ethical dilemmas
Two or more ethical principles apply.
Principles support mutually incompatible actions.
Moral distress
Nurse knows the ethically appropriate action.
Personal, institutional, or systemic barriers prevent action.
Moral Distress and Resiliency
Moral distress
Occurs when ethical judgment cannot be translated into action.
Compromises professional integrity.
Ethical competence requires:
Analytic skills
Ethical reasoning
Willingness to speak up
Professional responsibility:
Nurses act collectively to create work environments that support ethical practice.
Aligns with Provision 6 of the ANA Code of Ethics.
Institutional responses:
Moral distress measurement tools
Moral distress consult services
Ethics practice support structures
FIGURE 6-1: Moral Distress Thermometer
What it shows
A tool for assessing intensity of moral distress.
What nurses must know
Moral distress exists on a continuum.
Recognition is the first step toward action.
How it’s used in practice
Self-assessment
Trigger for ethics consultation or support services
Moral Resilience
Resilience
Capacity to recover, adapt, and thrive despite adversity.
Moral resilience
Capacity to respond well to morally distressing experiences.
Strengthens ethical action over time.
Key components commonly emphasized:
Supportive relationships
Acceptance of change
Perspective-taking
Self-care
Positive self-concept
Giving Voice to Values
Giving Voice to Values (GVV)
Values-driven leadership approach.
Focuses on ethical implementation rather than ethical analysis.
Core assumptions:
Most people want to act ethically.
Barriers are often practical rather than moral.
Key focus:
What to say
How to say it
How to act effectively
Emphasizes:
Practice
Skill-building
“Moral muscle memory”
Clinical relevance:
Prepares nurses to act consistently with values in real situations.
Reduces moral distress and burnout.
Moral Injury
Moral injury
Occurs when:
A betrayal of what is right
By oneself or someone in authority
In a high-stakes situation
Core features:
Emotional, spiritual, and psychological harm
Violation of deeply held moral beliefs
Manifestations may include:
Guilt
Shame
Loss of trust
Spiritual or existential distress
Moral injury differs from moral distress:
Moral injury is deeper and more enduring.
Occurs in multiple populations, including nurses.
FIGURE 6-2: Moral Injury in Nurses
What it shows
Moral injury affects nurses, not only combat veterans.
What nurses must know
Patient safety incidents can precipitate moral injury.
How it’s used in practice
Supports recognition of long-term ethical harm.
Justifies need for organizational and mental health support.
Nurse Self-Care Alert
Exposure to morally injurious experiences is associated with:
Depression
Anxiety
PTSD
Suicidal ideation
Behavioral changes
Nurses experiencing symptoms should seek professional and peer support.
Conscientious Objection
Conscientious objection
Refusal to participate in care that violates personal or professional moral standards.
Supported by the ANA Code of Ethics.
Applies when:
Care violates moral integrity.
Practice conditions exceed acceptable ethical limits.
Ethical boundaries:
Nurse must not abandon patients.
Appropriate disclosure and transition of care required.
Professional expectation:
Communicate concerns to leadership or educators.
Making Ethical Decisions
All accredited facilities must have mechanisms for addressing ethical problems.
Institutional resources may include:
Ethics committees
Ethics consultants
Nurse ethicists
Five-Step Ethical Decision-Making Process (Aligned with Nursing Process)
Step 1: Assess the Situation (Gather Data)
Identify:
Ethical concern and contextual factors
Individuals involved and their perspectives
Patient’s clinical, social, and legal context
Institutional constraints
Step 2: Diagnose (Identify) the Ethical Problem
Determine whether the issue is ethical:
Does it involve rights, duties, dignity, or moral values?
Identify:
Level of conflict (personal, institutional, societal)
Nurse’s role in the decision
Time sensitivity
Distinguish ethical problems from communication or legal issues.
Step 3: Plan (Identify and Weigh Alternatives)
Identify options.
Analyze short- and long-term consequences.
Apply:
Ethical theories and principles
Professional codes and standards
Institutional policies
Consult:
Experienced colleagues
Ethics committees or consultants
Select a defensible course of action.
Step 4: Implement the Decision
Carry out the chosen action.
Monitor outcomes.
Step 5: Evaluate the Decision
Reflect on:
Outcomes achieved
Lessons learned
System factors contributing to conflict
Identify improvements for future practice.
Box 6-4: Patient Care Study Using a Five-Step Ethical Process
What it shows
Application of ethical decision making in clinical practice.
What nurses must know
Ethical conflicts may involve:
Autonomy
Beneficence
Justice
Fidelity
Care-based ethics
Advocacy may involve:
Speaking up
Escalation
Policy review
How it’s used in practice
Models structured ethical reasoning.
Demonstrates advocacy under power imbalance.
Ethically Relevant Considerations
Eight considerations with high clinical relevance:
Balance of Benefits and Harms
Nurses assess benefits and burdens beyond physiologic outcomes.
Disclosure, Informed Consent, Shared Decision Making
Shared decision making integrates patient preferences and clinician expertise.
Norms of Family Life
Family dynamics influence care decisions.
Clinician–Patient Relationships
Ethical decisions occur within caring relationships.
Professional Integrity
Nurses owe duties to patients and to self.
Cost Effectiveness and Allocation
Justice guides fair distribution of limited resources.
Cultural and Religious Variation
Cultural sensitivity mitigates ethical conflict.
Power Considerations
Nurses challenge misuse of power and vulnerability.
Examples of Ethical Problems
Common contexts:
Nurse–patient
Nurse–provider
Nurse–nurse
Nurse–institution
Conflict between professional duty and personal conviction
Key Ethical Issue Types
Paternalism
Deception
Privacy and social media
Confidentiality
Allocation of scarce resources
Consent and refusal
New technologies
Unprofessional or illegal practice
Short staffing
Beginning-of-life decisions
End-of-life decisions
Nurses and Ethics Committees
Primary functions
Education
Policy development
Case consultation
Quality improvement
Research (in some committees)
Nurse contributions:
Clinical context clarification
Patient and family perspectives
Communication facilitation
Policy identification and revision
Conflicts of Commitment
Tension between:
Provision 2: Primary commitment to the patient
Provision 5: Duties to self (integrity, competence, growth)
Ethical challenge:
Balancing patient needs with nurse well-being.
Professional expectation:
Reflect on responsibilities.
Prioritize without abandoning self or patient.
Advocacy in Nursing Practice
Advocacy
Protection and support of patient rights.
Grounded in ANA Code:
Provision 3: Promote and protect patient rights, health, safety.
Provision 8: Address health disparities through collaboration.
Advocacy requires:
Loyalty to patient over institution when conflicts arise.
Evaluation of autonomy vs well-being.
Informed consent support.
Nursing Advocacy in Action
Advocacy involves:
Ethical reasoning
Communication
Interdisciplinary collaboration
Resource mobilization
Representing Patients
Nurses act as intermediaries:
Between patients and families
Between patients and providers
Advocacy includes:
Identifying conflicts
Facilitating access to services
Coordinating interdisciplinary support
FIGURE 6-3: Nurse as Patient Advocate
What it shows
Nurse facilitating communication and decision making.
How it’s used in practice
Supports informed consent and care coordination.
Promoting Self-Determination
Advocacy supports:
Patient decision making
Delegation to trusted surrogates
Nurses do not:
Make decisions for patients.
Nurses do:
Provide information
Clarify options
Facilitate communication
Concept Mastery Alert
Advocacy supports decisions; it does not replace patient choice.
Whistle-Blowing
Duty to report unsafe, unethical, or illegal care.
Risks historically included retaliation.
Professional protection affirmed:
Retaliation against nurses is unethical and unlawful.
Whistle-blowing aligns with:
Patient safety
Professional accountability
Being Politically Active
Nursing advocacy extends to:
Health policy
Workforce issues
Public health
Nurses influence legislation through:
Voting
Policy engagement
Professional organizations
Ethics and Academic Integrity
Academic expectations:
Honesty
Integrity
Civility
Ethical conduct in education predicts ethical conduct in practice.
Academic dishonesty undermines:
Public trust
Professional integrity
Patient safety
Final Note About Trustworthiness
Trustworthiness requires:
Competence
Willingness to act
Accountability
Ethical responsibility does not end with notification.
Nurses must:
Use the chain of command.
Continue escalation until patient needs are met.
Professional nursing identity:
Competent
Compassionate
Collaborative
Ethical advocate
Full Chapter Key Takeaways — Chapter 6: Values, Ethics, and Advocacy
(Organized by the headers/subheaders you provided. Content-only. Exam-relevant.)
Introduction
Nurses face ethical questions routinely (not only technical “how,” but “should”).
Expanding science/technology increases frequency of ethical conflicts in care decisions.
Nurses have heightened responsibility for advocacy when patients lack resources, voice, or protection.
Ethical practice requires:
Awareness of patient values + nurse values
Ability to identify ethical dimensions of everyday practice
Willingness to act within scope, accountability, and standards
Values
Values: beliefs about what matters/worth; guide behavior and choices.
Value system: ranked organization of values that guides conduct.
Values influence:
Beliefs about health/illness
Health behaviors
Responses to illness
Nurse–patient interactions (value differences affect care planning/teaching)
Development of Values
Values are learned over time through environment, family, culture.
Five common modes of value transmission (LO focus):
Modeling
Learning by observing behaviors of parents/peers/significant others.
Moralizing
Being taught a complete value system with little opportunity to weigh alternatives.
Laissez-faire
Minimal guidance; child explores values independently; may cause confusion/conflict.
Rewarding and punishing
Values reinforced through approval/rewards; discouraged through punishment.
Responsible choice
Encourages comparing competing values and consequences with support/guidance.
Values Essential to the Professional Nurse
Professional values guide:
Interactions with patients
Interprofessional conduct
Public trust and accountability
Five professional values (AACN) — Table 6-1:
Altruism
Autonomy
Human dignity
Integrity
Social justice
Professional expectation:
Nurses do not impose personal values as “more correct.”
Nurses must still judge/act when health, safety, well-being are at risk.
Person-centered care core attributes cited:
Holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, developmentally appropriate.
Table 6-1: Professional Values (What nurses must know)
Altruism
Concern for welfare/well-being of others.
Behaviors: culturally sensitive understanding, advocacy for vulnerable, mentoring, taking risks for patients/colleagues.
Autonomy
Right to self-determination.
Behaviors: honor choices, plan in partnership, provide info for informed decisions.
Human dignity
Respect inherent worth/uniqueness.
Behaviors: culturally respectful care, protect privacy/confidentiality, individualized care planning.
Integrity
Acting according to ethics + accepted standards.
Behaviors: honesty, accurate documentation, remedy errors, accountability.
Social justice
Upholding moral/legal/humanistic principles.
Behaviors: fairness, nondiscrimination, universal access advocacy, policy/legislation support.
Values Clarification
Values clarification: process of understanding one’s values/value system through examining choices and behaviors.
Clinical utility:
Helps nurses understand patient motivation.
Supports counseling/teaching aligned with what the patient values.
Three steps in the valuing process (LO focus):
Choosing
Freely choose among alternatives.
Consider consequences.
Prizing (treasuring)
Feel pride/happiness; affirm publicly.
Acting
Behave consistently with the value over time.
Clinical Applications (values clarification strategies in practice)
Use open questions and structured ranking tools to:
Identify patient’s primary values
Expose value conflicts
Connect values to health behaviors and outcomes
Common use cases:
Patient undervaluing health behaviors
Patient/family conflict affecting care adherence
Ethics
Ethics: systematic study of right/wrong conduct and moral reasoning.
Morals: personal/community standards of right/wrong (often distinguished from professional ethics).
Ethics is not equivalent to:
Religion
Law
Custom
Institutional practice
(Legal/customary ≠ ethically right by default.)
Values shape ethical conduct; higher value on safety/well-being increases likelihood of sacrifice for patient benefit.
Nursing Ethics
Nursing ethics is a subset of bioethics: study of ethical issues in nursing practice and reasoning used to make/evaluate judgments.
Bioethics core questions emphasized:
What kind of person should I be?
What duties do I have to others affected by my actions?
What do I owe the public/common good?
Ethical preparedness expectations for nurses (scope/standards emphasis):
Ongoing appraisal of personal/professional values and their effect on decisions
Awareness of obligations in the ANA Code of Ethics
Knowledge of ethical principles + how to apply them
Skills/motivation to implement decisions
Common ethical issues in daily nursing:
Cost containment harming patient welfare
End-of-life/beginning-of-life decisions
Confidentiality breaches
Incompetent/unethical/illegal practices by colleagues
Theories of Ethics
Ethical frameworks:
Action-guiding (“What should I do?”)
Character-guiding (“What kind of person should I be?”)
Two major action-guiding categories:
Utilitarian
Right/wrong based on consequences; “greater good.”
Deontologic
Right/wrong based on rules/duties independent of outcomes.
Nurses frequently apply principle-based and care-based approaches.
Principle-Based Approach
Blends utilitarian + deontologic elements.
Four core principles (Beauchamp & Childress) — Table 6-2:
Autonomy
Nonmaleficence
Beneficence
Justice
Nursing ethics often adds:
Fidelity
Veracity, accountability, privacy, confidentiality (named as central in nursing tradition)
Table 6-2: Principles of Bioethics (Exam-use summary)
Autonomy
Respect patient/surrogate right to decide.
Nurse role: provide info/support; collaborate; advocate.
Nonmaleficence
Avoid causing harm; prevent harm/risk when possible.
Beneficence
Actively promote patient benefit; balance benefits vs risks/harms.
Benefits/burdens may be defined differently by different stakeholders.
Justice
Fair distribution of benefits, risks, costs; recognize bias/discrimination.
Fidelity
Keep promises; do not abandon; uphold public trust and competence commitments.
Ethical dilemma occurs when adherence to principles yields conflicting actions.
Limits/critique addressed:
“Quandary ethics” risk: overfocus on dramatic end-of-life dilemmas while neglecting daily ethics (truthfulness, respect, responsibility).
Care-Based Approach
Ethics rooted in caring relationship and person-centered care.
Core characteristics listed:
Centrality of caring relationship
Dignity/respect of persons
Attention to particular circumstances of individual patients
Responsiveness and professional responsibility
Moral skills/virtues: kindness, attentiveness, empathy, compassion, reliability
Emphasis:
Daily ethical comportment, not only major treatment decisions.
Feminist Ethics
Ethical framework critiquing oppression/domination patterns affecting marginalized groups.
Includes focus on:
Inequities
Poverty/marginalization
Social policy advancing dignity, respect, legitimate choice, basic needs
Ethical Conduct
Ethical nursing practice requires:
Professional standards + professional values
Virtue cultivation
Knowledge of ethical frameworks
Familiarity with codes and standards guiding conduct
Ethical formation begins in school and is reinforced through role modeling and practice culture.
Moral Agency
Moral agency: capacity to be ethical and act ethically for the right reasons; trustworthiness demonstrated in clinical encounters.
Moral agency requires development beyond:
Scope-of-practice task lists
Role checklists
Agency elements highlighted as necessary:
Motivation
Professional support
Environment that enables action
Tenacity, courage, resilience, perseverance
Box 6-1: Elements of Moral Agency in Action (What nurses must know)
Key elements demonstrated:
Moral sensibility (recognize discrepancy/ethical discomfort)
Moral responsiveness (act rather than ignore)
Moral reasoning/discernment (justify action ethically)
Moral accountability (own responsibility to remedy system failure)
Moral character (virtues make ethical action more natural)
Moral motivation (patient interest over comfort/approval)
Moral valuing (willingness to accept discomfort for patient welfare)
Transformative ethical leadership (work to change culture)
Nurse Virtues
Virtues: cultivated dispositions motivating ethical conduct and good care.
Common virtues listed:
Competence
Compassionate caring
Subordination of self-interest to patient interest
Self-effacement
Trustworthiness
Conscientiousness
Intelligence
Practical wisdom
Humility
Courage
Integrity
Virtues must be internalized, not performed temporarily.
Civility
Civility is treated as ethically significant in current practice environments.
Linked ethical risks:
Bullying
Lateral violence
Unsafe/unwelcoming work climates
Work environment indicators included as reflection prompts:
Welcomed on unit
Help offered
Resources available
Appreciation expressed
Concern for well-being
Nursing Codes of Ethics
Codes listed:
ICN Code of Ethics
ANA Code of Ethics
CNA Code of Ethics
NSNA Code of Academic and Clinical Conduct
Code of ethics: principles reflecting profession’s primary goals, values, obligations.
ANA Code functions:
Statement of ethical obligations/duties
Nonnegotiable ethical standard
Profession’s understanding of its commitment to society
Code requirements can exceed legal requirements.
Violations may result in professional discipline (reprimand/censure/suspension/expulsion).
Box 6-2: ANA Code of Ethics Provisions (High-yield list)
Compassion and respect for dignity, worth, unique attributes of every person
Primary commitment to patient (individual/family/group/community/population)
Promote, advocate for, protect patient rights, health, safety
Authority/accountability/responsibility for practice; sound decisions/actions
Duties to self as to others: health/safety, integrity, competence, growth
Establish/maintain/improve ethical work environment for safe quality care
Advance profession via research, standards, policy
Collaborate to protect human rights, promote health diplomacy, reduce disparities
Profession integrates social justice into nursing and health policy; maintains integrity
Standards of Professional Nursing Practice
ANA Scope and Standards:
Ethical obligations emphasized under a designated standard (noted as Standard 7 in text).
Advocacy competencies emphasized as a distinct standard (noted as Standard 8 in text).
Expectation:
Nurses treat advocacy as a duty, not an optional ideal.
Nurses identify patients with unmet needs and determine actions required.
Bill of Rights for Registered Nurses
Purpose:
Workplace advocacy tool to support safe, quality care and nurse well-being.
Seven tenets (memorize list):
Right to practice fulfilling obligations to society and recipients of care
Right to environments supporting professional standards and legal scope
Right to ethical practice environment consistent with Code of Ethics
Right to advocate openly for self/patients without retribution
Right to fair compensation aligned with role/responsibilities
Right to safe environment for nurses and patients
Right to negotiate employment conditions individually or collectively
Ethical Experience and Decision Making
Two common ethical problems:
Ethical dilemma: competing principles support incompatible actions.
Moral distress: know right action but cannot carry it out due to barriers.
Moral Distress and Resiliency
Moral distress compromises integrity when ethical judgment cannot be acted on.
Nurses need:
Ethical reasoning
Skill to speak up
Workplace culture that supports ethical practice
Provision 6 emphasis:
Collective responsibility to create ethical practice environments
Practice resources discussed:
Moral distress assessment tools
Consult services
Organizational strategies to reduce distress
Figure 6-1: Moral Distress Thermometer
Used to assess level/intensity of moral distress for recognition and response planning.
Giving Voice to Values (GVV)
Values-driven leadership approach emphasizing:
Ethical implementation strategies
Practicing what to say/do
“Moral muscle memory”
Focus is not “be more ethical” but “act effectively on values.”
Moral Injury
Defined by:
Betrayal of what is right by authority/self in high-stakes context
Consequences may include:
Guilt, shame, existential/spiritual crisis, loss of trust
PTSD-like symptoms
Depression/anxiety/anger
Self-harm considerations and withdrawal from profession
Moral injury can occur in nurses, especially following patient safety incidents.
Figure 6-2: Moral Injury in Nurses
Identifies moral injury as relevant to nursing populations.
Conscientious Objection
Refusal to participate in care that violates ethical beliefs/standards.
Supported by ANA Code.
Nurses should use appropriate channels (instructor/leadership) when compromised.
Making Ethical Decisions
Facilities must have ethical problem-solving mechanisms (Joint Commission requirement).
Institutional resources:
Ethics committees
Ethics consultants/ethicists
Nurse ethicists
Five-Step Ethical Decision Making (using nursing process)
Assess: gather contextual, stakeholder, legal/institutional data
Diagnose: confirm ethical nature; define issue clearly; identify time constraints and role
Plan: generate options; weigh consequences; apply theory/principles/code/policies; consult
Implement: act and monitor outcomes
Evaluate: assess results; identify learning; identify system changes needed
Box 6-4: Five-Step Process in Action
Demonstrates structured option analysis and principle/care-based justification.
Ethically Relevant Considerations
Eight considerations emphasized:
Benefits vs harms
Disclosure/informed consent/shared decision making
Family norms and impact
Clinician–patient relationship centrality
Professional integrity of clinicians
Cost effectiveness/allocation (justice)
Cultural/religious variation
Power differences and vulnerability
Examples of Ethical Problems
Common ethical problem areas listed:
Paternalism
Deception
Social media privacy
Confidentiality
Scarce resource allocation
Consent/refusal validity
New technology conflicts
Unprofessional/incompetent/illegal physician practice
Unprofessional/incompetent/illegal nurse practice
Short staffing/union/going public
Beginning-of-life and end-of-life conflicts
Nurses and Ethics Committees
Ethics committee functions (as listed):
Education
Policy making
Case review/consultation
Quality
Research (in some cases)
Nurse role on committees:
Clarify technical facts
Identify decision makers
Represent patient’s best interests
Contribute patient/family context
Support group dynamics
Identify policy needs and revisions
Conflicts of Commitment
Code creates tension between:
Provision 2: primary commitment to patient
Provision 5: duties to self (integrity/competence/growth)
Nurses must:
Identify parties to whom they are responsible
Prioritize responsibilities
Maintain capacity to provide care (cannot give what is not possessed)
Advocacy in Nursing Practice
Advocacy: protection and support of another’s rights.
Code provisions emphasized:
Provision 3: promote/advocate/protect patient rights, health, safety
Provision 8: collaborate to protect human rights, reduce disparities
Core advocacy expectations listed:
Do not let institutional loyalty override patient commitment
Prioritize good of the individual patient over general societal good when in conflict
Weigh autonomy vs well-being (informed consent vs best interest)
Advocacy scope:
Patient safety and quality care
Nurse working conditions impacting patient care (safe staffing, safety)
Nursing Advocacy in Action scenario
Illustrates conflict over feeding assistance in advanced dementia care and surrogate claims about patient preferences.
Representing Patients
Nurse advocacy includes intermediary roles:
Patient ↔ family conflicts
Patient ↔ provider conflicts
Advocacy tasks:
Identify rights of all parties
Arrange resources (home care, hospice, social work referrals)
Promote dignified outcomes and informed decisions
High-risk advocacy populations listed:
Uninformed, sensory impairment, language barriers, very young/older adults, seriously ill, mentally/emotionally impaired, physical disabilities, limited financial/human resources
Promoting Self-Determination
Advocacy is linked to:
dignity and well-being through choice
Nurse role is to facilitate decision making, not decide:
Interpret findings
Provide information
Help organize feelings/options
Involve appropriate decision makers
Support surrogate delegation if preferred
Advocacy limits:
Does not require supporting every patient preference if ethically inappropriate.
Whistle-Blowing
Nurses witnessing unsafe care have a duty to report it.
Retaliation has historically occurred; case example illustrates:
reporting unsafe practice
retaliation
legal and professional consequences for retaliators
Core exam point:
Duty to report unsafe/unethical practice aligns with patient protection and professional accountability.
Being Politically Active
Nurses advocate in political arena for marginalized groups and vulnerable populations.
Nurses influence health care policy/legislation as a large voter bloc.
Advocacy targets include:
Access to care
Rationing criteria concerns
Public safety and workforce issues
Ethics and Academic Integrity
Nursing programs require:
honesty, integrity, ethical behavior, civility
Drivers of academic dishonesty noted:
pressure to succeed, competition, anxiety about job market
Ethical risk emphasized:
dishonesty as student may carry into clinical practice.
Final Note About Trustworthiness
Trustworthiness requires:
competence + willingness to act to secure patient outcomes (health/well-being/good dying)
Ethical responsibility is not complete after “notifying someone.”
Nurses must:
Use chain of command
Escalate until issue is resolved and patient needs are met
Professional identity highlighted:
competent, compassionate, collaborative advocate who makes the critical difference