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  1. Characterize the nurse’s role in recognizing and addressing ethical concerns.

  2. Recognize problems that warrant ethical analysis.

  3. Identify the steps involved in analyzing an ethical problem.

  4. Describe the influence of environment in resolving ethical problems and the nurse’s contribution to the work environment.


Ethical problems are pervasive in critical care settings. Serious illness and its treatment constrain patient autonomy and patients, families, and healthcare teams struggle to determine the ethical course of action when there is uncertainty about prognosis and patient outcomes. Healthcare team members experience moral distress when their own actions do not align with their professional values, and face ethical dilemmas when obligations to patients, employers, colleagues, and self suggest conflicting courses of action.

The first step to managing ethical problems is the recognition that they exist, referred to as ethical sensitivity. Because of the complexity of the healthcare environment, differentiating issues that require moral reasoning from other common problems such as poor communication, differences of opinion, or compassion fatigue can be challenging. Successful resolution of ethical issues depends on the ability to apply ethical decision-making skills and arrive at a conclusion about the right course of action. Whether or not that action is taken depends not only on the motivation of the individual nurse but also on the environment in which care is provided. This chapter introduces the elements that serve as a foundation for addressing ethical problems including professional codes and standards, institutional policies, and ethical principles. An approach to ethical decision making is described, and problems that commonly occur in the acute/critical care setting are discussed. The final section of this chapter looks at the work environment and its impact on the healthcare team’s ability to navigate ethical issues.


The most often cited ethical problems in health care are ethical dilemmas, moral uncertainty, and moral distress. The problems are discussed here from the nurse’s perspective but in reality all members of the healthcare team face ethical problems. An ethical dilemma occurs when the nurse identifies two (or more) ethically acceptable but mutually exclusive courses of action. The dilemma is further complicated as either choice can be supported by a line of ethical reasoning, yet each also has undesirable consequences. In cases of moral uncertainty, a nurse recognizes that an ethical problem exists but is unable to identify the correct course of action. An analysis that includes considering all the possible actions, beyond those that conflict can be helpful in resolving ethical dilemmas and moral uncertainty.

When the nurse experiences moral distress, on the other hand, there is little uncertainty about what course of action is correct but there is a profound inability to take that action. Internal factors such as fear of retribution and self-doubt can serve as the barrier to action. External factors that can constrain the nurse from taking action include hierarchies ...

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