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“Let us never consider ourselves finished nurses …

we must be learning all of our lives.”

–Florence Nightingale

Provide an educational tool to increase APRN students’ abilities to identify ethical concerns and work through them to find a solution.

Inform and expand current ethical pedagogy for APRN students. Faculty teaching in doctor of nursing practice, master of science in nursing, and certified nurse anesthetist programs; their students; and practicing APRNs will benefit from working through the case studies to identify and solve ethical dilemmas.

Provide classroom and clinical teaching in the form of case studies to foster critical thinking, judgment, and the skills needed to resolve ethical dilemmas. As healthcare increases in complexity, APRNs will continue to experience ethical conflicts and dilemmas. Providing guidance to APRNs in identifying and resolving ethical dilemmas can increase effective patient outcomes, and we can continue to be the most honest and ethical profession now and into the future.

Identify the problem.

Assess the factual information.

Identify the involved parties.

What is at stake?

What options are available, what process is needed to make a decision, identify the problem and associated components, assess the factual information, identify the involved stakeholders.

Autonomy: “Rational self-legislation and self-determination that is grounded in informedness, voluntariness, consent, and rationality.”

Beneficence: “Benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law.”

Justice: “A bioethical principle with various types or domains of justice, including distributive, retributive, restorative, transitional, intergenerational, and procedural. Bioethics is chiefly concerned with distributive justice. Distributive justice deals with the equitable distribution of social burdens and benefits society. When this allocation occurs under conditions of scarcity, it raises questions of rationing. The formal principle of justice states that equals shall be treated equally, and un-equals unequally, in proportion to their relevant differences.”

Nonmaleficence: This principle “specifies that a duty not to inflict harm and balances unavoidable harm with benefits of good achieved.”

Source: American Nurses Association, 2015 .

Nurse practitioners

Certified nurse-midwives

Clinical nurse specialists

Certified registered nurse anesthetists

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• Volume 14, Issue 2
• Case Studies in Nursing Ethics
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• Commentaries Testing children for adult onset conditions: the importance of contextual clinical judgement Anneke Lucassen Angela Fenwick Journal of Medical Ethics 2012; 38 531-532 Published Online First: 04 Jul 2012. doi: 10.1136/medethics-2012-100678

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Between mandatory and aspirational ethics in nursing codes: a case study of the Italian nursing code of conduct

• Stefania Chiappinotto   ORCID: orcid.org/0000-0003-4829-1831 1 ,
• Michael Igoumenidis   ORCID: orcid.org/0000-0002-9458-3424 2 ,
• Alessandro Galazzi   ORCID: orcid.org/0000-0003-0085-7015 1 ,
• Andjela Kokic 1 &
• Alvisa Palese   ORCID: orcid.org/0000-0002-3508-844X 1  

BMC Nursing volume  23 , Article number:  30 ( 2024 ) Cite this article

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Over the years, national and international nurses’ organisations have drawn up Codes of Conduct and Codes of Ethics. A new differentiation has emerged over time between mandatory and aspirational approaches underlying how nurses can be supported by documents with rules to be respected (mandatory ethics) or by incentives (aspirational ethics). However, to date, no research has applied these approaches to analyse available Codes and to identify which approach are predominantly used.

In this case study, the Italian Nursing Code of Conduct (NCC), published in 2019, composed of 53 articles distributed in eight chapters, was first translated, and then analysed using a developed matrix to identify the articles that refer to mandatory or aspirational ethics. A nominal group technique was used to minimise subjectivity in the evaluation process.

A total of 49 articles addressing the actions of the individual nurse were considered out of 53 composing the NNC. Articles were broken down into 97 units (from one to four for each article): 89 units (91.8%) were attributed to a unique category, while eight (8.2%) to two categories according to their meaning. A total of 38 units (39.2%) were categorised under the mandatory ethics and 58 (59.8%) under the aspirational ethics; however, one (1.0%) reflected both mandatory and aspirational ethics.

Conclusions

According to the findings, the Italian Professional Body (FNOPI) has issued a modern code for nursing professionals in which an aspirational perspective is dominant offering a good example for other nursing organisations in the process of updating their codes when aimed at embodying an aspirational ethics.

Peer Review reports

The term “profession” refers to a special type of occupation or a social role accompanied by an enduring set of normative and behavioural expectations. By and large, professions are self-regulated, and these expectations are usually imprinted in various codes, which amount to private systems of law and are issued by professional organisations [ 1 ]. In the specific field of the nursing profession, a rich history of creating and adhering to codes of conduct and/or codes of ethics has been reported [ 2 ], but the distinction between these two different categories of codes is not be clear. Indeed, as Paul Snelling [ 3 ] notes, published nursing codes fall into one or other of these categories, but in some codes the functions are confused and/or conflated. Generally, codes of conduct are about nurses’ obligations (standards of practice), whereas codes of ethics are at a higher level and specify how the ideal nurse should be (best practices). In other words, codes of conduct are manifestations of what can be described as mandatory ethics , and codes of ethics illustrate the highest standard of ethical practice, for which we can use the term aspirational ethics [ 4 ].

Within the context of mandatory ethics, nursing professionals are primarily concerned with practising in such a way that protects them from legal and disciplinary sanctions. Therefore, codes of conduct may embody such perspective including prohibited items– underlying forbidden actions and behaviours (negative duties) or a list of acts authorized for practice. From a linguistic perspective, this focus was much more evident in the past, as deontological texts in general and nursing codes in particular would overuse negative phrases, typically beginning with “do not” and “must not”. More positive approaches seem to be promoted at present; for instance, the mandate “do no harm” is now presented as a positive duty in the form of “Nurses facilitate a culture of safety in health care environments” [ 5 ]. However, there are those who argue that these inversions do not make a great difference in terms of essence. A positive requirement is just as restrictive as a negative prohibition, and we could replace any given negative rule with a corresponding positive rule, which can be logically and morally equivalent [ 6 ]. If there is a duty to tell the truth, it is implied that there is a duty not to lie; if there is a duty to keep patient information confidential, it is implied that there is a duty not to disclose this information, and so on. Inversions are not always as straightforward as the ones presented, but, in many instances, negative and positive duties are simply different sides of the same coin.

Yet positive duties are not only inversions of negative ones: they also refer to acts and attitudes that can be characterised as supererogatory – that is, doing more than enough. Aspirational ethics ask professionals to exceed the minimum standards of practice and behave in ways that cannot be enforced or covered by codes of conduct. This higher level of ethical behaviour is related to moral values and virtues, and it entails more reflection and discussion than mandates and prohibitions. As such, it integrates professional and personal ethical principles, and it is useful when facing new dilemmas which have never been encountered in practice [ 4 ]. A nurse who acts in the context of aspirational ethics strives for the best, even at great personal cost in terms of time, stamina and moral tranquillity. Given that there is no limit on doing more than enough, a conscientious professional could end up engaging in a relentless pursuit of excellence [ 7 ], which is simply not attainable.

This remark brings us to the issue of over-demandingness [ 8 ], which is the main problematic aspect of aspirational ethics and is especially relevant to nursing practice. Nurses have a duty to display beneficence, but its limits cannot be easily discerned, and no regulatory body can possibly control professionals’ willingness or ability to provide care in a supererogatory way. The nursing profession entails physical and psychological demands, and it is burdened by the continuing problem of under-staffing, so it is often up to individual nurses to decide when they have fulfilled their duties. Depending on context, various factors play a role in setting up these limits at an individual level, such as the nurse’s character and education, the working environment and influence of role-models or even psychological incentives – for instance, describing nurses as “heroes” (in the sense that they do more than their fair share) and heroism as a core nursing value [ 9 ]. There are those who argue that the use of heroism stifles meaningful discussion about the duty of care and its limits [ 10 ], but we assert that defining limits in care and beneficence is difficult in any case. This can only happen at an individual level and on a case-by-case basis.

One could then ask, what is the point of issuing codes of ethics and including aspirational elements in them? Is there a practical value in stating, for instance, that nurses affirm “the right to universal access to health care for all” [ 5 ], as the International Council of Nurses (ICN) does in its Code of Ethics? A nurse can affirm this right, but it certainly represents an ideal that is not feasible and is often not carried out within the context of modern managed care [ 11 ]. However, the imperfect implementation of aspirational goals should not discourage the continuing effort to improve nursing professional ethics – or any professional ethics for that matter. Ideal descriptions of nurses’ conduct are important in official texts; they serve as a source of inspiration for new colleagues, and as reminders for those who already practise and may be disillusioned with the health care reality. Besides, codes of ethics have always been aspirational in nature, focusing on virtuous characters who would simply know what their moral duty is, without having to resort to mandates and prohibitions, and would fulfil it to the best of their abilities – acknowledging personal and institutional limits in every case. Aspirational ethics are less definite and open to more exceptions and defences, thus encouraging critical thinking and allowing (but not forcing) professionals to assume greater personal responsibility [ 12 ].

Therefore, all professional organisations that follow prohibitive codes are recommended to adopt more aspirational standards when given an opportunity to revise these codes [ 13 ]. As noted earlier, nursing codes of conduct and codes of ethics are often merged into single documents, without giving adequate attention to these documents’ titles or to a consistent separation of conduct and ethics throughout the documents [ 3 ]. Still, what matters most is whether aspirational elements are included in them, regardless of the title or the terminology used. Their hidden messages [ 14 ], shape the practice, ways of thinking and training, as well as the manner that nursing professional behaviours can be judged, criticised, and evaluated. However, to the best of our knowledge, no explorations have been conducted on the available nursing codes of conduct (NCC) or codes of ethics to investigate their hidden perspectives towards an aspirational or a mandatory ethics.

The aim was to analyse the current Italian NCC [ 15 ] by developing and piloting a matrix capable of detecting the aspirational or a mandatory ethics hidden from view. Both the research processes and findings were intended at (a) expanding our knowledge regarding the main trends of the current codes of ethics; (b) providing methodologies and methods for the analysis of nursing codes both for didactic and research purposes; and (c) supporting nursing boards by informing the development or the revision processes of their codes.

A case study was performed in 2023, relied on the Crowe and colleagues’ methodology [ 16 ]. The design was identified according to the bounded-system intrinsic nature of the ethical guidelines in the profession; the unit of analysis was the most recent Italian NCC (Codice Deontologico delle Professioni Infermieristiche) [ 15 ], in its role of integrate document containing a set of articles addressing the nursing practice in Italy.

Unit of analysis and setting

The study was conducted by analysing the Italian NCC [ 15 ] developed and approved in 2019 by the National Federation of Nursing Professions Orders (FNOPI), which is a national body representing over 455,000 nurses [ 17 ]. It took part in establishing nursing orders at each provincial level. FNOPI was established by law in 1954 [ 18 ], and it is considered a subsidiary governmental body addressing the profession development and regulating its practice must follow through the NCC, which has juridical meaning given that all licensed nurses, allowed to practise in Italy after their subscription into the Nursing Order [ 19 ]. The current Code, composed of 53 articles distributed in eight chapters [ 15 ], was considered relevant to validly achieve the research aims.

Data collection method

First, we checked to see if the Italian NCC was officially available in the English language, to have a text in a common language given the multinational research team (see authors). Given that no official formal translation was retrieved, its translation in English was provided according to the “forward-only translation” process [ 20 ]: first, an expert in language translation, with a master’s degree in European and extra-European languages and literatures (AK), without any background in nursing, provided a first translation. Then, two researchers, educated at the PhD level in the nursing field, checked the translation (SC and AG) and provided changes to better reflect the meaning of each word and statement in the context of nursing care. Then, an additional check was provided by an expert nursing researcher educated at the PhD level (AP). To complete the process, official proof editing was sought from an independent language service, expert in the field of medical translation; the revised draft was checked again by the research team. In case of discrepancies, discussion was planned to solve all disagreements. However, no issues emerged, so this final version was considered in the following research steps [ 21 ]. In the meantime, the translation provided was assumed as the official translation by FNOPI and published on the organisation’s web page [ 22 ]. The final draft of the translation was then sent to a member of the research team (MI) with a background in nursing ethics and deontology to assess clarity.

The second step was to identify which sections would undergo assessment: the NCC is articulated in 53 articles, and the last four (numbers 50–53) were not taken into consideration because they are devoted to the entire nursing professional board and not to the individual nurse. Given that most articles comprised two or more sentences with different conceptual content, it was decided that the articles would be broken down in units, and then assessed separately. The identification of units was performed by two researchers (SC, AP), before independently and then agreeing upon; the processes resulted in 97 units.

Data analysis

A nominal group technique (NGT) [ 23 , 24 ] was established to minimise subjectivity in the evaluations. This methodology is suggested when the research area under investigation is unexplored, when there is no supporting literature or when the information available is contradictory [ 23 ]. NGT involves a group of experts [ 24 ] in four main steps [ 24 ], which we slightly adapted in our case study according to its peculiarity: (a) silent generation of ideas , in which each participant writes down their evaluations without comparing them with the others; (b) round robin , a round in which all participants express their previous evaluation without, however, discussing them; (c) discussion , where evaluations are clarified and similarities confirmed; and (d) voting/ranking , or agreeing to establish a consensus in those evaluation with disagreements.

First, an NGT member (MI) developed the analysis matrix (see Table  1 ) defining the criteria of evaluation for mandatory and aspirational ethics.

Mandatory ethics consist of the categories of rules that entail legal implications or rules that entail disciplinary implications and specific exceptions. These rules and their exceptions refer to the minimum expectations from practitioners (in this context, nurses). They are held ethically or legally blameworthy for failing to uphold these rules, but not perceived as praiseworthy for doing so.

Aspirational ethics consist of the categories of unspecific exceptions – that is, this type of exception usually demands that practitioners (in this context, nurses) use their moral judgment and make up their own exceptions according to each situation and incentives. Incentives can be related to actions, in which lies the main problem with aspirational ethics, in the sense that these supererogatory actions may be too demanding; or they may be related to virtues – that is, to the perceived characteristics of the ideal practitioner that may or may not be realistically attainable.

Based on the data analysis grid (Table  1 ), agreed upon by the NGT members (see authors), the process began according to the main steps established by Mullen et al. [ 24 ]:

Two researchers (AP and SC) conducted an evaluation of each individual article and unit of the Italian NCC independently, deciding whether each statement fell within the category of mandatory ethics (rules or specific exceptions) or aspirational ethics (unspecific exceptions or incentives).

During a meeting, both researchers who had conducted the evaluations (AP and SC) presented their results, identifying the areas of common agreement and those of conflict.

Then, an online NGT meeting was organised in which the two researchers (AP and SC) presented the results achieved to a third researcher (MI). Other members (see authors) were also present. During the meeting, the rationale behind each choice was explained, and the areas of conflict and those of mutual agreement were discussed, in which however the third researcher (MI) sometimes proposed a different categorisation. All researchers were encouraged to write down their motivations after having carefully re-read the evaluation, so the rationale for the choices could be deepened. It was agreed that, in some cases, the units could fall under more than one category; this overlapping was expected, and it was decided not to force a single categorisation, so as not to lose any potential insight.

During an additional NGT meeting, the remaining conflicting categorisations (7/97 units, 7.2%), were resolved, until consensus was reached. The consensus was qualitatively expressed as the main approach (mandatory or aspirational) embodied in each item of the NCC.

The data analysis was conducted by involving each member of the team and providing independence and cross checking in multiple meetings [ 25 , 26 ]. Furthermore, considering the required translation into English of the NCC, the process of translation from Italian to English was preliminarily conducted by the Italian team, by involving individuals with different backgrounds; the translation was also checked by the non-native Italian member of the team to assess its clarity [ 20 ]. Furthermore, each code article was broken down into units to assess each specific indication: the Italian language is well recognised as having complex construction [ 27 ] and to prevent missed elements, each unit was analysed. The integrity of individuals/organisations involved was ensured: no one researcher was involved or had roles in the development of the NCC to ensure an independent evaluation.

The 49 articles considered of the NCC were broken down into 97 units (from one to four for each article) (Table  2 ): 89 units (91.8%) reflected a unique category (mandatory or aspirational), while eight (8.2%) were attributed to two categories according to their meaning. A total of 38 units (39.2%) were categorised under the mandatory ethics and 58 (59.8%) under the aspirational ethics; however, one (1.0%) reflected both mandatory and aspirational ethics and was categorised both under rules entailing disciplinary implication and incentives related to actions .

Starting with mandatory ethics from the category of rules that entail legal implications , 20 units (20.6%) reflected this category. These units concerned issues linked to Italian laws and regulations: some examples are those regarding confidentiality (Article 19), person’s rights (Article 19), professional secrecy (Article 27), privacy (Article 28), the use of physical restraints (Article 35) and abusive practices (Article 44). On the other side, the category of rules that entail disciplinary implications included 21 units (21.6%), where nurses are expected to demonstrate some professional behaviour (e.g. the care relationship even in case of different ethical conception, Article 6) or some professional values (e.g. dignity, freedom and equality, Article 3). Moreover, regarding the category of specific exceptions , only five units (5.1%) were identified: abstention due to conflicting values or ethical and professional principles (Article 6), the limitation of interventions when not proportionate for the condition of the assisted person (Article 25), the use of physical restraint only in exceptional cases (Article 35), issues related to the conflict of interest (Article 43) and the necessity of specific skills in case of consultancy and expert activities (Article 48).

Regarding unspecific exceptions related to aspirational ethics , six units (6.2%) were included in this category. These concerned complex situations requiring difficult decisions for nurses, such as that regarding the conscience clause (Article 6), the respect of a child’s willingness (Article 23) or that regarding inappropriate nursing care (Article 38). The category of incentives related to actions was found to be the richest, including 42 units (43.3%) with various situations and actions that nurses should ideally carry out, such as listening, dialoguing (Article 4); providing educational and informative interventions (Article 7); acting with research in clinical, organisational and educational fields (Article 9); applying good practices for pain management and related symptoms (Article 18); or ensuring person and personal decorum (Article 45). The category of incentives related to virtues included 11 units (11.3%) containing the ideal values for an aspiring nurse in his/her profession. Health culture (Article 7), intra- and interprofessional interactions (Article 16) or professional responsibility (Article 37) are some examples in this category.

Our case study investigated the hidden perspectives towards an aspirational or a mandatory ethics embodied in the Italian NCC. The discussion is developed around four main lines: in the context of (a) the overall findings that emerged, (b) the analytical frequencies documented in the two main perspectives (aspirational or mandatory), (c) the research context in the field and (d) the methodological issues.

First, according to the findings, aspirational ethics elements were dominant. Thus, the Italian NCC asks that professionals to exceed the minimum standards of practice and behave in ways that cannot be enforced or covered by codes of conduct: for example, NCC suggests nurses to adopt caring relationships, also using listening and dialogue, or to consider relationship time as caring time (e.g., Article 4). This is a higher level of ethical behaviour related to moral values and virtues, and it entails more reflection and discussion than mandates and prohibitions (e.g., [ 7 ]). This finding suggests that the Italian NCC may be considered a good example of Code expressing an aspirational approach; this may help other nursing professional organisations which are due to update their codes and wish to provide a higher-level ethical framework.

Second, according to the frequencies that emerged in the analysis, 38 units fell under the general category of mandatory ethics, and 58 under the category of aspirational ethics (one was categorised in both perspectives). Regarding sentences categorised as mandatory, it is possible to observe how they are often associated with Italian laws or current legislation (e.g. Continuing Medical Education regarding Law 229/1999 [ 28 ]; privacy regarding Law 196/2003 [ 29 ]). This may explain why these sentences are structured as rules or as specific exceptions to the rules. However, the NCC’s general spirit is oriented towards a higher level, with many positive requirements and few prohibitory items, thus enhancing its aspirational nature. In fact, all the articles concerning communication (e.g. Articles 21, 29) and the relationship with the assisted person (e.g. Article 24), person-centred care (e.g. Article 17), as well as the educational aspects of the professional role (e.g. Article 8), were categorised within the aspirational approach. This suggests an important step for professional development, which no longer places the nurse within a series of activities that he or she must or must not do, but which invites every professional to critically reflect on his or her own actions, activities and choices. To be consistent with this nature, it may be suggested to rename the Italian NCC in the “Code of Ethics and Conduct”. In fact, Snelling [ 3 ] argues that there is a significant difference between codes of conduct and codes of ethics, as the former mainly target regulatory functions, whereas the latter describe higher ethical functions. Some professional organisations, such as the Nursing and Midwifery Board of Australia, keep them separated, issuing a Code of Professional Conduct [ 30 , 31 ] and a Code of Ethics for nurses. However, we see no problem with a mixed, aggregate form, which can be more practical and integrative. All nurses have known colleagues who are inspirational, just as there are some who are less so – for whatever reason. A nursing code should include provisions to cover both cases. It should exemplify supererogatory conduct, and, at the same time, acknowledge that a grounded, regulatory approach is more appropriate for some professionals. In this sense, it should be noted that there exist consciously integrative codes as evidenced by their titles, such as the Nursing Council of Hong Kong Code of Ethics and Professional Conduct [ 32 ], and the Nursing and Midwifery Board of Ireland Code of Professional Ethics and Conduct [ 33 ]. Future revisions of the Italian Code could use a more integrative title, for reasons of conceptual clarity.

Third, in the context of the research available, this is the first exercise attempting to identify and discern between the mandatory or aspirational nature of a given code in the nursing discipline. Available assessments of various codes [ 3 , 34 ] have pursued different aims without providing a distinction between mandatory and aspirational. More specifically, Snelling [ 3 ] provided a comparative assessment of various nursing codes by considering the ICN Code of Ethics for Nurses, the United Kingdom’s Nursing and Midwifery Council Code, the Nursing and Midwifery Board of Australia Codes of Professional Conduct and of Ethics, the Nursing Council of New Zealand Code of Conduct, the Canadian Nurses’ Association Code of Ethics, the Nursing Council of Hong Kong Code of Ethics and Professional Conduct, the Nursing and Midwifery Board of Ireland Code of Professional Ethics and Conduct and the American Nurses Association Code of Ethics. Snelling [ 3 ] has highlighted several significant differences between ethical and conduct codes, which generally correspond to the differences between ethics and law. Our study perspective was different, because the main distinction was between aspirational and mandatory ethics – although mandatory ethics also include legal implications. Other authors have analysed the content and the process of revising nursing codes. For instance, Epstein and Turner [ 35 ] described the 2015 revision of the American Nurses Association Code of Ethics for Nurses with Interpretive Statements ; moreover, Tisdale and Symenuk [ 34 ] make a comparative assessment of the nursing codes in Canada from 1957 to 2020 and their relation to human rights in terms of language, positioning and descriptions between different code editions. These approaches are useful, and they can serve to inform nursing scholars and professionals of the value of codes in specific contexts, just as the present research exercise does regarding mandatory and aspirational ethical elements.

Fourth, from the methodological point of view, the analysis resulted with some articles being included in one singular categorisation (e.g. Article 3), while others were categorised under more categories (both rules that entail disciplinary implications and incentives related to actions [Article 4], thus under mandatory and aspirational ethics) and others were under more categories but from the same perspective (e.g. rules that entail legal and disciplinary implications, Articles 35, 37). Despite this being beyond the scope of this research exercise, complex articles including several recommendations with different perspectives (from mandatory to aspirational) may increase the learning complexity of the code among students, as well as the critical analysis of concrete situations. Therefore, the degree of simplicity of each article/element should be debated as an occasion to innovate the code according also to the lessons learnt during the pandemic [ 36 ].

Moreover, we have decided to identify categories that were not mutually exclusive: although most units have been classified into only one category (e.g., “Related to virtues: what the practitioner’s character should be (attitudes)”), in eight cases these were included in two categories, mainly under the mandatory ethics as entailing both legal and disciplinary implications. This last peculiarity may reflect the Italian NCC, which has been approved in its value by the law [ 19 ], as the basis of professional practice together with the Nursing Profile (defined by the Ministerial Order 739/1994 [ 37 ]) and the nursing curriculum as the complex of theoretical and practical competences learnt during the nursing programme. Therefore, the Italian NCC is not only issued by the Nursing Board with deontological purposes but also has legal implications.

An additional reflection concerns the terminology used in the NCC. The most recent Italian Code is called a “Code of Conduct”; however, our research exercise suggests that it contains many elements that can be characterised as aspirational, in the sense that they refer to an ideal nursing professional, and not to someone who just fulfils mandatory duties. From a content point of view, this Code [ 15 ] also contains several ethically sensitive terms (e.g., the word “patient” was avoided in favour of “assisted person” [ 38 ]) and included articles that concern important issues involving complex ethical choices (e.g., conscience clause, Article 6; physical restraints, Article 35). However, some of these issues, as conscience clause and physical restrain, that are so sensitive from an ethical point of view are still treated with a mandatory approach, and not supporting nurses in higher ethical actions suggesting areas of future debate and improvement.

Limitations

The research process had several limitations. First, the Italian NCC consists of a series of articles composed of a few to several units [ 39 ], and this increased the complexity of the analysis. The Italian language, which is recognised as complex, and the structure of the Italian NCC together suggested breaking the articles up into units, a process that may be not required in the analysis of other codes. For example, the ICN Code of Ethics for Nurses [ 5 ] is composed mainly of simple elements or sentences, which would potentially render the analysis easier. Therefore, the data analysis process conducted may require some adaptations when repeated for other nursing codes. Second, only those articles regarding nurse practitioners were analysed, those concerning the professional body were omitted from the analysis (Articles 50–53). Future research exercises should also consider these articles by providing an appropriate framework of analysis. Third, only the most recent NCC was considered; analysing the previous codes (e.g. [ 40 ]) established in the Italian context to describe the historical trends may provide meaningful data regarding the developments undertaken by the profession in its ethical reflections and recommendations. Fourth, we performed the categorization of each unit/Article by involving experts in the field with a deep knowledge regarding available laws and rules; however, continuously checking the consistency of the categorization performed to detect changes in the rules and to minimize subjective interpretation is required. Moreover, although we reflected a multicultural perspective involving members from two countries, a wider perspective may be useful to enrich the analysis and the debate (e.g. [ 41 ]) by providing, for example, Anglo-Saxon, Germanic, or Scandinavian perspectives.

This case study was aimed at developing and analysing the Italian NCC with a matrix, to identify of which approach is prevalent in this historical period (mandatory vs. aspirational ethics). Our attempt was to assess whether professional ethics in nursing is based on normative indications (generally negative), or on a higher vision of the profession, that is, aspirational. According to the findings, the Italian Professional Body (FNOPI) has issued a modern code for nursing professionals in which an aspirational perspective is dominant. As a results, it sets a good example for other nursing professional organisations in the process of updating their codes when aimed at embodying an aspirational ethics.

The matrix developed to analyse the code can be further developed to establish an instrument for didactic and professional purposes. Moreover, future studies could use the matrix to compare the current version of the Italian NCC with other codes at the international level, and to detect differences and similarities in their perspectives; moreover, the matrix could be useful to analyse the codes established over time in the same country or across countries to detect changes in the perspectives from mandatory to aspirational or vice versa.

Data availability

Data is provided within the manuscript.

Not applicable.

Abbreviations

International Council of Nurses

Nursing Code of Conduct

National Federation of Nursing Professions Orders

Nominal Group Technique

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Stefania Chiappinotto, Alessandro Galazzi, Andjela Kokic & Alvisa Palese

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Chiappinotto, S., Igoumenidis, M., Galazzi, A. et al. Between mandatory and aspirational ethics in nursing codes: a case study of the Italian nursing code of conduct. BMC Nurs 23 , 30 (2024). https://doi.org/10.1186/s12912-024-01697-3

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A Case-Centered Approach to Nursing Ethics Education: A Qualitative Study

Affiliations.

• 1 Department of Nursing, Chung-Ang University, Seoul 06974, Korea.
• 2 Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul 06974, Korea.
• 3 Department of Family Health Nursing, College of Nursing, The Catholic University of Korea, Seoul 06974, Korea.
• PMID: 33113978
• PMCID: PMC7660290
• DOI: 10.3390/ijerph17217748

Nurses deal with ethical decisions as they protect patients' rights, but a consensus on effective approaches to nursing ethics education is lacking. The "four topics" method can facilitate decision-making when nurses experience ethical dilemmas in practice. This study aimed to describe nursing students' perspectives on and experiences of a case-centered approach to nursing ethics education using the four topics method. This qualitative study consisted of two phases. First, we delivered case-centered nursing ethics education sessions to nursing students using the four topics method. Then, we conducted two focus group discussions that explored students' perspectives on and experiences of nursing ethics education. Data were analyzed using conventional content analysis. Four themes were identified: the importance of ethics education as perceived by nursing students, problems in current nursing ethics education, the experience of case-centered nursing ethics education using the four topics approach, and suggestions for improving nursing ethics education. The case-centered approach using the four topics method is effective in enhancing nursing students' nursing ethics ability. It is crucial to understand that nursing students would like to set up their own ethical standards and philosophy. Continuous efforts to encourage students' participation and to provide ethical reflection opportunities during clinical practice are needed to better connect theory with clinical practice.

Keywords: four topics approach; nursing education; nursing ethics; nursing student; qualitative research.

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• Research Support, Non-U.S. Gov't
• Education, Nursing*
• Ethics, Nursing*
• Focus Groups
• Qualitative Research
• Students, Nursing*
• Young Adult

10 Examples of Ethical Dilemmas in Nursing

When caring for human lives, the decisions you have to make as a nurse are anything but black and white. In addition to taking vital signs and doing dressing changes, there are a realm of tough choices and ethical dilemmas that nurses have to face every day.

Picture this: a nurse finds himself torn between respecting a patient's right to refuse treatment and their deteriorating health. Moral puzzles like these leave even the most experienced nurses scratching their heads and feeling caught between a rock and a hard place. However, understanding how to handle ethical dilemmas isn't just a theoretical exercise. It's a crucial skill that nurses need to have in their toolkits. 

The nursing code of ethics acts as a guide for nurses to help in these decisions, but it can be helpful to see actual examples of ethical dilemmas in nursing and what a nurse should do with each of them. That’s exactly what this article is about. 

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10 common ethical dilemmas in nursing .

While there are many different situations in which a nurse may find themselves dealing with an ethical dilemma, here are 10 common ethical dilemmas in nursing to consider and how a nurse might deal with them:

1. Patient Autonomy vs. Beneficence

Balancing a patient's right to make decisions about their own care with the nurse's duty to promote their overall well-being.

Let's say a patient diagnosed with diabetes refuses to take insulin, despite it being essential for controlling their blood sugar levels and preventing serious complications. 

In dealing with this situation, a nurse should follow the nursing code of ethics and take the following steps:

Respect Autonomy: Respect the patient's right to make decisions about their own care, even if they disagree with those decisions. 

Provide Information: Ensure the patient has accurate and comprehensive information about the treatment, including its benefits, risks, and alternatives. This allows the patient to make an informed decision.

Assess Understanding: Engage the patient in open and non-judgmental communication to assess their understanding of the treatment and the potential consequences of refusing it. 

Collaborative Decision-Making: Engage the patient in collaborative decision-making. Involve them in discussions and explore alternatives that align with their values and preferences. This approach fosters a sense of working together and mutual respect.

Seek Additional Perspectives: If the patient's decision still conflicts with the nurse's professional judgment and poses a significant risk to the patient's health, the nurse should seek guidance from the healthcare team and the nurse manager or supervisor they report to.

Document the Process: Throughout the decision-making process, carefully document all discussions, assessments, and the patient's decisions. This documentation serves as evidence that the nurse has fulfilled their ethical and professional responsibilities.

>> Related: What is Autonomy in Nursing?

2. Confidentiality vs. Duty to Warn 

Struggling with maintaining patient confidentiality while also considering the potential harm to others if vital information is not shared.

Imagine a scenario where a nurse working in a mental health facility becomes aware that a patient with a history of violent behavior has confided in the nurse about their plan to cause harm to their former partner. 

The nurse finds themselves in a challenging ethical dilemma: on one hand, they have a duty to maintain the confidentiality of the patient's personal information, and on the other hand, they have an obligation to protect other people from harm.

To deal with this situation, the nurse should take the following steps:

Evaluate the Severity of the Threat: Carefully assess the level of risk involved in the patient's intentions. Is there an immediate and credible threat to the safety of the potential victim? Consider factors such as the patient's history, current mental state, and access to means for carrying out the harm.

Engage in a Therapeutic Relationship: Explore the underlying issues and reasons behind the patient's harmful intentions. Attempt to address any underlying issues or triggers that may contribute to their behavior and encourage them to seek alternative ways to cope.

Seek Supervision and Consultation: It’s important for the nurse to consult with their supervisor or team members about the appropriate course of action to ensure the safety of the potential victim.

Follow Legal and Ethical Guidelines: Be aware of local laws and regulations regarding the duty to warn or protect. If there is a legal obligation to disclose information in order to prevent harm, the nurse should adhere to those requirements while minimizing the breach of confidentiality to the extent possible.

Document the Process: Document all steps taken, including the patient's disclosure, assessments, consultations, and decisions made. This documentation serves as evidence that the nurse acted ethically, responsibly, and in line with professional standards.

3. End-of-Life Care

Managing the ethical complexities around decisions about withdrawing or withholding life-sustaining treatment, considering the patient's wishes, quality of life, and family dynamics.

For example, consider the situation where a nurse is caring for an elderly patient with a terminal illness. The patient expresses the desire to die a peaceful death without aggressive interventions. However, the patient’s family opposes this and wants “everything medically possible” to be done to save the patient’s life. 

The nurse finds themselves in a complex ethical dilemma, torn between honoring the patient's wishes and respecting the concerns of the family.

Here’s how the nurse might address this situation:

Communication and Education: Engage in open and compassionate communication with both the patient and the family about the patient's medical condition. Discuss the patient’s prognosis, available treatment options, and the potential benefits and downsides of continuing or discontinuing life-sustaining measures. 

Respect for Autonomy: Advocate for the patient's right to self-determination and respect their wishes regarding end-of-life care.

Collaboration and Mediation: Facilitate a respectful and open dialogue, promoting a collaborative decision-making process. The nurse can involve the healthcare team, including palliative care specialists and social workers, to provide support, guidance, and mediation to resolve this situation.

Consider Ethical Decision-Making Frameworks: The nurse should use ethical principles in the nursing code of ethics, such as beneficence, non-maleficence, autonomy, and justice, to analyze the situation and guide their actions. By considering the patient's values, goals, and potential impact on their quality of life, the nurse can advocate for the most ethically appropriate course of action.

Supportive Care: Regardless of the final decision made, the nurse should provide holistic and supportive care to the patient and their family. This includes addressing physical, emotional, and spiritual needs, ensuring optimal comfort, and facilitating open communication to foster a sense of trust and understanding.

4. Resource Allocation

Facing the difficult task of distributing limited resources fairly and ethically among patients, especially during times of scarcity or emergencies.

Consider this scenario: During a severe flu outbreak, a nurse working in a hospital emergency department faces the ethical dilemma of resource allocation. The hospital is overwhelmed with patients and the available resources, such as beds, ventilators, and medications are limited. The nurse must make decisions about which patients receive the resources, balancing the needs of the patients in their care while also considering the needs of other patients in the hospital.

The nurse should manage this situation with fairness and transparency, using the following steps:

Prioritization and Triage: Follow established guidelines and protocols for triaging patients based on the severity of their condition and their likelihood of benefiting from the available resources. This ensures that decisions are made based on clinical needs rather than personal biases.

Open Communication: Maintain open and transparent communication with patients and their families. Explain the challenges faced due to limited resources and the criteria being used for resource allocation. This promotes understanding and trust, even in difficult circumstances.

Collaboration and Consultation: Work collaboratively with the healthcare team, including physicians and hospital administrators, to make informed decisions about resource allocation. Seeking input from multiple perspectives helps ensure fairness and accountability.

Consider Ethical Decision-Making Frameworks: Use the ethical principles of fairness and justice in the nursing code of ethics to guide the nurse’s actions. By considering factors like the potential benefits, risks, and overall impact on patients and the community, the nurse can strive to allocate resources in an equitable and ethical manner.

Advocacy and Support: Advocate for the well-being and rights of their patients, even when difficult decisions must be made. 

5. Informed Consent

Ensuring patients have a clear understanding of the risks, benefits, and alternatives of proposed treatments or procedures before they provide consent.

Here’s an example of how this ethical dilemma could occur: A nurse assists a physician who is rushing to obtain informed consent for a surgical procedure, despite the patient's pain and anxiety. However, the nurse quickly recognizes the patient's limited understanding of the procedure’s implications, raising ethical dilemmas regarding informed consent.

To handle this situation, the nurse should follow these steps:

Ensure Adequate Information: Intervene respectfully but assertively and ask the physician to slow down and provide the patient with complete information about the procedure, risks, benefits, potential outcomes, and available alternatives. 

Clarify Patient Understanding: Speak with the patient and assess their understanding of the information provided. Encourage the patient to ask questions and address any concerns they may have. 

Advocate for Time and Support: If the patient appears overwhelmed or is struggling to comprehend the information, the nurse should advocate for additional time or resources, such as involving a family member or providing educational materials or an interpreter (if appropriate) to support the patient in making an informed decision. 

Document the Process: Document the steps taken to address the concerns related to informed consent. Be sure to include any discussions, explanations provided, patients' questions, and their ultimate decision. Accurate documentation demonstrates the nurse's commitment to upholding ethical standards and professional accountability.

6. Cultural and Religious Beliefs

Navigating conflicts between a patient's cultural or religious values and the standard practices or protocols of healthcare.

In a multicultural society, nurses often encounter ethical dilemmas when a patient's cultural or religious beliefs clash with the standard practices or protocols of healthcare. An example is when a nurse is caring for a patient from a cultural background who strongly believes in traditional healing methods and is hesitant to accept Western medicine.

In this situation, the nurse should have a culturally sensitive discussion with the patient and demonstrate respect for diversity. Here are the steps the nurse should take:

Culturally Competent Assessment: Conduct a culturally competent assessment to understand the patient's cultural and religious beliefs, values, and preferences regarding healthcare. This requires active listening, open-mindedness, and avoiding assumptions or stereotypes.

Establish Trust and Rapport: Build a trusting relationship with the patient by acknowledging and respecting their cultural and religious beliefs. This can be achieved through effective communication, empathy, and demonstrating cultural humility.

Collaborative Decision-Making: Engage the patient and their family in collaborative decision-making regarding their healthcare. Respectfully discuss the patient's beliefs and preferences, and explore opportunities to integrate traditional healing practices with evidence-based Western medicine. 

Consultation and Education: If there are concerns about the patient's well-being or the appropriateness of certain traditional healing methods, the nurse should seek guidance from a cultural consultant, interpreter, or healthcare team. 

Advocacy and Liaison: Serve as an advocate for the patient, ensuring their cultural and religious rights are respected within the healthcare system. This may involve facilitating communication between the patient and healthcare providers, ensuring the provision of culturally competent care, and addressing any cultural or religious barriers that may arise.

7. Impaired Colleague

Grappling with the ethical responsibility of reporting concerns about a colleague's impairment due to substance abuse or mental health issues.

This situation might occur when a nurse becomes aware that a nursing colleague is impaired while on duty. The impaired nurse exhibits erratic behavior and smells strongly of alcohol. The nurse who witnesses this behavior finds themselves in a challenging ethical dilemma, torn between their duty to ensure patient safety and their loyalty to their colleague.

Nevertheless, the nurse needs to prioritize patient safety and act professionally by following these steps:

Immediate Concern for Patient Safety: The nurse's primary responsibility is to ensure the safety and well-being of patients. If they observe signs of impairment in their colleague that could compromise patient safety, they should take immediate action.

Reporting: The nurse should report their observations and concerns to the appropriate authority within the healthcare facility, such as the nurse manager or supervisor. This report should be made objectively without personal judgments or assumptions and with a focus on patient safety.

Confidentiality and Professionalism: Maintain confidentiality throughout the reporting process, being mindful not to disclose personal details of the impaired colleague unless necessary for the investigation.

Collaboration and Support: Collaborate with the healthcare team and support the impaired colleague's well-being by encouraging them to seek appropriate help and support, such as employee assistance programs or counseling services. 

Ethical Obligation: Nurses have an ethical obligation to protect the welfare of patients and maintain the standards of the nursing profession. This includes recognizing and addressing impairment issues among colleagues to ensure safe and quality care.

8. Professional Boundaries

Striking a balance between providing compassionate care and maintaining appropriate professional boundaries, particularly when it comes to personal relationships with patients.

In this example, let’s look at a scenario where a nurse develops a close friendship with a patient and begins sharing too many personal details about their own life unrelated to the patient’s healthcare needs.

When the nurse realizes what’s happening, they need to prioritize maintaining professional boundaries and act in the best interest of the patient by following these steps:

Recognize the Boundary Issue: Use personal reflection to recognize when professional boundaries are being crossed or compromised. Acknowledging this ethical dilemma is the first step toward resolving it.

Reflect on the Nurse-Patient Relationship: The nurse should remind themselves of their professional role, the duty of care, and the need to maintain objectivity and professional distance.

Reestablish Boundaries: Take appropriate actions to reestablish and reinforce professional boundaries with the patient. This may involve redirecting conversations back to the patient's healthcare needs, avoiding personal disclosures, and focusing on the patient's well-being.

Seek Guidance and Supervision: If the situation becomes challenging to resolve alone, the nurse should seek help from a supervisor, nurse manager, or experienced nursing team member. Consulting with experienced professionals can provide valuable insights and support in addressing this ethical dilemma.

Continuous Professional Development: Engage in ongoing professional development and education regarding nursing ethics and setting professional boundaries. Staying current on ethical guidelines and participating in discussions and training on maintaining professional boundaries can help prevent future boundary issues with patients.

9. Whistleblowing

Facing the ethical dilemma of reporting concerns about wrongdoing or unethical practices within the healthcare system, despite potential professional and personal repercussions.

An example of whistleblowing would be when a nurse becomes aware that a colleague is stealing controlled substances from the medication supply. The nurse decides to report this to their supervisor because it compromises patient safety and violates professional and legal standards. However, the nurse is worried about their colleague being disciplined and possibly losing their license.

Here are the steps the nurse should follow:

Gather Evidence: Collect factual evidence such as documentation discrepancies in medication records, witnessing the colleague's actions, or capturing any other supporting documentation. 

Consult with Colleagues: Seek advice from trusted colleagues, supervisors, or mentors within the healthcare organization. Discuss the situation and determine the best course of action. It’s important to maintain confidentiality during these discussions to protect both the patient and the nurse making the report.

Follow the Proper Chain of Command: Follow the established reporting channels within their healthcare organization. This typically involves reporting concerns to a supervisor, nurse manager, or a designated ethics or compliance hotline. Ensure that the report is made in writing and contains all relevant details and evidence.

Protection and Confidentiality: Be familiar with the whistleblower protection policies and laws in their jurisdiction. The nurse should ensure that their report is treated confidentially and that appropriate steps are taken to protect them from retaliation.

Documentation: Keep a detailed record of all actions taken, including the date and time of the incident, any conversations or consultations, and copies of the report submitted. This documentation helps demonstrate the nurse's commitment to reporting and acting in accordance with professional and ethical standards.

10. Ethical Use of Technology

Considering the ethical implications of using technology in healthcare, such as maintaining patient privacy and security, avoiding biases in algorithms, and ensuring equitable access to care.

An example of this ethical dilemma could occur when a nurse becomes concerned about potential biases in an algorithm and decides to report this to her supervisor. She recognizes that an algorithm where she works may disproportionately allocate resources based on patient factors such as age, race, and gender, resulting in inequitable access to care.

The nurse should advocate for equitable care by taking these steps:

Investigate and Evaluate: Become familiar with the AI algorithm being used and investigate its development process. Assess whether the algorithm has been validated and tested for biases and fairness. 

Raise Concerns: If the nurse identifies biases or inequities in the algorithm, they should communicate their concerns to the appropriate individuals, such as nurse leaders, healthcare administrators, or the technology implementation team. 

Collaborate for Improvement: Engage in collaborative discussions with the healthcare team, including the nursing supervisor, IT specialists, and data scientists. Work with the team to develop strategies to eliminate biases and ensure equitable use of the technology for all patients.

Promote Patient Advocacy: Advocate for the rights and well-being of the patients who may be affected by the technology. This involves ensuring informed consent and transparency regarding the use of AI algorithms. Patients should have the opportunity to understand and discuss the potential biases and their impact on their care.

Continuous Evaluation: Advocate for ongoing evaluation and monitoring of all AI technology being used in patient care to identify and resolve biases or unintended consequences. 

Ethical dilemmas are common in nursing and can be difficult to deal with. But you don’t have to make the decisions about these issues alone. Seek out the support and input of your nursing colleagues, supervisor, or nurse manager. By doing so, you will feel more comfortable and confident about how to handle the ethical dilemma you find yourself in.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Leona Werezak BSN, MN, RN is the Director of Business Development at NCLEX Education. She began her nursing career in a small rural hospital in northern Canada where she worked as a new staff nurse doing everything from helping deliver babies to medevacing critically ill patients. Learning much from her patients and colleagues at the bedside for 15 years, she also taught in baccalaureate nursing programs for almost 20 years as a nursing adjunct faculty member (yes! Some of those years she did both!). As a freelance writer online, she writes content for nursing schools and colleges, healthcare and medical businesses, as well as various nursing sites.

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Ethical Issues in Nursing: Explanations & Solutions

June 5, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

Ethical issues happen when choices need to be made, the answers may not be clear and the options are not ideal. The result could be declines in the quality of patient care; problematic clinical relationships; and moral distress, which is defined as knowing the right thing to do but not being allowed or able to do it. Nurse managers, in particular, are susceptible to ethical issues in nursing and moral distress because of their leadership and mentoring roles. Nurses and other medical staff look to nurse managers for appropriate and ethical decisions.

Before stepping into a role as a nurse manager, registered nurses (RNs) should understand the role ethical decision-making plays in the day-to-day work. Through Duquesne University’s Master of Science in Nursing program, students explore the foundations of ethical management and leadership from professors with real-world experience. The coursework not only covers the fundamentals of ethical nursing but delves deep into controversial case studies, giving students the chance to examine alternative viewpoints and develop reasoning skills.

For nurse managers, ethical decision-making stems from the American Nurses Association Code of Ethics, which was developed as a guideline for nursing responsibilities “in a manner consistent with quality in nursing care and the ethical obligations of the profession.” Nurse managers help solve ethical issues in nursing through using their leadership qualities to implement the Code of Ethics in their daily lives.

Nurses’ Code of Ethics

ANA adopted its first Code of Ethics in 1950. Since then, it has undergone several revisions to offset advances and changes in research, technology, law and overall challenges in nursing. The guidelines are divided into nine provisions that cover topics that include human dignity, confidentiality, moral virtue and healthcare as a right. ANA said that each of the provisions covers topics important to the challenges of nursing in the 21st century.

“The code is particularly useful in today’s healthcare environment because it reiterates the fundamental values and commitments of the nurse, identifies the boundaries of duty and loyalty and describes the duties of the nurse that extend beyond individual patient encounters,” ANA said in a statement.

Daily, nurse managers face a barrage of decisions and must maintain ethical fortitude to ensure the health, safety and well-being of their patients and staff. They actively work toward resolving ethical issues in nursing that they find in their workplace.

Examples of Ethical Dilemmas in Nursing

The ANA Code of Ethics provides a standard by which nurse managers can assess ethical issues in nursing. However, the way it addresses ethical dilemmas can vary in different situations. One ethical dilemma that can occur in healthcare facilities is when nurses themselves are not properly equipped to complete their duties. Nurses who notice their coworker’s lack of knowledge face an ethical dilemma of whether they should bring the issue to their nurse manager. To help curb this ethical dilemma, nurse managers can work hard to educate their nurses regarding the Code of Ethics as well as educate them regarding the Code of Ethics for their specific medical facility. Nurse managers can also provide regular trainings for their nurses regarding recurring issues.

One example of a common ethical dilemma nurses deal with is establishing boundaries with patients. Nurses and nurse managers devote their careers to helping patients receive the care they need, so it can often be difficult to establish professional boundaries. Patients should not rely on nurses beyond their professional capacity and should not develop romantic relationships with them or offer them gifts. Nurse managers can intervene in situations where ethical and professional boundaries are crossed by either patients or nurses.

Another ethical issue in nursing pertains to patient privacy. Nurses and nurse managers have access to a patient’s records and medical history and cannot ethically or legally release that information to anyone besides the patient. Nurses should have the best interest of patients in mind, understanding that they need to protect their privacy and medical data.

Common Ethical Situations for Nurse Managers and Nursing Ethics Examples

Even though nursing is a fast-paced job with new challenges daily, many nurse managers report facing similar ethical dilemmas. A recent study found that the most frequently occurring and stressful ethical situations are protecting patients’ rights, staffing, advanced care planning and decision-making. Exacerbating the problem is the large number of inexperienced nurses entering the field, many who have never faced ethical issues in nursing. Such challenges make experienced nurse managers all the more critical to daily healthcare needs nationwide.

The following are some other examples of common ethical situations that nurse managers face:

• Honesty vs. withholding information. Family members may want to withhold medical information from sick patients to protect their emotions. However, patients have the right to know about their medical conditions. Deciding how to share this information, especially if it goes against the family’s beliefs, can be a touchy situation. ANA advocates for truth telling, or veracity, as a key factor in nurse-patient relationships.
• Science vs. spirituality. Healthcare, which is science-based and results driven, can impede religious or personal beliefs. Some religions restrict medical interventions and lifesaving techniques. Nurses focus on providing medical care to reduce suffering and to allow patients to concentrate on self-care. For patients or their families with strong religious or spiritual convictions, the focus may be on adhering to a strict set of guidelines. The ANA Code of Ethics states that nurses should respect the “unique differences of the patient,” including “lifestyle, value system, and religious beliefs.” However, respect for the belief “does not imply that the nurse condones those beliefs or practices on a personal level.”
• Healthcare needs vs. resource allocation. The rising cost of healthcare is increasingly putting nurse managers at odds with budgeting constraints and patient needs. A large number of medical facilities have scarce resources, which puts patients at risk for not getting the care they need. These resources range from medical equipment to healthcare staff. Research suggests that nurse leaders must include staff in the budgeting process so that they can better understand the needs and demands.
• Autonomy vs. beneficence. Nurses are required to administer prescribed medicine, but patients, at the same time, can refuse them. Patient autonomy can go against medical directives, despite clearly defined needs. Patients have a right to refuse all medical care. ANA highlights that it is important for nurses and nurse managers to understand patient backgrounds and individual circumstances to inform the patient of the medical necessity. ANA explains: “Using ethical principles to arrive at a solution should be done in an atmosphere of caring, respect, openness, and honesty. This process should be based on a sound ethical, decision-making model, using the best evidence-based-practice guidelines available.”

How to Deal With Ethical Dilemmas in Nursing

Nurses undergo many years of education and clinical training before they can become certified nurses, and yet, dealing with real ethical issues in nursing can be far more complex than solving hypothetical issues in textbooks. Nurses can learn how to deal with ethical dilemmas in the workplace through gaining experience and interacting with patients over time. Although nurses have great levels of empathy, it can benefit them to establish professional boundaries with each of their patients at the outset of their careers. Whenever nurses struggle to identify whether something is ethical, they can review the ANA Code of Ethics.

Nurses can also benefit by surrounding themselves with well-seasoned nurses as well as experienced nurse managers. They can rely on the guidance of nurse managers when it comes to situations they may not know how to address. Nurse managers can cultivate educational environments, in which they regularly discuss ethical issues with the nurses in their units. By having open dialogues about ethical issues, nurses can learn from the mistakes others have made and learn how to approach ethical issues and challenges.

Help Avoid Ethical Dilemmas in Nursing

The Duquesne University School of Nursing’s MSN program integrates ethical problem-solving and decision-making to help MSN graduates explore and address ethical issues. Students in each of Duquesne University’s MSN tracks — Adult-Gerontology Acute Care Nurse Practitioner, Family (Individual Across the Lifespan) Nurse Practitioner, Psychiatric-Mental Health Nurse Practitioner, Executive Nurse Leadership and Health Care Management, Forensic Nursing and Nursing Education and Faculty Role — learn how ethics and problem-solving play distinct roles in nursing.

U.S. News & World Report ranked Duquesne University’s online MSN program among the Best Online Graduate Nursing Programs in 2017. If you are interested in advancing your career as a nurse manager, explore how Duquesne University’s Master of Science in Nursing program can help you pursue your professional goals and help you avoid ethical issues in nursing.

Recommended Readings

Family Nurse Practitioners and Professional Liability Insurance

Importance of Nurse Manager Resilience

Using Escape Rooms for Nurse Education

American Nurses Association, View the Code of Ethics for Nurses 

Houston Chronicle , “Legal & Ethical Issues That Health Care Professionals Face” 

Lippincott Solutions, Best Practices for Ethical Nursing Leadership 

Medical Records Info, Top 10 Most Prevalent Ethical Issues in Nursing 

National Center for Biotechnology Information, “Ethical Problems in Nursing Management —A Cross-Sectional Survey About Solving Problems” 

NurseChoice, “4 Common Nursing Ethics Dilemmas” 

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Ethical Decision Making

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#37074: Ethical Decision Making

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Nurse P is a staff nurse in the coronary care unit of a large medical center. One morning he is informed that a patient from the recovery room will soon be admitted to the coronary care unit and assigned to him. The patient, a white man, 67 years of age, with known history of myocardial infarction, also has cancer of the prostate. The initial hospital admission was for a transurethral resection, which had been aborted in the operating room when the patient developed cardiac changes following spinal anesthesia. The patient had been transported to the recovery room with the diagnosis of possible myocardial infarction and was to be transferred to the coronary care unit for management and evaluation.

Nurse P heads to the recovery room with a bed to pick up the patient. When he arrives, the patient is being coded. He had apparently gone into ventricular tachycardia/ventricular fibrillation in the recovery room and had required countershock, cardiopulmonary resuscitation (CPR), intubation, lidocaine, and vasopressors to maintain his blood pressure. A Swan-Ganz catheter was put in place. Recovery rhythm was sinus bradycardia to sinus tachycardia with occasional pauses. The patient was acidotic, in pulmonary edema by chest x-ray with an alveolar oxygen partial pressure (PaO 2 ) of 50–60 mm Hg, a fraction of inspired oxygen (FIO 2 ) of 100%.

During the events of the code, an attending cardiologist (Dr. D) passed by, observed the code, and made the following statement to the recovery room staff and coronary care unit resident: "Say, that's Mr. S. I know him from his last hospitalization of 1 month ago when I was attending in coronary care unit. I believe he has a living will." While the patient is stabilized, Dr. D calls the patient's relative, who happens to work in another part of the medical center. The relative also expresses the belief that Mr. S has a living will and does not want to receive extraordinary support measures. Dr. D relays this information to the other physicians, and there is general agreement that conservative measures to ensure support are indicated while the living will is located.

The coronary care unit resident and Nurse P transport Mr. S to the coronary care unit. When admitted, the patient's systolic blood pressure is 70 mm Hg while on dobutamine 8 mcg/kg and dopamine 26 mcg/kg. The patient occasionally responds to verbal commands, opens his eyes, grips Nurse P's hands, and responds to pain in the upper extremities (his lower extremities are still under the effects of the spinal anesthesia). Cardiac monitoring shows that the patient is still having sinus tachycardia.

At this point, the coronary care unit resident and an intern approach Nurse P and inform him that they believe that the present treatment of the patient is cruel. Upon locating old medical records, they learned that the patient had been designated "do not resuscitate" (DNR) on his last admission, and the patient is supposed to have a living will, although it has still not yet been located. They order Nurse P to slowly turn off the intravenous (IV) drip of dopamine and dobutamine. Nurse P is faced with an ethical dilemma.

Rationale and Comments

The treatment modalities in Mr. S's treatment plan were basic: IV therapy, medication, and oxygen support. Some people might say the hospital team missed its chance when it failed to act decisively when it might have omitted the resuscitation of this patient. The IV, medication, and oxygen support may have been seen as obligatory for the patient and as supportive care.

Two reasons for this position might be offered. First, it might be argued that aggressive resuscitation is extraordinary, whereas an IV drip is ordinary. Another question might be whether the patient saw the IV as serving a purpose any more than the CPR served. Second, the difference between the CPR omission and stopping the IV drip is that one is an omission and the other would be a withdrawal. This raises the question of whether there is a difference between the two. Maintaining such a distinction might incline caregivers to be reluctant to start treatments such as an IV drip. Defenders of the view that there is no legitimate moral difference, believe that it is better to start a treatment when there is doubt about the correctness of the course and then withdraw if the time comes when it is clear that the patient would not have wanted the treatment to continue.

Here, however, Nurse P is being told by a resident and intern to turn off the IV drip on the basis of an unconfirmed belief that the patient has a living will and the fact that he reportedly had been designated for nonresuscitation on his last hospital admission. Nurse P must face the question of whether that is sufficient reason to stop the treatment even with the apparent approval of Mr. S's relative.

It is likely that the next of kin's judgment would be sufficient in the case where the patient's wishes cannot be determined, but that does not seem to lead to a clear answer here. First, we are not sure if the relative is Mr. S's next of kin. Moreover, even if it is, it seems possible that Mr. S has expressed his own wishes, and those wishes would surely take precedence. While the assumption is that he has a living will, no one seems to know exactly what it says. Some living wills are written for the purpose of insisting that treatment continue. The other possibility is that the living will could have been changed or voided by the patient between hospitalizations. Therefore, any action based on assumptions is taking considerable liberty. Also, any previous DNR order during another hospitalization would not be in effect for the present hospitalization. Again, there is the danger of paternal decision making by physicians and others for the patient [33] .

More prudent action here must be considered in the light of the PSDA. Because a living will is thought to exist and a relative was found, no withdrawal in the treatment of Mr. S should occur. The following would be a reasonable and prudent decision making process on behalf of the patient, Mr. S: (1) the living will document should be obtained (there should have been a copy from the last hospitalization, or perhaps in the possession of other family members or with the primary care physician's office); (2) relatives should be notified, and those, by law and policy of the hospital, could consent for continuation or removal of treatment modalities in the absence of an advance directive; and (3) consideration of the patient's wishes and witnessed comments and conversations in the past regarding healthcare decisions to be made for him under specific circumstances should be ascertained, in the absence of an advance directive.

Every situation that presents itself may be different, but ethical decision making based on a framework of ethical theories can provide the nurse with useful means for resolving ethical dilemmas in patient care.

What happens when, for example, patients are unable to make decisions for any reason? A blending of theoretical ethical systems and principles and a practical framework on which the healthcare professional can help patients and their families make healthcare choices is our next area for discussion.

Patient M, a woman, 34 years of age, is in critical condition and is scheduled for emergency surgery following a severe motor vehicle accident. You have been informed that her two children have been killed in the crash. She is almost hysterical and is asking you repeatedly about the condition of her children as you prepare her for emergency surgery. Do you tell the mother the truth about her children at this time or wait until after the surgery?

The ethical principles involved are beneficence and veracity (i.e., doing what is in your patient's best interest and telling the truth) and to a certain extent non-maleficence. This is an emotional issue, as most ethical dilemmas are, so be careful not to get into the "what if" trap (e.g., "What if Patient M were not in a critical condition, but was still facing surgery," or, "What if this woman was a close friend or family member?"). Remain as objective as possible when gathering facts and assessing the information and do not let emotions cause altered behavior.

Other considerations are personal values. Telling the truth is a concept that varies substantially between individuals. Personal views on absolute versus situational ethical reasoning will also affect the decision-making process and, perhaps, the definition of and decision-making use of the veracity principle. It is also very important to remember that there are other healthcare professionals to assist in the dilemma and help make a collaborative decision.

The other major consideration is knowing your hospital's policies in regard to deciding ethical issues. The groundwork should be there for you, and you should be familiar with it. If your workplace does not have policies that address making ethical decisions, you may want to refer to the suggested Guidelines for Ethical Decision Making in Patient Care, included later in this course. It may be helpful for your use and can be adapted to fit your institution.

CASE STUDY 1: AN INTOXICATED PATIENT

Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead. The patient presents to the emergency department alert and oriented without significant findings other than the 10-cm laceration. However, his speech is slurred, and he readily admits to drinking 10 beers during the last few hours. The emergency department is very busy with more urgent cases, and the patient becomes impatient because of the wait. Patient J wishes to leave but is urged by the ED staff to wait and is told that he should not drive. He is clearly lucid and states that he will not wait any longer and intends to drive himself home.

Using the acronym R.O.L.E. as their framework, note that the authors identify the same decision-making issues as the framework and algorithm examples discussed in this course.

R: Risks of medical treatment . In this case the proposed treatment bears little risk to the patient. Few people have life-threatening complications from laceration repair; therefore, the chance of the patient experiencing untoward harm from the procedure is remote.

O: Opinion of the patient . Why does the patient want to leave the emergency department? Does he understand the risks and benefits of the procedure? Is he competent to make this decision in his intoxicated state?

L: Life quality . Will not having the laceration repaired significantly affect the patient's quality of life? Would an unsutured wound healing for an extended period affect the patient in his profession and render him unable to earn a living? For example, would he be unable to wear required safety equipment, such as a helmet or goggles, because of the laceration? Is the patient involved in a profession, such as acting, where a potentially disfiguring scar could affect his career?

E: External factors . Is there any obligation on the part of the healthcare team to third parties (i.e., those who may be traveling at the same time as the patient and who may be endangered from a safety standpoint)?

The conflict in this case is between the patient's right to autonomy and self-determination and the staff's concern for his well-being and the safety of others. From both a legal and ethical standpoint, competent adults have the right to decide whether they will accept medical treatment. This right relates to the ethical principle of autonomy and the legal doctrine of informed consent.

In their professional education, nurses and physicians are frequently taught to apply very strict standards in the determination of patient capacity or the ability to make decisions. There is not allowance for medicated patients to sign consent forms, and frequently, it is assumed that developmentally disabled, intoxicated, and critically ill patients lack the capacity for decision making. In the emergency setting, in particular, there is a bias toward intervention and treatment if there is any doubt about patient capacity.

However, none of the above conditions negates the patient's ability to make responsible healthcare decisions. From an ethical standpoint, the patient is a capable decision maker if:

The patient can understand information relevant to the decision at hand.

The patient can interact and communicate with caregivers about the decision.

The patient can weigh the possible alternatives.

Given these guidelines, Patient J was clearly capable of refusing medical treatment, despite the feelings of the ED staff about the necessity of suturing the wound.

But what about the third parties who may be affected by Patient J's decision to drive while intoxicated? Do the healthcare professionals have a duty to prevent him from driving? In instances such as these, care providers must remember that their first duty is to the patient. A decision to violate patient confidentiality or to detain the patient against his will automatically places the caregivers in a position that may require justification of actions. If the patient is clearly too intoxicated to drive, a prudent course of action would be to document that the patient was asked to stay and that he was advised that if he chose to leave, his license plate number would be given to the police. Always check the policies and procedures, guidelines, and protocols in your facility to see what resources and assistance you have in these situations.

CASE STUDY 2: A SUSPECTED CASE OF CHILD ABUSE

(From the book Leadership Roles and Management Functions in Nursing: Theory and Application , in a chapter entitled "Ethical Issues" [45] .)

You are a nurse on a pediatric unit. One of your patients is a girl, 15 months of age, with a diagnosis of failure to thrive. The mother has stated that the child appears emotional, cries a lot, and does not like to be held. You have been taking care of the infant for the two days since her admission, and she has smiled and laughed and held out her arms to everyone. She has eaten well.

There is something about the child's reaction to the mother's boyfriend that bothers you. The child appears to draw away from him when he visits. The mother is very young and seems to be rather immature but appears to care for the child.

This is the second hospital admission for this child. Although you were not on duty for the first admission six weeks ago, you check the records and see that the child was admitted with the same diagnosis. While you are on duty today, the child's father calls and inquires about her condition. He lives several hundred miles away and requests that the child be hospitalized until the weekend (it is Wednesday) so that he can "check things out." He tells you that he feels the child is mistreated. He says he is also concerned about his ex-wife's four-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child. From what little the father said, you are aware that the divorce was very bitter and that the mother has full custody.

You talk with the physician at length. He says that after the last hospitalization he requested that the community health agency call on the family. Their subsequent report to him was that the 4-year-old appeared happy and well and that the 15-month-old appeared clean, although underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children. He says the mother has been good about keeping doctor appointments and has kept the children's immunizations up to date.

The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified and the state medical aid will not pay for the additional days.

When the mother and her boyfriend come to pick her up, the baby clings to you and refuses to go to the boyfriend. She is also very reluctant to go to the mother. All during the discharge you are extremely uneasy. When you see the car drive away, you feel very sad. What should you do?

Upon returning to the unit, you talk with your supervisor, who listens carefully and questions you at length. Finally, she says, "It seems as if you have nothing concrete to act upon and are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do."

You leave the supervisor's office still troubled. She did not tell you that you must do nothing, but you feel she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses. Perhaps the disgruntled ex-husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. He often looked like an abused child. You go about your duties and try to shake off your feeling.

If the pediatrician had not yet alerted the community health nurses or another child welfare agency, this option might have been taken by the nurse. She had reasonable suspicion given the child's reaction, underweight condition and ex-husband's concern. A call would not have been inappropriate. However, this action had already been taken. The child had no other signs that she was an abused child or that she was in danger of being abused. The nurse in this situation was going on strong feelings, but little evidence.

CASE STUDY 3: THE STUDENT NURSE PERFORMING UNSAFE PRACTICE

From the Journal of Nursing Administration , we find a case to study regarding the public and professional responsibility of hospitals [46] . Hospitals throughout the country are held in high esteem within their communities for public service. They earn the public's trust by providing safe, good quality patient care. Many community hospitals serve as teaching sites for students' practicum programs, as did the hospital in this case study. Health facilities also have an obligation to share the responsibility for the quality of the nursing program by providing practice sites and nursing role models. In the case presented, the hospital should have been more proactive in addressing the quality of this practice issue.

MW is a senior nursing student at a local university. The university's nursing program requires a 200-hour practicum be completed six weeks before graduation. MW chose the intensive care unit (ICU) at a community hospital for her practicum site. MW contracted with one of the ICU staff nurses to serve as her preceptor for the six-week time period. The nurse preceptor is responsible for assisting MW to meet the course objectives. MW, the nurse preceptor, and the nursing instructor met before the practicum to discuss course objectives and expectations.

During the six weeks, MW was assigned to work the same schedule as the nurse preceptor, which was the night shift. Within the first week, the nurse preceptor reported to the ICU nurse manager that MW had displayed some inappropriate behaviors. These behaviors included inappropriate dress for work, an arrogant attitude toward the staff nurses, and considerable discussion about the amount of money MW would make as a nurse. The nurse manager and nurse preceptor discussed these issues with MW, and the behaviors improved somewhat.

By the end of the second week, the nurse preceptor reported another disturbing incident to the nurse manager. During the previous shift, MW and the nurse preceptor cared for a peritoneal dialysis patient. The nurse had explained the dialysis process to MW, and MW assisted with some of the procedure. After one of the dialysis exchanges, MW was instructed to empty and measure the dialysate output. Under the nurse preceptor's supervision, MW completed this procedure. MW and the nurse preceptor concurred that the amount of fluid removed from the patient was 1,400 cc. MW was given the responsibility of recording the amount on the dialysis flow record.

At the end of the shift, when intake and output was being calculated, the nurse preceptor noticed that the amount of dialysate fluid recorded by MW was 1,000 cc. When questioned about the discrepancy, MW responded that the recorded 1,000 cc amount was similar to the amounts recorded by other nurses. The nurse preceptor explained that the dialysate had been changed for the purpose of removing more fluid; thus, a greater amount of dialysate output was desired and expected from this dialysis exchange. MW stated that she did not want her recorded amount to be dramatically different from other recorded amounts. The nurse preceptor reinforced the reasoning behind the dialysis orders and that the actual amount removed is what needed to be recorded. When MW did not correct the dialysis flow record, the nurse preceptor recorded the actual dialysate output.

The nurse manager documented the incident and contacted the nursing instructor. The nurse manager informed the nursing instructor that MW's practicum in the ICU was terminated, and she would not be allowed to return to the ICU. The nurse manager requested that the incident be reviewed by the university's nursing program before MW continued the program.

The nursing instructor discussed the incident with MW. Later, the nursing instructor told the ICU nurse manager: "The incident does not appear to be serious. MW is completing her practicum requirement at another hospital and is doing great. She will be graduating with her class." Following this conversation, the ICU nurse manager discussed the incident with the hospital's director of nursing and sent a letter to the dean of nursing at the university documenting her concerns about MW's performance. The nurse manager never received a response to this letter. MW went on to another ICU clinical site to continue her practicum. When the nurse manager at the new facility was alerted to the previous incident, she monitored MW closely. She and the charge nurse of the ICU unit found similar inaccuracies in documentation. Further, documentation was made for vital signs by MW. However, she was observed during one shift to have not taken a blood pressure cuff or thermometer into any of her patient rooms. When the charge nurse took her own vital signs on the patients, none matched the documentation of MW.

When approached, MW indicated that "vital signs don't change much in four hours and probably don't need to be monitored that often." When questioned about the vital signs she had recorded, MW stated, "I don't want my charting to stand out and be different. None of my patients have been harmed, so I don't see what the problem is." MW was terminated from this practicum site as well and told she could not apply for a position there after graduation.

The ethical decision-making model outlined in this course can be helpful.

First, name the dilemma. The nurse is violating several ethical principles in this situation: beneficence, the duty to do good; non-maleficence, the duty to cause no harm; veracity, the duty to tell the truth; and respect for persons, the duty to honor the responsibilities of her position and to care for patients without bias, in this case, without regard for how she imagines she will be perceived.

Second, sort the issues. MW is displaying both unethical and illegal behaviors. She is falsifying patient information and potentially endangering her patients while disregarding her responsibilities. The nurse has shown that she values fitting-in over gathering accurate patient information.

Third, solve the problem. Ethical considerations and recommendations would include the reporting by the hospital to the school of nursing. The hospital should formally address concerns to the division director, dean of the school of nursing, and/or the governing board and request a written follow-up on the findings and actions of the investigation. The hospital should also investigate its State Nursing Practice Act and regulations relative to the governance of a student nurse's role. The hospital should obtain an understanding of the responsibility and accountability of the nursing faculty as well as the hospital's and staff nurse's role in this incident. The hospital should then seek and follow the advice of the State Board of Nurse Examiners. Specific actions to withhold the student's prospective licensure should not be sought unless required by the State Nursing Practice Act.

Fourth, take action. The hospital has an ethical responsibility to review the case in whatever forum its policy specifies. In many organizations, the hospital nursing leadership group is the forum. After the problem has been identified and reviewed with the individual, a probationary period should be given for the student's performance to improve. In this case, MW was counseled by the nurse preceptor in the first ICU practicum site. The school should have used the second practicum site as the probationary review. This was not done. Only the clinical nurses were aware of MW's move to another unit, and they began to evaluate her performance there. The school should have been a part of the process. Because this practice standard violation involved a student, a member of the school's faculty was included in the review. During the practice review process, the name of the individual must be disclosed and a determination made whether the practice violation is serious enough to warrant the student's suspension from clinical practice pending a complete investigation. Whatever the outcome, the contractual agreement between the hospital and the school should be reviewed to clarify guidelines. The decision makers must choose which course of action they feel best meets the particular situation and implement. Given the circumstances in this instance, termination of employment was deemed to be the most appropriate course of action.

Fifth, evaluate and reflect on the action. Time must be taken in re-evaluating with all parties involved how the decision-making process was handled. One question to be asked by the reviewers is: "Given what we know now, would we make the same decision today that we made then?" In this particular case scenario, and in any similar to it, as professionals, nurses have an obligation to act truthfully and to protect the patients (veracity and beneficence). Nurse leaders have an obligation to investigate practice concern and take the appropriate steps to correct practice problems of any nursing employee or student. This decision is absolutely justifiable.

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Case Study – A Multidisciplinary Healthcare Team Disagrees

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• The Maryland Nurse Maryland February 2016 issue is now available.

Case Study in Nursing Ethics Human Rights and Human Dignity

This article appears on page 4 of

The Maryland Nurse Maryland February 2016

Patients trust that by virtue of being a patient, a nurse is providing unconditional care to them. This is especially true for incapacitated patients who are unable to self-advocate for appropriate and empathetic care. However, ethical conflicts can arise for nurses caring for incapacitated patients because these patients cannot make their wishes known or participate in their own care. Nurses find themselves in positions to make decisions for patients that often challenge the ability of the nurse to maintain patient dignity while protecting the patient from harm. One example of this is the decision to use sedation as restraint for incapacitated patients with agitation. While this makes sense clinically, it can challenge the ethical framework of nursing care. This case study illustrates the importance of knowing how to apply the Code of Ethics for Nurses to these difficult situations.

As professional nurses, we make decisions that may affect the very human “being” of the patients for whom we provide care. Being human is inherent; it just “is.” The Code of Ethics for Nurses begins by informing nurses that human dignity is inherent also. “All persons should be treated with respect simply because they are persons” (ANA American Nurses Association, 2015, p. 45).

Provision 1 states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).

Provision 1 establishes the fundamental premise for the ethical delivery of all nursing care and is based on human rights, the fundamental freedoms that all persons are entitled to because they are human (ANA American Nurses Association, 2015, p. 45). Delivering ethical nursing care in a complex health care environment is not always clear. Situations occur that result in ethical conflict when it is difficult to determine or perform the right course of action. Nurses must be aware of the significance of human rights in order to provide ethical nursing care and advocate for the rights of patients in these situations. The risk of ethical conflict exists when patients cannot make their own decisions or assert their rights. They are vulnerable to violations of these rights (Center for Ethics and Human Rights, 2010). A study that explored nurse leaders’ identification of risk factors that lead to complex ethical situations included patients with altered capacity as a contributing risk factor to nurses’ ethical conflicts (Pavlish, Brown-Saltzman, So, Heers, & Iorillo, 2015).

The purpose of this article is to examine an example of a complex situation that involves the use of sedation as a restraint in an incapacitated patient, identify the ethical conflicts, and show how the code of nurses guides the nurse in everyday practice. The case is a compilation of events and patients experienced over years of nursing in diverse environments. Many nurses can relate to similar situations in their practice.

Case Study Mrs. Smith is an incapacitated patient admitted to the hospital with confusion and weakness. Her diagnosis is pneumonia, complicated by end stage cirrhosis and an elevated ammonia level. During the previous shift, Mrs. Smith became physically aggressive, confused, and uncooperative. She fell but had no injury. Staff was not able to console or manage her behavior and obtained orders to sedate her. After multiple doses of sedation, Mrs. Smith is resting but heavily sedated. Now some nurses’ advocate for continued sedation throughout the night for behavioral control. Others advocate for continued sedation to prevent another fall. What is the dilemma? The Code of Ethics asserts the need to balance patient dignity with sedation.

Conflict with Provision 1 “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).

According to the ANA position statement on restraints, “Restraining or secluding patients either directly or indirectly is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient or resident” (Center for Ethics and Human Rights, 2012).

It is important to understand that sedation is a chemical restraint when it used to restrict or manage the patient’s behavior or to restrict their freedom of movement, and when it is not a standard medication or dose for care of the patient’s condition. Chemical or (physical restraints) can lead to incontinence, pressure ulcers, pneumonia, muscle weakness, and other health issues (Center for Ethics and Human Rights, 2012). This is not in the patient’s best interest and will lead to other health declines over time.

Conflict with Provision 2 “The nurses primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA American Nurses Association, 2015, p. 5).

Administering sedation as a restraint to control behavior is in conflict with nurses’ ethical responsibility of beneficence and nonmaleficence to the patient. In its position statement on restraints, the ANA recognizes that nurses may face pressure from peers to use restraints (Center for Ethics and Human Rights, 2012). However, these intentions may not be in the interest of the patient. The nurse’s primary focus is the patient. Provision 2 states this and reflects upon Provision 1 as it explains that each plan of care must reflect the fundamental commitment of nursing to the uniqueness, worth, and dignity of the patient (ANA American Nurses Association, 2015).

How the Code Directs Nursing Care Nurses assume a great amount of responsibility when providing care to incapacitated patients. There can be conflict between doing what is right and good for the patient while avoiding harm. It is not appropriate to administer sedation for convenience.

However, should nurses sedate a patient to prevent another fall? In this case, study falls prevention interventions are in place as per policy, except for an option of assigning one to one observation to this patient because staff is not available. The conflict is now between the responsibility to keep the patient safe or using a practice such as sedation that is not safe. How should a nurse make the decision and know they have done the right thing? Follow the guidance provided in Code of Ethics for Nurses Provision 2, begin to think of the care plan for the patient who is confused, agitated, and at risk for falls.

Implementation of Ethical Nursing Care Recognizing uncertainty in a course of action is the first step in providing ethical nursing care. Imagine yourself as the nurse caring for Mrs. Smith. Begin by following the nursing process. Your nursing assessment finds her asleep, vital signs are with in parameters, and she has loud snoring respirations. She arouses to gentle shaking and answers simple questions. She is agitated during the assessment but cannot keep her eyes open. She intermittently follows commands with heavy limbs. She remains sedated, and you wonder about the prolonged effects of all the medications she received because of her extensive medical problems. You review her records and see that she was articulate and oriented a few days ago, and wonder how much the elevated serum ammonia level affects her behavior. You also note that her dose of lactulose was increased, and that she did not receive it earlier due to her behavior, but she does take it now.

Mrs. Smith does not exhibit the same behavior that she did earlier. You are not sure that she needs sedation. A sitter would be beneficial, but none is available. If you sedate her and she cannot take her medication, the condition will worsen and the incapacitation will increase. As her nurse, you feel the appropriate goal is to keep her safe from falls, harm, and her symptoms. This demonstrates respect for patient dignity and human rights by exhibiting a caring ethic. Nurses’ ethical responsibilities are to promote health, prevent illness, restore health and alleviate suffering (Center for Ethics and Human Rights, 2010). The Code of Ethics for Nurses guides nurses in this situation by instilling the nurse with the fundamental elements of respect for the human being under care.

The ANA position statement on restraints provides valuable guidance in making an ethical decision in this situation and tells nurses what to do. 1.    All behavior has meaning. 2.    Patient needs are best met when behavior is understood. 3.    A systemic approach of assessment, intervention, and evaluation is the best means to respond to behavior (Center for Ethics and Human Rights, 2012, p. 9).

During the shift, Mrs. Smith intermittently tries to get out of bed and causes the bed alarms to sound. However, she is still unable to keep her eyes open and still seems sedated. Now the reason for her agitation is that she needs to void and attempts to get to the bedside commode, has abdominal discomfort related to the lactulose, and is simply trying to reposition herself in bed and secure her blankets and pillows. These are all needs that nurses should address. The nursing process does not identify a diagnosis that supports sedation for this patient. You now can plan and implement care according to the unique needs of Mrs. Smith. She is still agitated but sleeps for long periods between episodes. Each time she awakens, she is more appropriate. By morning, the disruptions are less frequent, she is more awake, and she is able to converse. This is a more desirable outcome.

Conflict Provision 4 “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care” (ANA American Nurses Association, 2015, p. 15).

This provision directs nurses to take action and accountability for situations that prevent or interfere with delivery of ethical care for a patient. In this case, refer to Provision 4.3, “Nurses must bring forth for review difficult issues related to patient and/or institutional constraints upon ethical practice for discussion and review” (ANA American Nurses Association, 2015, p. 16). The implications of this case are apparent when reviewed in an ethical context. In this case, because of staffing issues, a one on one sitter was not available. This caused some nurses to consider sedation as a likely treatment to manage behavior and prevent falls. The institution does have a responsibility to support an environment and provide resources that are conducive to the delivery of ethical nursing care. Nurses have an ethical obligation to inform nurse leaders of these implications and offer ethically informed suggestions to improve care. Nurse leaders also have an obligation to promote ethical care by influencing changes to make this happen. The Nursing Code of Ethics provides the ways and means by which to learn from and improve nursing care.

Conclusion The Nursing Code of Ethics Provision 1 provides unwavering position in this case study. The use of sedation for the purpose of restraint or behavior management is not ethical and does not respect the inherent dignity of the person receiving nursing care. Provision 2 provides guidance because it directs nurses’ primary focus to the patient. It is not appropriate to use sedation for nurse convenience. Provision 4 guides nurses in taking action to change practice in difficult situations in which ethical conflicts occur. In this case, continued sedation would prohibit this vulnerable patient’s ability to express basic human needs, accept care and treatment, and may cause negative health outcomes. The nursing profession has a responsibility to uphold an unwavering trust that an incapacitated patient receives dignified nursing care that is his or hers by inherent rights. Through knowing and applying the Code of Ethics, nurses are better prepared to provide patient-centered care and uphold social trust in the nursing profession.

References ANA American Nurses Association. (2015). Code of Ethics for Nurses with Interpretitive Statements. Silverspring, Maryland: nursebooks.org. Retrieved October 18, 2015 from www.nursingworld.org. Center for Ethics and Human Rights. (2010, June 14). ANA Position Statement: The Nurses Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity and Human Rights in Practice Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements Center for Ethics and Human Rights. (2012, March 12). ANA Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements Pavlish, C., Brown-Saltzman, K., So, L., Heers, A., & Iorillo, N. (2015). Avenues of Action in Ethically Complex Situations: A Critical Incident Study. JONA: The Journal of Nursing Administration, 45(6), 311-318.

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Delve into the intricacies of a nursing case study, a critical component in nursing education and practice. This comprehensive guide will establish a robust understanding of the construction, relevance, and application of these integral studies. You'll explore various formats, ethical implications, and practical examples, ultimately honing your skills in creating effective nursing case studies. With an in-depth analysis and step-by-step guidance, this guide is crucial for aspiring or seasoned nursing professionals looking to enhance their case study proficiency.

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Understanding the Concept of a Nursing Case Study

Entering the field of nursing often requires more than simple rote learning. It demands an in-depth understanding of specific patient conditions, collaborative care planning, and the application of theoretical knowledge in practical scenarios. This is where a nursing case study plays a key role.

A nursing case study is a comprehensive examination of a patient's status, which comprises the gathering, assessment, and interpretation of data through various medical examinations and tests. This process allows healthcare professionals to make better-informed decisions about a patient's care plan and overall health management.

What is a Nursing Case Study: An Introduction

A Nursing Case Study is an in-depth examination of a patient case, wherein the nurse documents detailed information about the patient—everything from their initial history, diagnosis, to treatment—whilst also noting observations and reflecting on their nursing care.

A nursing case study typically includes sections for patient history, diagnosis, nursing assessment, treatment, and results. You will:

• Start by documenting a detailed patient history including previous medical conditions and lifestyle.
• Then, you'll progress to the diagnosis of the patient's condition.
• Next, perform a nursing assessment to identify potential health risks or complications.
• Formulate a treatment plan based on the assessment.
• And finally, evaluate the results of the treatment plan and adjust as necessary.

These comprehensive evaluations are critical in the field of nursing as they not only allow for appropriate patient care but also help guide future medical recommendations.

For example, consider a patient diagnosed with type 2 diabetes who complains of unexpected weight loss. A comprehensive nursing case study would involve recording the patient's current symptoms, medical history, conducting a nursing assessment to identify potential complications, and formulating a treatment plan. The results of this treatment would be regularly evaluated and adjusted to optimise the patient's health.

Importance and Relevance of a Nursing Case Study in Clinical Placement

A nursing case study plays an indispensable role in clinical placement . As you navigate your clinical experience :/p>

• You can use case studies as a reference tool in diagnosing, planning, implementing and evaluating patient care .
• Through case studies, you can also enhance your critical thinking and problem-solving skills.

Clinical placement refers to the practice-based learning experience that allows nursing students to apply their theoretical knowledge in a real-world clinic or hospital setting.

Such hands-on experience is essential to developing a solid understanding and mastery in nursing. A thorough nursing case study stands as a practical resource, providing valuable insights into complex patient conditions and providing a framework for delivering effective patient care. Furthermore, it also enables better comprehension of theoretical practice, thus bridging the gap between theory and application in nursing.

Exploring the Format of a Case Study in Nursing

It is crucial to understand the layout of a nursing case study. Having a solid grasp of the format will enable you to document all essential pieces of information about your patient care efficiently and thoroughly. Furthermore, clear structuring strongly supports effective communication within the healthcare team .

Remember, just like other academic papers, a nursing case study generally follows a logical flow that reflects the nursing process . This process includes five steps: Assessment, Diagnosis, Planning, Implementation and Evaluation; often abbreviated as ADPIE.

How to Write a Nursing Case Study: Step by Step Guide

When writing a nursing case study, it's vital to maintain a clear, structured and detail-oriented approach. Here, you will learn a standard step-by-step guide to creating your case study.

• Review the Patient History : Start by gathering all relevant details about the patient's medical history. Include specifics like past medical conditions, medication use, lifestyle factors and family history of diseases.
• Document Recent Health Assessments : Mention any recent diagnostic tests and their results, physical examination findings, and present complaints or conditions if any.
• Analyze Clinical Data : Analyze the data from the assessments and tests to identify any pertinent patterns or connections.
• Formulate Nursing Diagnoses : Based on your analysis, formulate nursing diagnoses . A nursing diagnosis can be described as a clinical judgement concerning a human response to health conditions.
• Develop a Comprehensive Care Plan : After diagnosis, establish a comprehensive care plan detailing the intended therapeutic interventions and expected outcomes. Remember, it's crucial to form SMART (Specific, Measurable, Achievable, Relevant, Time-bound) outcomes.
• Evaluate Progress : Lastly, evaluate the patient's progress towards the desired outcome and note any necessary changes to the care plan.

Please, keep in mind that the case study should follow a narrative approach, ensuring the information flows logically while maintaining patient confidentiality at all times.

An example could be a nursing case study for a patient with pneumonia . First, the patient's history is gathered, noting previous respiratory issues or any risk factors like smoking or occupational exposure. Next, the current clinical data would be documented, such as the results of a chest X-ray showing an infection in the lungs , together with vital signs and physical examination results. The data is then analyzed to arrive at a nursing diagnosis of impaired gas exchange related to alveolar consolidation, as evidenced by abnormal breath sounds and decreased oxygen saturation levels. The care plan would include interventions such as administering prescribed medications, oxygen therapy , and promoting good lung hygiene, with the expected outcome of improved respiratory function. Regular progress evaluations would be made, adjusting the plan as required.

Key Components of a Well-Written Nursing Case Study

The resultant quality of a case study depends on whether all key components are properly addressed. Here are some pivotal sections that should be present:

• Introduction : This provides a brief overview of the patient's demographic information and reason for admission.
• Patient History : The patient’s medical, surgical, and family history, including lifestyle factors.
• Physical Examination : Findings from the nurse's initial physical assessment of the patient, noting any abnormalities.
• Nursing Assessment : Identification of health issues or potential complications based on nursing theory.
• Nursing Diagnosis : Clinical judgement concerning a human response to health conditions.
• Nursing Interventions and Rationale : Explanation of the actions taken by the nurse to reach the planned outcomes, with a clear rationale behind each intervention.
• Expected Results and Actual Outcomes : Anticipation of results after interventions and comparison with actual outcomes. Adjustments to interventions may be made based on this comparison.

By giving due importance to each of these components, you ensure that the case study is comprehensive, accurate, and informative. This process aids in the ongoing optimisation of patient care, and shows the continual evidence-based practice in nursing.

Diving into Nursing Case Study Examples

An understanding of nursing case studies is significantly enhanced with the examination of practical examples. Analysis of these examples provides a real-life context to theories and practices, reinforcing their relevance and applicability. It is a great tool for learning by experience and expanding your knowledge in the field.

Reviewing nursing case study examples can spotlight the importance of thorough data collection, patient history compilation, diagnosis determination, and subsequent treatment provisioning. It permits you to appreciate the diversity of patient conditions, honing your skills in managing complex health situations effectively.

Nurse Practitioner Case Studies: Comprehensive Analysis

Nurse Practitioner case studies offer rich insights into the critical role nurse practitioners play within healthcare teams, particularly in primary care settings.

A Nurse Practitioner (NP) is a registered nurse with additional education and training in a particular area like family practice or paediatrics allowing them to examine, diagnose, and treat patients.

By looking into nurse practitioner case studies, you can expand your understanding of the advanced critical thinking, decision-making, and leadership skills exercised by NPs in diverse health scenarios. Here are the major steps that are typically followed during case analysis:

• First Step - Understanding the Patient's Details : The big picture of the patient's background, including their demographics, social, medical and personal history.
• Second Step - Identification of the Care Gaps : Identifying the issues in the existing care provision and areas of improvement for the Nurse Practitioner.
• Third Step - Formulation of a Healthcare Plan : The NP devises a robust patient-specific care plan detailing the required interventions.
• Fourth Step - Execution and Evaluation of the Plan : The plan is implemented, and the results are closely monitored for necessary changes.

Consider a Nurse Practitioner case study involving a 70-year-old female with a history of hypertension . The patient complaints of frequent headaches and tiredness. The NP begins by understanding the patient's overall health background, and then identifies the gaps in care—possibly inadequate control of hypertension. The NP formulates a plan that includes adjustment of antihypertensive drugs, lifestyle changes, and regular blood pressure monitoring . The execution of this plan is followed by a careful analysis of the patient's improvement in symptoms and hypertension control.

Delegation of Nursing Management Case Study: An Overview

Evaluating delegation in nursing management through case studies is an excellent way to understand its significance in nursing practice and learn the best principles for its application.

Delegation in nursing management refers to the process of assigning tasks to subordinates or team members in a way that maximises the efficiency and effectiveness of healthcare delivery.

Delegation is a crucial skill for every nurse, especially for those in leadership roles. It not only ensures smoother workflow but also empowers less experienced nurses, imparting skill development opportunities. The following points are important when analysing a delegation case study:

• Assessing the Situation : First, understand the precise patient care scenario and the workforce available.
• Identifying the Skills Required : After assessing the situation, identify the kind of skills needed for the delegated tasks.
• Assigning the Task : Delegate the task to the most competent and available person, considering their individual competencies and workload.
• Monitoring and Feedback : After delegation, it's crucial to supervise the task completion and provide constructive feedback to enhance performance in the future.

For instance, consider a case study highlighting delegation in a busy hospital setting. The nurse manager has to manage the care of 30 patients with only five nurses on duty. After assessing the situation and the individual abilities of the nurses, she assigns roles like medication administration , wound care , and patient education optimally. She then monitors the work and offers feedback after the shift, leading to efficient patient care despite the heavy workload.

Learning from these case studies equips you with efficient strategies for nursing management and ensures streamlined patient care. This knowledge acquisition is essential in modern healthcare settings to establish a patient-centred, coordinated approach.

Case Studies in Nursing Ethics

Examining case studies in nursing ethics is an invaluable way to explore the complex nature of ethical dilemmas in clinical settings. It allows you to conceptualise ethical concepts applied to patient care, while providing robust resources for learning and growth.

These case studies essentially offer an exploration into the intersection of healthcare, morality, philosophy, and social justice, which is represented in daily nursing practice.

Ethical Dilemmas in Nursing: Case Study Illustrations

An 'ethical dilemma' refers to situations where moral obligations conflict or where moral reasoning is not clear-cut. Nurses frequently encounter such dilemmas in their practice, making it crucial to understand how to approach these complex situations.

Ethical dilemma in nursing is a scenario where a decision must be made between two morally correct courses of action, but they are conflicting.

In nursing, the prime focus is always to provide the best possible care for a patient. However, ethical dilemmas arise when the right course of action is unclear, or when different beliefs and values clash. These situations can be stressful and deciding on the course of action can be challenging. Reviewing case study illustrations of ethical dilemmas can be a powerful teaching tool that facilitates a deeper understanding of these challenges.

Here are the most common ethical dilemmas that nurses face:

• Disclosure : How much information about the patient's health should be shared and with whom?
• Quality of Life : When a patient is suffering, what measures should be taken to maintain quality of life versus prolonging life itself?
• Professional Boundaries : How does a nurse maintain the right balance between being professional yet compassionate and empathetic?
• Cultural Differences : Treatment should be offered based on the patient's cultural beliefs, but what happens when these are in conflict with standard healthcare practices?
• End of Life Decisions : Addressing issues like euthanasia, Do Not Resuscitate orders and withdrawal or withholding of treatment.

It’s worth remembering that these issues often put a nurse’s professional duty against their personal beliefs, which further increases the complexity of managing them effectively.

For instance, consider a scenario where a patient’s religious beliefs prohibit blood transfusions, but they require one to survive. In carrying out the patient's wishes, the health provider might have to compromise the patient's wellbeing. Conversely, if the nurse ignores the patient's wishes to save their life, it can be considered a disregard for the patient's autonomy and beliefs. Thus, navigating this delicate balance may present an ethical dilemma.

Learning from Ethical Scenarios in Nursing Case Studies

Each ethical scenario in nursing case studies is a profound learning opportunity. Through exploring these intense and complex scenarios, you evolve as a nurse, honing your critical thinking, decision-making and reflection skills.

When analysing an ethical scenario, it's best to follow these steps:

• Identify the Dilemma : First, identify the ethical issue at hand and why it creates a dilemma.
• Understand the Context : Ascertain the involved parties, their beliefs or values, and how they relate to the situation.
• Evaluate the Options : Review the possible actions you could take, bearing in mind ethical guidelines and professional duties.
• Seek Advice : Consult with colleagues, mentors or your nursing governing body if in doubt. Asking for perspectives helps create a broader view of options.
• Make an Informed Decision : Based on all the information and advice, make a decision. Always keep the patient's best interest in focus.

Consider a case study where a patient refuses necessary treatment due to their religious beliefs. You first identify the ethical dilemma: respecting the patient's autonomous decision versus ensuring their wellbeing. The context includes the patient's health condition and their deeply-held religious belief. Possible options would be to respect the patient's choice, seek legal advice, discuss alternatives, or try to convince the patient or their family. Seeking advice from senior colleagues or the nurse manager may offer valuable insights into managing such situations. Finally, the decision should be taken considering all perspectives while maintaining the prime focus on the patient's wellbeing and rights.

With each ethical scenario analysed, you gain a deeper understanding of the ethical dimensions of nursing. This understanding fortifies your ability to provide effective, ethical patient care and to handle challenging situations in your nursing journey.

Tips and Techniques for an Effective Nursing Case Study

Nursing case studies are an integral part of nursing education and practice. They provide an in-depth insight into patient care, from diagnosis to treatment, through a practical approach. Understanding how to write them effectively is a vital skill for both nursing students and practicing nurses.

Improving Your Writing Skills for Nursing Case Studies

Improving your writing skills specifically for nursing case studies primarily means honing your ability to accurately document and articulate patient interactions, clinical symptoms, nursing interventions , and treatment results. It’s about refining your observational, analytic, and reporting skills.

Here's a list of techniques you can follow to enhance your case study writing skills :

• Understand the Format : Familiarise yourself with the structure and formatting of nursing case studies. Standard sections include patient history, diagnosis, nursing assessments, treatment, and evaluation.
• Be Clear and Precise : Use clear, precise language and mention facts accurately. Avoid unneeded jargon or long sentences.
• Consistent Clinical Terminology : Utilise the approved clinical language, acronyms, and terminology consistently for clarity and professionalism.
• Detail-Oriented Observation : Be observant about the smallest details related to a patient's symptoms, behaviours, reactions to interventions, and overall progress. Every tiny detail could be significant.
• Reflective Thinking : Develop your reflective thinking skills. Reflect on your nursing interventions: what has worked, what hasn't, and potential improvements.

Reflective thinking in nursing is a process where nurses analyse their clinical experiences to learn and improve their practices. It aids in transforming practical experiences into meaningful knowledge.

Suppose you are documenting a case study about a patient with diabetes suffering from recurring cases of hypoglycaemia. You'll need to provide a comprehensive patient history, precise details about their symptoms, and a clear description of your nursing interventions to prevent these episodes. Be sure to use consistent terminology and observe all related factors, like the patient's diet or emotional state, which could impact their sugar levels. The report should include regular evaluations of the patient's condition, and your reflections on the efficacy of your implemented care plan.

Do's and Don'ts in Writing a Nursing Case Study

To ensure you create compelling, informative, and accurate nursing case studies, here are some indispensable do's and don'ts to keep in mind:

Reflective writing in nursing case studies is a process where nurses consider their experiences, actions, feelings, and responses and analyse their impacts on patient outcomes . It includes assessing what was done well, what could be improved, and steps for future development.

If you have handled an incident of rapid patient deterioration in a clinical setting, instead of merely describing the event chronologically in the case study, engage in reflective writing. Discuss the nursing assessments undertaken, the intuitions you had, the quick decisions you made, and the outcomes you achieved. Reflect on your emotions, your learning, and the improvements you would implement in similar future scenarios.

Following these tips will, without a doubt, help you improve the quality of your nursing case studies, either for academic or professional purposes. Understanding the importance of each step, from precise patient details to reflective evaluations, is key to writing an effective nursing case study.

Nursing Case Study - Key takeaways

• A Nursing Case Study involves gathering patient history, analyzing clinical data, formulating nursing diagnoses, developing a comprehensive care plan, and evaluating progress.
• Nursing Case Study examples illuminate the process and importance of thorough data collection, patient history compilation, diagnosis determination, and subsequent treatment.
• The delegation of nursing management Case Study explores the efficient assignment of tasks within a nursing team, maximizing efficiency and effectiveness of healthcare delivery.
• Case studies in nursing ethics provide insight into ethical dilemmas in clinical settings and help to conceptualize ethical concepts applied to patient care.
• The format of a nursing case study typically includes an introduction, patient history, physical/nursing assessment, nursing diagnosis, nursing interventions and rationale, and expected/actual outcomes.

Frequently Asked Questions about Nursing Case Study

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A nursing case study is an in-depth analysis of a patient or group of patients, involving observations, data collection, diagnosis, planning and implementing interventions, then evaluating outcomes. It incorporates a nurse's clinical reasoning in patient care.

Case studies bridge theoretical learning and actual practice, enabling the application of learned knowledge in real scenarios. They promote critical thinking, decision-making, and enhance clinical skills while providing evidence-based learning.

The nurse analyses patients’ health records, carries out physical assessments, interacts with patients to gain insights into their experiences, symptoms, and responses to treatment, and implements interventions while evaluating the outcomes.

What are nursing case study examples and what do they provide?

Nursing case study examples provide insights into how theoretical nursing knowledge is applied in real-world situations. They equip you with an understanding of different patient conditions and nursing responsibilities.

What does a nursing management case study involving delegation illustrate?

A nursing management case study involving delegation shows the importance of efficient task distribution, quick judgment-making in stressful situations, and careful selection of staff members for specific tasks based on their competence.

What do Nurse Practitioner case studies typically illustrate?

Nurse Practitioner case studies illustrate the comprehensive, patient-centred care provided by NPs, including initial interaction and assessment, diagnosis and treatment, and evaluating outcomes through patient responsiveness over time.

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Ethical dilemmas experienced by nurses while caring for patients during the COVID‐19 pandemic: An integrative review of qualitative studies

Ana luiza ferreira aydogdu.

1 Faculty of Health Sciences, Department of Nursing, Health and Technology University, Istanbul Turkey

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.

This study aimed to identify ethical dilemmas faced by nurses while caring for patients during the COVID‐19 pandemic.

Nurses express several concerns during disease outbreaks, some of which are related to ethical dilemmas.

It is an integrative review in which four databases were searched. Critical appraisal tools and PRISMA guidelines were used. Content analysis was performed to analyse the obtained data.

A total of 14 studies were identified. The results are presented into four categories: concerns with beneficence–nonmaleficence; awareness of need for autonomy; challenges to justice; and coping with ethical dilemmas.

While caring for patients during the COVID‐19 pandemic, nurses often put their own health and that of their families at risk. The ethical dilemmas faced by nurses are mainly caused by the lack of Protective Personal Equipment (PPE), shortages of medical supplies and personnel and the uncertainties that permeate an environment threatened by a new and highly contagious disease such as COVID‐19.

Implications for nursing management

This review provides information that can inspire nurse managers working during the COVID‐19 pandemic to support and empower nurses to act in accordance with ethical principles, which is important in order for nurses to protect themselves while providing efficient and effective care.

1. INTRODUCTION

The advent of the COVID‐19 pandemic has had a significant impact on humanity; although several fields have been affected by the pandemic, the most impacted was undoubtedly the health care sector (al Thobaity & Alshammari,  2020 ). Since its emergence in late December 2019, the disease has infected and caused the death of millions of people (World Health Organization [WHO],  2022 ), and still today, more than 2 years later, it continues to challenge scientists and health professionals with the emergence of mutations and variants (Ramesh et al.,  2021 ).

Lack of knowledge about the disease, its contagion and treatment; fear of getting infected; fear for loved ones; discriminatory acts; and shortage of human and medical resources are some of the challenges faced by health professionals since the beginning of the pandemic (al Thobaity & Alshammari,  2020 ; Moussa et al.,  2021 ; Mulaudzi et al.,  2021 ; Sperling,  2020 ). Especially nurses, who are health professionals present at all times on the front line of the battle against the COVID‐19, faced and still face several difficulties due to the pandemic. Rationing of limited resources, restrictions on the freedom and autonomy of patients and their families and the distinction between groups, in choosing who should receive care when patients are many and nurses are few, are among the many ethical problems faced by nurses (Sperling,  2020 ). Nurses face yet another huge ethical dilemma, as they have an obligation to care for patients and for themselves and their families (Binkley & Kemp,  2020 ; Linton & Koonmen,  2020 ). When providing care to patients with COVID‐19; nurses have to deal with all these ethical dilemmas, which, in addition to putting pressure on them, interfere with the quality of care (al Thobaity & Alshammari,  2020 ; Sperling,  2020 ). Thus, it is important to examine the ethical dilemmas faced by nurses during the COVID‐19 pandemic.

2. BACKGROUND

Nurses in their daily practices have to protect their patients and their families without neglecting self‐care; these ethical problems are obviously exacerbated in periods of crisis (Linton & Koonmen,  2020 ). As in previous outbreaks, nurses are currently facing excessive workload, shortages of medical supplies and human resources, lack of knowledge and skills and fear of getting infected and infecting loved ones (Kollie et al.,  2017 ; Sperling,  2020 ), which can trigger ethical dilemmas due to the risk of harming themselves and others. During the decision‐making process, nurses are guided by ethical principles such as respect for autonomy, beneficence, nonmaleficence and justice (Mulaudzi et al.,  2021 ).

Whereas the ethical principle of beneficence is related to doing good, the principle of nonmaleficence is about not causing harm to the patient (Varkey,  2021 ). During the pandemic, both principles were threatened since nursing shortages, lack of knowledge about the disease, treatment limitations, lack of resources, such as Protective Personal Equipment (PPE), and other medical materials prevented some patients from receiving assistance promptly, in addition to threatening the health of caregivers (Mulaudzi et al.,  2021 ).

The ethical principle regarding autonomy refers to the rights of individuals to dignity, to be informed about their health and to be able to make choices without suffering external pressure (Mulaudzi et al.,  2021 ); patients are also entitled to confidentiality regarding their health status and treatment (Shekhawat et al.,  2020 ). Holistic and humanized care is centred on the individuals, including attention to their values, preferences and needs; patients must be free to choose their treatment, therefore having the right to be informed about their illness and the entire assistance process, including nursing care (Fontes et al.,  2020 ). Nurses are trained to provide this type of care to patients. However, in periods of crisis, lack of knowledge and uncertainties arise and profound changes in the world health scenario give rise to situations that threaten the patient's autonomy over his/her own life, and nurses are also affected by these changes, facing major ethical problems (Fontes et al.,  2020 ). Still, on the ethical principle of autonomy, it is necessary to emphasize that nurses also have the right to make autonomous decisions about their obligations to serve others when their lives are threatened by PPE shortages (Mulaudzi et al.,  2021 ).

Justice implies equity, fairness and proportionality; thus, the concept of justice in the field of health also refers to the elimination of unequal access to health services, guaranteeing access to quality health for all (Jaziri & Alnahdi,  2020 ). If before the pandemic for some countries guaranteeing quality health care for all was a huge challenge, with the emergence of the COVID‐19, the situation has worsened worldwide (Jaziri & Alnahdi,  2020 ; Mulaudzi et al.,  2021 ). It is still necessary to consider the situation of health professionals, especially nurses, who, due to an unequal distribution of PPE, faced great risk when providing care to patients with COVID‐19 (Mulaudzi et al.,  2021 ).

Health institutions must be well organised to provide care during times of crisis. Pandemics lead to the rapid spread of disease affecting the ability of these institutions to provide assistance to the population. Health care institution administrators and also nurse managers must envision this possibility and must be prepared for such events before they occur (Gul & Yucesan,  2021 ). It is also important to ensure organisational fairness so that everyone who is part of the health team feels valued and indispensable (Yildirim et al.,  2021 ). Efficient and effective management of human resources, equipment, materials and information is essential for the control of pandemics (Gul & Yucesan,  2021 ). In addition, nurse managers play an important role in supporting their team so that frontline nurses can develop emotional and professional competence to respond to emergencies (Tan et al.,  2020 ).

Health professionals must develop their functions based on scientific knowledge, technical and communication skills associated with ethical and professional values (Varkey,  2021 ). However, during the COVID‐19 pandemic, ethical principles are being threatened in several dimensions, putting at risk not only the quality of care but also the physical and mental health of nurses and other health care workers (Linton & Koonmen,  2020 ; Mulaudzi et al.,  2021 ). Thus, organisational support is pivotal for nurses to cope with ethical dilemmas (American Nurses Association [ANA],  2020 ). Importantly, the focus of this review is to examine the ethical dilemmas experienced by nurses while caring for patients with COVID‐19.

4.1. Design

This integrative review of qualitative studies was conducted using the Whittemore and Knafl ( 2005 ) framework. As qualitative research allows exploring people's lived experiences (Creswell,  2013 ), the selection of studies in which this method was used was considered better suited to identify ethical dilemmas experienced by nurses during the COVID‐19 pandemic.

4.2. Search strategy

The search for original primary qualitative research articles on ethical dilemmas experienced by nurses while caring for patients during the COVID‐19 pandemic was carried out in December 2021. The descriptors used for the database searches were ‘Covid’ AND ‘ethical dilemmas’ AND ‘nurses’. The electronic databases searched were PubMed, Google Scholar, MEDLINE and Scopus.

4.3. Inclusion and exclusion criteria

Original primary qualitative research articles reporting ethical dilemmas of nurses caring for patients with COVID‐19, whose full texts were available on the Internet in English, were included. Articles that included other participants besides staff nurses (other health care workers, nurse managers, nursing assistants), those that despite addressing experiences did not assess ethical dilemmas perceived by nurses while caring for patients during the COVID‐19 and non‐qualitative studies were excluded.

4.4. Search outcome

The Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) was used to guide the selection of articles (Figure  1 ). Through the electronic databases, 918 articles were found, with the inclusion of four more articles found through other sources, a total of 922 articles were identified, then 19 duplicate articles were excluded, and the result decreased to 903. Titles and abstracts were read, and 889 articles were excluded for not matching the inclusion criteria of the review. The remaining 14 articles were read and re‐read, and all were included in the quality appraisal.

Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) flow diagram of search, screening and selection of articles for the integrative literature review

4.5. Quality appraisal

The articles were appraised using the Critical Appraisal Skills Programme (CASP) (CASP,  n.d .). The CASP is a checklist with 10 main questions used to evaluate qualitative studies (CASP,  n.d .). Each main question was rated as ‘Yes’ (2 points), ‘Unclear’ (1 point) or ‘No’ (0 points). The included studies scored between 17 and 20 points. Regarding the methodological quality of the studies, the most common weaknesses found were a lack of information on the relationship between researcher and participants and geographic limitations. No articles were excluded based on critical appraisal; all 14 evaluated articles were included in this review (Table  1 ).

Critical Appraisal Skills Programme (CASP) a checklist

4.6. Data extraction

General information was extracted from the selected studies and organised through an evidence‐based instrument developed and pilot tested on the first two included articles by the author. The form contains the following headings: reference, title, journal, country, aim, design, participants, main results and limitations. Relevant data are included in quality appraisal (Table  1 ) and summary table (Table  2 ).

Reviewed articles and summary of results

4.7. Data synthesis

Data analysis involved a long process in which comparisons of information were conducted resulting in codes organised into categories (Whittemore & Knafl,  2005 ). Data were thoroughly and repeatedly analysed by the author. Grammatical methods were used for coding similar information contained in the studies included in this review (Saldana,  2013 ). The codes originated by comparing the data of the reviewed studies were organised into four categories: concerns with beneficence–nonmaleficence; awareness of need for autonomy; challenges to justice; and coping with ethical dilemmas (Table  3 ).

Categories and codes

Abbreviation: Protective Personal Equipment.

The 14 selected articles are from 10 different journals. Thirteen (92.8%) of the studies were carried out in 2021. The number of participants varied from 10 to 43 nurses. Studies were conducted in Iran ( n  = 4), China ( n  = 2), Turkey ( n  = 2), the United States ( n  = 2), Canada ( n  = 1), Jordan ( n  = 1), Korea ( n  = 1) and Sweden ( n  = 1). In nine studies, the majority of participants were female; in two studies, all participants were female (Kwon & Choi,  2021 ; McMillan et al.,  2021 ); in two studies, gender was not mentioned (Kelley et al.,  2021 ; Silverman et al.,  2021 ); and in one study, the majority of participants (60%) were male (Alloubani et al.,  2021 ).

A total of seven articles had the main objective related to topics on nurses' ethics during the COVID‐19 pandemic (Abbasinia et al.,  2021 ; Alloubani et al.,  2021 ; Jia et al.,  2021 ; Karaca & Aydin Ozkan,  2021 ; Liu et al.,  2021 ; McMillan et al.,  2021 ; Rezaee et al.,  2020 ; Stenlund & Strandberg,  2021 ), four articles (Kelley et al.,  2021 ; Kwon & Choi,  2021 ; Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ) had nurses' experiences in care of patients with COVID‐19 as main objective, one article (Silverman et al.,  2021 ) was about moral distress in nurses caring for patients with COVID‐19, and the remaining article (Mohammadi et al.,  2021 ) was conducted with nurses who were infected with COVID‐19. The participants' perceptions of ethical dilemmas are presented in the results of all 14 articles. The results of this review are presented into four categories: beneficence–nonmaleficence; autonomy; justice; and coping with ethical dilemmas.

5.1. Concerns with beneficence—Nonmaleficence

According to the analysed literature, nurses questioned themselves at various moments due to different circumstances, having doubts if they were doing what was good and right for patients during the COVID‐19 pandemic. Nurses reported that at times, they no longer knew what was ethical and what was not, that many decisions were made without nurses being consulted, and they were the last ones to know for example about the placement of patients (Kelley et al.,  2021 ). Nurses faced dilemmas as they had to protect themselves, fight for their rights and, at the same time, be beneficial to patients and the community (Alloubani et al.,  2021 ; Kelley et al.,  2021 ; Liu et al.,  2021 ; Muz & Erdogan Yuce,  2021 ; Silverman et al.,  2021 ). Nurses faced clinical dilemmas due to fighting an unknown virus and, consequently, lack of information about the illness and its treatment (Abbasinia et al.,  2021 ; Kelley et al.,  2021 ; Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ; Rezaee et al.,  2020 ; Silverman et al.,  2021 ). Ethical dilemmas in nursing management were identified as important information was not shared with frontline nurses in time (Kelley et al.,  2021 ; Muz & Erdogan Yuce,  2021 ), equipment was not equally distributed and nurses had to work with limited PPE (Kelley et al.,  2021 ; Liu et al.,  2021 ; Moghaddam‐Tabrizi & Sodeify,  2021 ). Some nurses reported a lack of time (Muz & Erdogan Yuce,  2021 ; Silverman et al.,  2021 ; Stenlund & Strandberg,  2021 ), human resources (Liu et al.,  2021 ; Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ) and medical supplies (Jia et al.,  2021 ; Liu et al.,  2021 ; Silverman et al.,  2021 ; Stenlund & Strandberg,  2021 ) to provide the necessary care.

Not being able to provide holistic patient care was another fact pointed out by nurses as a trigger for ethical dilemmas. Difficulties in providing psychological (Jia et al.,  2021 ; Muz & Erdogan Yuce,  2021 ), physical (Jia et al.,  2021 ; Karaca & Aydin Ozkan,  2021 ; Liu et al.,  2021 ; Muz & Erdogan Yuce,  2021 ) and social care (Jia et al.,  2021 ;Kwon & Choi,  2021 ; McMillan et al.,  2021 ) and lack of spiritual care (Rezaee et al.,  2020 ), comfort care (Kelley et al.,  2021 ; Silverman et al.,  2021 ), end of life care (Kelley et al.,  2021 ; McMillan et al.,  2021 ) and family‐centred care (Rezaee et al.,  2020 ) were identified by nurses during the COVID‐19 pandemic. These dilemmas emerged because nurses had a lack of knowledge and skills to work in COVID‐19 wards (Jia et al.,  2021 ; Karaca & Aydin Ozkan,  2021 ; Kelley et al.,  2021 ; Liu et al.,  2021 ); thus, they feared that they were not doing their job correctly (Jia et al.,  2021 ; Kelley et al.,  2021 ; Muz & Erdogan Yuce,  2021 ; Silverman et al.,  2021 ) and that they were harming the patient due to inexperience or lack of necessary training (Karaca & Aydin Ozkan,  2021 ). In addition, due to nursing shortages and long shifts, nurses were not able to stay at patients' bedsides at the time of need (Rezaee et al.,  2020 ; Stenlund & Strandberg,  2021 ).

Nurses also experienced moral distress because they felt unable to provide the necessary support to patients who suffered from the loss of loved ones or because they felt lonely in isolated rooms (Jia et al.,  2021 ; Kelley et al.,  2021 ; Kwon & Choi,  2021 ; Stenlund & Strandberg,  2021 ). Nurses faced dilemmas due to the prohibition of visits to patients during the COVID‐19 pandemic, as they had doubts whether this measure was more beneficial or harmful to patients and their families (Kwon & Choi,  2021 ; Stenlund & Strandberg,  2021 ). Nurses pointed out that family visits are not only important to provide emotional support but also to give information about patients (Stenlund & Strandberg,  2021 ). Especially in palliative care services, visitor restrictions were pointed out as a huge ethical dilemma for nurses, because contact with family is considered a palliative intervention (Kwon & Choi,  2021 ; McMillan et al.,  2021 ). Nurses also emphasized the lack of support for families after the patient's discharge or death (Rezaee et al.,  2020 ). Patients were in dire need of spiritual care, which unfortunately could not be provided at that time, so nurses witnessed the loss of spiritual vitality of patients (Rezaee et al.,  2020 ).

Due to the chaotic situation characteristic of a pandemic period, confusion, denial of reality and indecision were perceived by nurses who cared for patients with COVID‐19 (Abbasinia et al.,  2021 ; Kelley et al.,  2021 ; Silverman et al.,  2021 ), facts that can affect the nursing care. Nurses experienced role confusion as some of them had to perform practices that doctors should do (Karaca & Aydin Ozkan,  2021 ; Kelley et al.,  2021 ) or provide the support that should be given by a psychologist (Liu et al.,  2021 ). The low sense of responsibility in the nursing units and the insufficient assistance to the emergency can result in problems related to professional ethics (Jia et al.,  2021 ). Nurses reported that some doctors were monitoring patients by video or telephone, avoiding entering the wards (Jia et al.,  2021 ; Silverman et al.,  2021 ). In addition, the fear of becoming infected can make health professionals act slower than usual while providing care to patients or entering COVID‐19 wards (Jia et al.,  2021 ).

Even if nurses were afraid of caring for patients with COVID‐19, they were aware that it was their duty as nurses to care for patients regardless of their illnesses (Alloubani et al.,  2021 ; Kelley et al.,  2021 ; Liu et al.,  2021 ; Muz & Erdogan Yuce,  2021 ; Silverman et al.,  2021 ); they were concerned with providing safe care to patients updating themselves (Karaca & Aydin Ozkan,  2021 ), and they were reminding each other all the time about the need to protect themselves and patients (Liu et al.,  2021 ). However, nurses believe that they should not be forced to care for COVID‐19 patients because some nurses could be pregnant or have elderly family members (Alloubani et al.,  2021 ), and an unhealthy and stressful nurse is not able to take care of others well (Mohammadi et al.,  2021 ; Muz & Erdogan Yuce,  2021 ). Nurses can feel powerless when trying to do the right thing in a time of uncertainty (Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ; Stenlund & Strandberg,  2021 ).

5.2. Awareness of need for autonomy

The studies identified that in some situations, the patient's autonomy and self‐determination were not maintained, which led to the emergence of ethical dilemmas in nurses. Patients' rights were neglected, and some patients could not even choose their treatment or care plans because they could not communicate (Jia et al.,  2021 ; Karaca & Aydin Ozkan,  2021 ) and were forced to give consent as they had no other options (Karaca & Aydin Ozkan,  2021 ).

Some studies pointed out that patients' opinions, perspectives, values and beliefs were not taken into account as visits restrictions were mandatory (Kwon & Choi,  2021 ; Liu et al.,  2021 ; McMillan et al.,  2021 ; Silverman et al.,  2021 ; Stenlund & Strandberg,  2021 ). Nurses emphasized that because visits were not allowed, patients could not choose to be close to a loved one at the time of death, and many families were unable to see the patient for the last time (Kelley et al.,  2021 ; Kwon & Choi,  2021 ; Silverman et al.,  2021 ; Stenlund & Strandberg,  2021 ). Nurses reported dilemmas regarding visitor restrictions, stating that it was too hard to see patients far from their families (McMillan et al.,  2021 ; Stenlund & Strandberg,  2021 ). Some nurses described the visitor restrictions as cruelty, a robbing time (McMillan et al.,  2021 ) and a threat to the freedom of patients, staff and visitors (Liu et al.,  2021 ).

Some issues addressed in the studies imply both patients' autonomy, concerning the right to receive information about his/hers health status and treatment, and nurses' duty to act with professionalism. Nurses reported that information such as oxygen saturation was omitted to protect the patient's mental health (Liu et al.,  2021 ). Relatives did not have full access to information about patients as communication was done by telephone, which limited the interaction between nurses and family members (Stenlund & Strandberg,  2021 ). Decisions on not to resuscitate elderly patients were made without the patient or family being able to choose (Silverman et al.,  2021 ), and some patients and family members were deciding about maintaining treatments that, according to nurses, were useless (Silverman et al.,  2021 ). Nurses faced ethical dilemmas due to violation of patient privacy and dignity; as there were too many patients to care for in the same unit, patient privacy was neglected (Karaca & Aydin Ozkan,  2021 ; Stenlund & Strandberg,  2021 ). Nurses also pointed out as an ethical dilemma, the importance of keeping individual patient confidentiality and providing the necessary information to the authorities (Karaca & Aydin Ozkan,  2021 ).

5.3. Challenges to justice

Nurses need to be impartial and fair when giving care. The scientific literature reported many challenges faced by nurses regarding justice during the COVID‐19 pandemic. Nurses faced dilemmas especially in the first days of the pandemic due to limited medical resources (Jia et al.,  2021 ; Liu et al.,  2021 ; Silverman et al.,  2021 ), which makes it difficult to provide equal care. Nurses also reported the difficulty of choosing among patients who needed more care (Karaca & Aydin Ozkan,  2021 ). Young patients with wives and children waiting for them desired to live too strong; on the other hand, older patients would refuse the treatment, but nurses knew that all patients should receive care (Liu et al.,  2021 ).

It is difficult to provide equal care when patients are admitted according to hospital capacity, not based on their medical needs (Silverman et al.,  2021 ). Inequalities in caring and visitor policies were identified (Kelley et al.,  2021 ). Nurses reported that there were so many COVID‐19 patients to care for that they were unable to provide the necessary care for all of them and had to choose between patients (Silverman et al.,  2021 ). Unequal care was also noticed when nurses emphasized that whereas in some institutions patients did not receive any visits, in others, the rules of time and scheduling of visits varied (McMillan et al.,  2021 ).

The principle of justice was mentioned by nurses who became infected with COVID‐19, according to them, while they were patients their rights were not respected and they did not receive equal treatment (Mohammadi et al.,  2021 ). Nurses also emphasized the lack of professionalism that generated inequality between nursing and other professions (Kelley et al.,  2021 ; Mohammadi et al.,  2021 ); nurses stayed at patients' bedsides at all times, whereas doctors avoided entering the wards (Jia et al.,  2021 ; Kelley et al.,  2021 ). Even cleaning staff avoided entering the patients' rooms, and cleaning was often done by nurses (Kelley et al.,  2021 ). Nurses felt as if their lives were less important than the lives of other professionals (Kelley et al.,  2021 ), and they emphasized that nurse managers should advocate for frontline nurses (Silverman et al.,  2021 ). On the other hand, some nurse participants pointed out that due to the pandemic period, the community looked at them with different eyes, and the nursing profession was valued (Muz & Erdogan Yuce,  2021 ).

5.4. Coping with ethical dilemmas

Studies identified ways to cope with ethical dilemmas. Study and discussion groups with the presence of doctors and nurses (Liu et al.,  2021 ) and planning, control, support, catharsis, focus (Jia et al.,  2021 ), talking to loved ones, journaling, exercising (Silverman et al.,  2021 ), learning specialized skills in nursing, scientific research and management were the means used by nurses to solve problems related to ethical dilemmas (Jia et al.,  2021 ). Thus, through their professional values and sense of obligation, nurses solved some of the emerged dilemmas providing the best possible care during the pandemic (Abbasinia et al.,  2021 ; Karaca & Aydin Ozkan,  2021 ; Liu et al.,  2021 ; Moghaddam‐Tabrizi & Sodeify,  2021 ).

Nurses pointed out that working in such a critical period has improved interpersonal relationships at the workplace and that intra‐ and inter‐professional relationships were important for solving their dilemmas (Abbasinia et al.,  2021 ; Kelley et al.,  2021 ); they tried to see the situation as an opportunity to serve the community and the profession (Moghaddam‐Tabrizi & Sodeify,  2021 ). Nurses sought support from the government, nursing association and the community (Moghaddam‐Tabrizi & Sodeify,  2021 ), and they also emphasized that support from administrators of health institutions (Abbasinia et al.,  2021 ; Alloubani et al.,  2021 ; Jia et al.,  2021 ; Rezaee et al.,  2020 ), and especially, nurse managers (Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ; Silverman et al.,  2021 ) are pivotal to resolving their ethical dilemmas. Clear and strategic communication by nursing leaders was identified as an important point to alleviate the ethical dilemmas experienced by frontline nurses (Kelley et al.,  2021 ). Also, continuing education and counseling programmes were reported as important measures not only to afford nurses knowledge but also to provide a safe environment for patients (Moghaddam‐Tabrizi & Sodeify,  2021 ; Muz & Erdogan Yuce,  2021 ). However, some nurses pointed out a lack of further organisational support (Kelley et al.,  2021 ; Silverman et al.,  2021 ).

6. DISCUSSION

This integrative review sought to identify ethical dilemmas faced by nurses while caring for patients during the COVID‐19 pandemic. Nurses reported ethical dilemmas related to lack of knowledge and skills to care for patients with COVID‐19, lack of human and medical resources and absence of holistic care; because of these facts, they had doubts about whether or not they were being beneficial for patients. During the pandemic, autonomy and privacy of patients were threatened, and due to some circumstances, equal care was not provided to patients; thus, nurses experienced ethical problems. Participants also mentioned the inequality between nurses and other health care workers, stating that the risks of infection were greater for members of the nursing team as they were at the patient's bedside all the time. To solve ethical problems, nurses resorted to their own professional values and also had the support of government, community, family members, administrators and nursing team, especially nurse managers.

The ethical principles of beneficence (do good) and nonmaleficence (do no harm) mean providing benefits to people (Varkey,  2021 ) and must be followed by nurses in the exercise of their functions. During periods of crisis, nurses often do not have much choice and have to adopt attitudes less than perfect that end up generating ethical dilemmas (Robert et al.,  2020 ). Nursing is a science and an art that, to be practised efficiently and effectively, requires specialized knowledge and skills, which, in turn, are acquired through years of study and experience (Vega & Hayes,  2019 ). Nurses must be well‐prepared for providing care, but with the emergence of the pandemic, many of them had to work in COVID‐19 wards and use medical equipment they had never used before without receiving adequate training (Morley et al.,  2020 ; Sperling,  2021 ). Similar situations were described by nurses who cared for patients with Middle East Respiratory Syndrome (MERS) (Kim,  2018 ) and Ebola (Raven et al.,  2018 ). Furthermore, fear of COVID‐19 can undermine nursing care, and the fear of becoming infected is mentioned by nurses in several studies carried out during the COVID‐19 pandemic (Moussa et al.,  2021 ; Sperling,  2021 ); despite being afraid of becoming ill, nurses must be aware of their obligation to care for their patients (Casey,  2015 ). On the other hand, self‐care is more than an ethical obligation because nurses need to be physically, mentally and socially healthy to provide quality care to patients and the community (Linton & Koonmen,  2020 ; Souza e Souza & Souza,  2020 ). Thus, nurse managers need to understand the impact of the COVID‐19 pandemic on frontline nurses and support them by providing training and promoting a safe environment for staff and patients (Tan et al.,  2020 ; Yildirim et al.,  2021 ). Also, ethics consultants can help nurses to develop the necessary skills to deal with ethical dilemmas (Bampi & Grande,  2020 ) arising from the COVID‐19 pandemic.

The rapid shift from patient‐centred care to public health‐centred care has also shifted the focus of ethics in nursing, and nurses had to adapt to this new reality immediately, which caused ethical problems (Hossain & Clatty,  2021 ). Nurses are trained to provide holistic patient care; however, during the COVID‐19 pandemic, mainly due to the lack of human and medical resources, this care was not always possible (Hossain & Clatty,  2021 ). Nurses had to make difficult ethical decisions, often contrary to their training and understanding of beneficence (Hossain & Clatty,  2021 ; Mulaudzi et al.,  2021 ). Nurses caring for patients with COVID‐19 emphasized the need for special training to provide care during the pandemic (Rathnayake et al.,  2021 ). In addition, the fact that patients are isolated and distant from their families can generate dehumanizing scenarios; it can negatively affect care and generate ethical dilemmas for nurses. It is important to find imaginative solutions that protect the community and at the same time do not harm the psychosocial health of the patient and their loved ones (Morley et al.,  2020 ). Rights, such as autonomy, trust, minimizing harm and proportionality must be considered when adopting strategies concerning hospital and nursing home visitors during the COVID‐19 pandemic (Hartigan et al.,  2021 ).

Autonomy is a person's right to make choices based on his/her own values and beliefs (Varkey,  2021 ) so patients have the right to be fully informed about their illness and its treatment and may, therefore, accept or not medical procedures and nursing care; thus, before any health care worker can provide assistance, the patient's consent is required (Varkey,  2021 ). The individual has a right to privacy, which is the right to self‐determination in which the person has moral authority over his/hers personal characteristics (Demirsoy & Kirimlioglu,  2016 ). In crises such as the COVID‐19 pandemic, patient privacy can be threatened (Shekhawat et al.,  2020 ). Due to the COVID‐19 pandemic, measures were taken to protect the community, and the individual interests were pushed; thus, nurses faced ethical problems because of such changes (Fontes et al.,  2020 ). It is important to highlight that the healthy nurse–patient relationship is pivotal for the success of caring, and patients must trust in nurses; ethical problems experienced during the COVID‐19 pandemic should not harm the long history of trust between nurses and patients (Morley et al.,  2020 ). Therefore, nurses must be guided by leaders who are transparent in their communication, thus being role models to support the nursing team with adequate knowledge and judgement for ethical decision‐making (Markey et al.,  2021 ).

According to the ethical principle of justice, nursing care must be fair, equitable and adequate (Varkey,  2021 ). Concerning patients with COVID‐19, it is difficult to make a decision to optimize the use of medical devices, excluding low‐risk individuals, treating patients similarly and choosing those worse off (Jaziri & Alnahdi,  2020 ). The distribution of resources requires health professionals to make fair and transparent decisions. During the pandemic period, the distribution of scarce resources often prioritized young people over elderly ones because young patients have the highest life expectancy (Jaziri & Alnahdi,  2020 ). In addition, nurses are facing challenges due to a shortage of staff, beds and medical supplies during the COVID‐19 pandemic (al Thobaity & Alshammari,  2020 ); therefore, providing fair care is not an easy task.

Not only patients but also health professionals must be treated equitably. Nurses are on the front line in the fight against COVID‐19; they have numerous roles in the treatment of patients with COVID‐19; and compared to other health professionals, they remain in direct contact with patients for longer periods; therefore, they are a group with a high risk of getting infected (al Thobaity & Alshammari,  2020 ; Souza e Souza & Souza,  2020 ). In addition, due to reduced numbers of PPE, some health professionals do not enter the rooms of patients with COVID‐19, and the duties that should be done by them end up being performed by nurses (Morley et al.,  2020 ). During the COVID‐19 pandemic, nurses are making difficult choices because, as they run the risk of becoming infected when treating patients with COVID‐19, their choices can be a decision between their own lives or the lives of patients (Mulaudzi et al.,  2021 ); this decision becomes even more difficult if the distribution of PPE is not equal (Moradi et al.,  2021 ; WHO,  2020 ). Nurses in risk groups or who do not feel safe due to lack of necessary PPE should not care for patients with COVID‐19 (ANA,  2020 ).

Nurses' professional values (Sperling,  2021 ) and moral resilience (Hossain & Clatty,  2021 ), hospitals, institutions, administrators (ANA,  2020 ) and especially nurse managers' support are pointed out as important factors in helping nurses resolve ethical dilemmas during the COVID‐19 pandemic (Markey et al.,  2021 ). The approach of nurse managers, being role models, respecting team members and patients, thus developing a work environment supported by ethical principles, is of fundamental importance for nurses to be able to make appropriate decisions and resolve their ethical dilemmas (Markey et al.,  2021 ; Zhou & Zhang,  2021 ).

6.1. Limitations

Using a search approach that specifically looked for the term ‘ethical dilemma’ may have overlooked sources discussing ethical conflicts without using this exact descriptor. In addition, only studies published in English, whose full texts were available on the Internet, were included; thus, relevant studies may have been excluded. It is important to emphasize that because the COVID‐19 pandemic remains ongoing, different nursing ethical dilemmas may be noticed in the future.

7. CONCLUSIONS

Nurses are facing huge ethical dilemmas during the COVID‐19 pandemic, mainly because in providing the care, they often put their own health and that of their families at risk. Ethical nursing dilemmas regarding beneficence, nonmaleficence, autonomy and justice were identified in this literature review. The reasons for these ethical problems are usually related to the lack of PPE, shortages of medical supplies and personnel and the uncertainties that permeate an environment threatened by a new and highly contagious disease such as COVID‐19.

Knowing about the various ethical dilemmas faced by nurses during the COVID‐19 pandemic provides information for support programmes to be developed in health institutions to minimize the problems faced by these professionals whose roles are fundamental for the control of the pandemic. Further research carried out using broader search criteria should be done to identify and describe additional sources of nursing ethical conflicts during the pandemic.

8. IMPLICATIONS FOR NURSING MANAGEMENT

This review provides information that can inspire nurse managers working during the COVID‐19 pandemic to support and empower nurses to act in accordance with ethical principles, which is important in order for nurses to protect themselves while providing efficient and effective care. It is known that nurses need, in addition to training and knowledge, to feel safe to provide quality care. The nurse manager must develop an appropriate and secure working environment in which nurses are well supported to make decisions based on ethical principles. The support of nurse managers is widely cited by nurses as being fundamental for solving problems during routine nursing practices; in cases of crisis such as the COVID‐19 pandemic, the role of the nurse manager as a model for the nursing team becomes even more important.

CONFLICT OF INTEREST

The author declares that there is no conflict of interest with respect to the research, authorship and/or publication of this article.

ETHICAL APPROVAL

No ethical approval was required for this integrative review.

ACKNOWLEDGEMENT

This research received no specific grant from any funding agency in the public commercial or not‐for‐profit sector.

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DATA AVAILABILITY STATEMENT

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Nursing Case Studies with Answers

Explore Nursing Case Studies with Answers and examples in Carepatron's free downloadable PDF. Enhance your nursing knowledge and prepare for exams with practical scenarios.

By Wynona Jugueta on Apr 08, 2024.

Fact Checked by Ericka Pingol.

What is a case study?

A case study in medicine is a detailed report of a patient's experience with a disease, treatment, or condition. It typically includes the patient's medical history, symptoms, diagnostic tests, treatment course, and outcome.

Some key things to know about medical case studies template . First, they delve deep into the specifics of a single case, providing a rich understanding of a particular medical situation.

Medical professionals use case studies to learn about rare diseases, unusual presentations of common conditions, and the decision-making process involved in complex cases.

Case studies can identify exciting areas for further investigation through more rigorous clinical trials. While informative, they can't be used to develop general treatment guidelines because they only focus on a single case.

Overall, medical case studies are valuable tools for medical education and research, offering insights into human health and disease complexities.

Printable Nursing Case Studies with Answers

Download this Nursing Case Studies with Answers to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients.

What is in a nursing case study?

A nursing case study is a detailed examination of a patient's health condition, treatment plan, and overall care journey, specifically from the perspective of nursing practice. These case studies are essential components of nursing education and professional development, providing valuable insights into clinical scenarios and patient care experiences.

In a case nursing study template , various elements are typically included to comprehensively understand the patient's situation. First and foremost, the case study outlines the patient's demographic information, including age, gender, medical history, and presenting symptoms. This demographic overview sets the stage for understanding the context in which healthcare interventions occur.

Moreover, nursing case studies often delve into the nursing assessment process, highlighting the initial and ongoing assessments nurses conduct to gather relevant patient health status data. These assessments involve physical examinations, vital sign monitoring, and assessment tools to identify potential health issues and risk factors.

Critical thinking skills are essential in nursing case studies, as they enable nurses to analyze complex clinical situations, identify priority needs, and develop effective care plans tailored to individual patients. Nursing students and experienced nurses use case studies as opportunities to enhance their critical thinking abilities and clinical decision-making processes.

Nursing case studies serve several vital purposes within healthcare education and professional practice, whether they are a primary care physician or a group of nursing students. Let's explore each purpose in detail:

Enhancing clinical reasoning skills

One primary purpose of nursing case studies is to enhance nursing students' and practicing nurses' clinical reasoning skills. By presenting realistic patient scenarios, case studies challenge individuals to analyze clinical data, interpret findings, and develop appropriate nursing interventions. This process promotes critical thinking and problem-solving abilities essential for effective nursing practice.

Applying theoretical knowledge to practice

Nursing case studies provide a bridge between theoretical knowledge and practical application. They allow nursing students to apply concepts learned in the classroom to real-world patient care situations. By engaging with case studies, students can integrate theoretical principles with clinical practice, gaining a deeper understanding of nursing concepts and their relevance to patient care.

Facilitating interdisciplinary collaboration

Another purpose of nursing case studies is to facilitate interdisciplinary collaboration among healthcare professionals. Nurses often collaborate with physicians, specialists, therapists, and other team members in complex patient cases to deliver comprehensive care. Case studies offer opportunities for nurses to explore collaborative decision-making processes, communication strategies, and teamwork dynamics essential for providing quality patient care.

Promoting evidence-based practice

Nursing case studies are crucial in promoting evidence-based practice (EBP) within nursing and healthcare settings. Nurses can make informed decisions about patient care interventions by analyzing patient scenarios and considering current research evidence. Case studies encourage nurses to critically evaluate research findings, clinical guidelines, and best practices to ensure the delivery of safe, effective, and patient-centered care.

Fostering professional development

Engaging with nursing case studies contributes to the ongoing professional development of nurses at all stages of their careers. For nursing students, case studies provide valuable learning experiences that help prepare them for clinical practice. For experienced nurses, case studies offer opportunities to refine clinical skills, stay updated on emerging healthcare trends, and reflect on past experiences to improve future practice.

How to write a nursing case study?

Writing a nursing case study involves several essential steps to ensure accuracy, relevance, and clarity. Let's break down the process into actionable steps:

Step 1: Select a patient case

Begin by selecting a patient case that presents a relevant and compelling healthcare scenario. Consider factors such as the patient's demographic information, medical history, presenting symptoms (e.g., joint stiffness, pain), and healthcare needs (e.g., medication administration, vital signs monitoring). Choose a case that aligns with your learning objectives and offers meaningful analysis and discussion opportunities.

Step 2: Gather relevant data

Collect comprehensive data about the selected patient case, including medical records, test results, nursing assessments, and relevant healthcare documentation. Pay close attention to details such as the patient's current health status, past medical history (e.g., diabetes), treatment plans, and any ongoing concerns or challenges. Utilize assessment tools and techniques to evaluate the patient's condition thoroughly and identify areas of clinical significance.

Step 3: Assess the patient's needs

Based on the gathered data, evaluate the patient's needs, considering physical, emotional, social, and environmental factors. Assess the patient's pain levels, mobility, vital signs, and other relevant health indicators. Identify any potential complications, risks, or areas requiring immediate attention. Consider the patient's preferences, cultural background, and individualized care requirements in your assessment.

Step 4: Formulate nursing diagnoses

Formulate nursing diagnoses that accurately reflect the patient's health needs and priorities based on your assessment findings. Identify actual and potential nursing diagnoses related to the patient's condition, considering factors such as impaired mobility, ineffective pain management, medication adherence issues, and self-care deficits. Ensure your nursing diagnoses are specific, measurable, achievable, relevant, and time-bound (SMART).

Step 5: Develop a care plan

Develop a comprehensive care plan outlining the nursing interventions and strategies to address the patient's identified needs and nursing diagnoses. Prioritize interventions based on the patient's condition, preferences, and care goals. Include evidence-based nursing interventions to promote optimal health outcomes, manage symptoms, prevent complications, and enhance the patient's overall well-being. Collaborate with other healthcare professionals as needed to ensure coordinated care delivery.

Step 6: Implement and evaluate interventions

Implement the nursing interventions outlined in the care plan while closely monitoring the patient's response to treatment. Administer medications, provide patient education, perform nursing procedures, and coordinate care activities to effectively meet the patient's needs. Continuously evaluate the effectiveness of interventions, reassessing the patient's condition and adjusting the care plan as necessary. Document all interventions, observations, and outcomes accurately and comprehensively.

Step 7: Reflect and seek assistance

Reflect on the nursing case study process, considering what worked well, areas for improvement, and lessons learned. Seek assistance from nursing instructors, preceptors, or colleagues if you encounter challenges or have concerns about the patient's care. Collaborate with interdisciplinary team members to address complex patient issues and ensure holistic care delivery. Continuously strive to enhance your nursing practice through ongoing learning and professional development.

Nursing Case Studies with Answers example (sample)

Below is an example of a nursing case study sample created by the Carepatron team. This sample illustrates a structured framework for documenting patient cases, outlining nursing interventions, and providing corresponding answers to guide learners through the analysis process. Feel free to download the PDF and use it as a reference when formulating your own nursing case studies.

Download this free Nursing Case Studies with Answers PDF example here 

Why use Carepatron as your nursing software?

Carepatron stands out as a comprehensive and reliable solution for nursing professionals seeking efficient and streamlined workflows in their practice. With a range of features tailored to the needs of nurses and healthcare teams, Carepatron offers unparalleled support and functionality for managing various aspects of patient care.

Nurse scheduling software

One of the key advantages of Carepatron is its nurse scheduling software , which simplifies the process of creating and managing schedules for nursing staff. With intuitive scheduling tools and customizable options, nurses can easily coordinate shifts, manage availability, and ensure adequate staffing levels to meet patient needs effectively.

Telehealth platform

In addition, Carepatron offers a robust telehealth platform that facilitates remote patient monitoring, virtual consultations, and telemedicine services. This feature enables nurses to provide continuity of care beyond traditional healthcare settings, reaching patients in remote areas or those unable to attend in-person appointments.

Clinical documentation software

Furthermore, Carepatron's clinical documentation software streamlines the documentation process, allowing nurses to easily capture patient data, record assessments, and document interventions. The platform supports accurate and efficient documentation practices, ensuring compliance with regulatory standards and promoting continuity of care across healthcare settings.

Commonly asked questions

In clinical terms, a case study is a detailed examination of a patient's medical history, symptoms, diagnosis, treatment, and outcomes, typically used for educational or research purposes.

Case studies are essential in nursing as they provide real-life scenarios for nurses to apply theoretical knowledge, enhance critical thinking skills, and develop practical clinical reasoning and decision-making abilities.

Case studies in nursing education offer benefits such as promoting active learning, encouraging problem-solving skills, facilitating interdisciplinary collaboration, and fostering a deeper understanding of complex healthcare situations.

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Overhead Squat Assessment

Get access to a free Overhead Squat Assessment template. Learn how to perform this test and interpret the results.

Osteoarthritis Diagnosis Criteria

Understand the signs, causes, and effective criteria for diagnosis. Download our free PDF example for a detailed understanding.

Stages of Relapse Worksheet

Download our free Stages of Relapse Worksheet to effectively track and manage signs of emotional, mental, and physical relapse.

Cervical Flexion Rotation Test

Discover the Cervical Flexion Rotation Test for assessing upper cervical spine dysfunction, ideal for diagnosing cervicogenic headaches and neck issues.

Levels of Hoarding Test

Access a resource that will aid you in evaluating a patient's hoarding disorder. Download our Levels of Hoarding Test today!

Antisocial Personality Disorder Treatment Plan

Discover an effective treatment plan for Antisocial Personality Disorder to help individuals manage symptoms and improve quality of life.

Vineland Adaptive Behavior Scale

Learn more about the comprehensive Vineland Adaptive Behavior Scale, which assesses adaptive behaviors in individuals and provides targeted support.

Norton Scale

Learn about the Norton Scale, a tool used in healthcare to assess the risk of pressure ulcers. Understand its significance and application.

Medical Diagnosis Form

This form helps healthcare professionals gather patient information for accurate diagnosis. Download a free medical diagnosis form template.

Authenticity Test

Discover how authentic you are with our Authenticity Test. Uncover your true self, live more authentically, and improve your life satisfaction. Try it now!

Beers Criteria Template

Explore the Beers Criteria Template, guiding principles for safer medication use in older adults—essential knowledge for healthcare professionals.

Non-Medical Home Care Assessment Form PDF

Download, print, and fill out our Non-Medical Home Care Assessment Form PDF for thorough evaluation and personalized care plans. Streamline your caregiving process today!

Miracle Question Worksheet

Use a helpful tool when practicing solution-focused therapy to engage and build motivation among clients. Download your free PDF here.

AC Joint Test

Explore AC Joint Test procedures, results interpretation, and next steps for managing injuries like AC joint separation and arthritis.

Discover the ins and outs of the PVD Test with our comprehensive guide and template. Learn about its purpose, procedure, risks, and more.

Immature Personality Disorder Test

Assess and understand immature personality disorder with Carepatron's free PDF test and examples. Get insights into this personality disorder and learn more about it.

Snapping Hip Test

Gain access to an essential resource, the Snapping Hip Test, to assist you in diagnosing a snapping hip during physical assessments. Download today!

Hip Quadrant Test

Learn how detailed records promote quality of care for patients with hip pathologies. Download our Hip Quadrant Test to document the process.

Shame Resilience Theory Template

Download a free resource that clients can use for a more goal-directed approach to building shame resilience.

Disruptive Mood Dysregulation Disorder Treatment Plan

Unlock efficient anxiety care with Carepatron's software, featuring patient management tools, secure communication, and streamlined billing.

Multiple Sclerosis Test

Discover the symptoms, causes, diagnosis, and treatment options for Multiple Sclerosis and understand comprehensive care approaches.

MCL Injury Test

Discover key insights on MCL injuries, from symptoms and diagnosis to recovery. Get expert advice for effective treatment and healing.

Dermatomyositis Diagnosis Criteria

Learn about the diagnostic criteria for dermatomyositis and see an example with Carepatron's free PDF download. Get the information you need to understand this condition.

Hip Mobility Test

Learn how to assess your hip mobility with a simple test. Download Carepatron's free PDF guide with examples to improve hip flexibility and function.

Massage Chart

Explore our comprehensive Massage Chart for holistic healthcare solutions and techniques. Perfect for practitioners and enthusiasts alike!

Occupational Therapy Acute Care Cheat Sheet

Streamline patient recovery with key strategies for enhancing independence in acute settings. Download our free Occupational Therapy Acute Care Cheat Sheet.

Neck Pain Chart

Explore our comprehensive Neck Pain Chart for insights into causes, symptoms, and treatments. Find relief and understanding today.

Sedation Scale Nursing (Ramsay Sedation Scale)

Discover key sedation scales used in nursing, including RASS and Ramsay Scale, for accurate patient sedation assessment in critical care settings.

Blood Tests for Lupus

Download a free Blood Tests for Lupus template. Learn the various types of tests used to diagnose this disease.

Neurological Exam Template

Discover the importance of neurological assessments for diagnosing and monitoring conditions with our comprehensive guide and template. templates

Homeopathic Dosage Chart

Discover the principles of homeopathy, dosage guidelines, and effectiveness, with references and a downloadable chart for practical use.

Gout Diagnosis Criteria

Uncover the essential Gout Diagnosis Criteria here, including symptoms, diagnostic tests, and the American College of Rheumatology guidelines.

Peroneal Tendon Tear Test

Learn about the Peroneal Tendon Tear Test and use our template to record results!

Ear Seeds Placement Chart

Learn what ear seeds are and download our Ear Seeds Placement Chart template!

Physical Therapy Initial Evaluation

Unlock the benefits of Physical Therapy Initial Evaluation: a key step in personalized treatment planning for improved mobility and pain relief.

Osteoarthritis Treatment Guidelines

Learn about the management of osteoarthritis, treatments, causes, and care strategies. Access tips for managing symptoms and improving quality of life in our guide.

Prone Knee Bend Test

Learn about the Prone Knee Bend Test and how it assesses radicular pain.

PTSD Treatment Guidelines

Download our PTSD Treatment Guidelines template to access evidence-based treatment plans, diagnostic tools, and personalized care strategies.

Assess alcohol use with AUDIT-C: quick, accurate alcohol screening tests for hazardous drinking. Learn your risk level in minutes. Download our free template now!

EFT Cycle Worksheet

Download our free EFT Cycle Worksheet example and discover the benefits of integrating it into your practice.

Torn Meniscus Self Test

Discover how to identify a torn meniscus with our self-test guide. Learn about meniscus function and symptoms, and download our free self-test template today.

Prediabetes Treatment Guidelines

Download a free Prediabetes Treatment Guidelines and example to learn more about managing prediabetes effectively.

Nurse Practitioner Performance Evaluation

Enhance clinical performance, communication, and patient satisfaction in your healthcare system. Download our Nurse Practitioner Performance Evaluation today!

Occupational Therapy Pediatric Evaluation

Learn about the process of pediatric occupational therapy evaluation. Download Carepatron's free PDF example to assist in understanding and conducting assessments for children.

Dementia Treatment Guidelines

Explore comprehensive dementia treatment guidelines and use Carepatron's free PDF download of an example plan. Learn about effective strategies and interventions for dementia care.

Coping with Auditory Hallucinations Worksheet

Use our Coping with Auditory Hallucinations Worksheet to help your patients manage and differentiate real sensations from hallucinations effectively.

Tight Hip Flexors Test

Assess the tightness of your patient's hip flexor muscles with a tight hip flexors test. Click here for a guide and free template!

Gender Dysphoria DSM 5 Criteria

Explore the DSM-5 criteria for Gender Dysphoria with our guide and template, designed to assist with understanding and accurate diagnosis.

Bronchitis Treatment Guidelines

Explore bronchitis treatment guidelines for both acute and chronic forms, focusing on diagnosis, management, and preventive measures.

Patient Safety Checklist

Enhance safety in healthcare processes with the Patient Safety Checklist, ensuring comprehensive adherence to essential safety protocols.

Fatigue Assessment

Improve workplace safety and employee well-being with this valuable resource. Download Carepatron's free PDF of a fatigue assessment tool here to assess and manage fatigue in various settings.

AC Shear Test

Get access to a free AC Shear Test. Learn how to perform this assessment and record findings using our PDF template.

Hip Flexor Strain Test

Access our Hip Flexor Strain Test template, designed for healthcare professionals to diagnose and manage hip flexor strains, complete with a detailed guide.

Nursing Assessment of Eye

Explore comprehensive guidelines for nursing eye assessments, including techniques, common disorders, and the benefits of using Carepatron.

Nursing Care Plan for Impaired Memory

Discover our Nursing Care Plan for Impaired Memory to streamline your clinical documentation. Download a free PDF template here.

Clinical Evaluation

Explore the process of conducting clinical evaluations and its importance in the therapeutic process. Access a free Clinical Evaluation template to help you get started.

Finger Prick Blood Test

Learn how to perform the Finger Prick Blood Test in this guide. Download a free PDF and sample here.

Criteria for Diagnosis of Diabetes

Streamline diabetes management with Carepatron's templates for accurate diagnosis, early treatment, care plans, and effective patient strategies.

Psych Nurse Report Sheet

Streamline patient care with our comprehensive Psych Nurse Report Sheet, designed for efficient communication and organization. Download now!

Promis Scoring

Introduce a systematic approach to evaluating patient health through the PROMIS measures and learn how to interpret its scores.

Chronic Illnesses List

Access this helpful guide on chronic illnesses you can refer to when working on prevention, diagnosis, and treatment planning.

Therapy Letter for Court

Explore our guide on writing Therapy Letters for Court, offering templates and insights for therapists to support clients' legal cases effectively.

Nursing Nutrition Assessment

Learn about nursing nutrition assessments, including examples and Carepatron's free PDF download to help you understand the process and improve patient care.

Facial Massage Techniques PDF

Unlock the secrets of rejuvenating facial massage techniques with Carepatron's comprehensive PDF guide. Learn how to enhance your skincare routine and achieve a radiant, glowing complexion.

Blood Test for Heart Attack

Learn about the importance of blood tests for detecting heart attacks and download Carepatron's free PDF example for reference. Find crucial information to help you understand the process.

Mental Health Handout

Learn key insights into mental health conditions, warning signs, and resources. Access a free Mental Health Handout today!

Procedure Note Template

Ensure patient identity, consent, anesthesia, vital signs, and complications are documented. Download our accessible Procedure Note Template today!

Nursing Home Report Sheet

Discover a comprehensive guide on creating a Nursing Home Report Sheet. Includes tips, examples, and a free PDF download to streamline healthcare reporting.

Obesity Chart

Explore our free Obesity Chart and example, designed to help practitioners and patients monitor overall health risks associated with obesity.

Charge Nurse Duties Checklist

Take charge with our comprehensive Charge Nurse Duties Checklist. Free PDF download available!

Pre-employment Medical Exam

Ensure job applicants' fitness for duty with our Pre-Employment Medical Exam Template. Comprehensive guide for thorough health assessments.

Medical Clearance Form

Get your health clearance certificate easily with our Medical Clearance Form. Download for free for a streamlined process and hassle-free experience.

Level of Care Assessment

Discover what a Level of Care Assessment entails and access Carepatron's free PDF download with an example to help you better understand the process.

Standard Intake Questionnaire Template

Access a standard intake questionnaire tool to help you enhance the initial touchpoint with patients in their healthcare process.

Patient Workup Template

Optimize patient care with our comprehensive Patient Workup Template. Streamline assessments and treatment plans efficiently.

Stroke Treatment Guidelines

Explore evidence-based Stroke Treatment Guidelines for effective care. Expert recommendations to optimize stroke management.

Counseling Theories Comparison Chart

Explore a tool to differentiate counseling theories and select approaches that can work best for each unique client.

Nursing Registration Form

Learn what a nurse registry entails, its significance to registered nurses, and the application process completed through a Nursing Registration Form.

Physical Therapy Plan of Care

Download Carepatron's free PDF example of a comprehensive Physical Therapy Plan of Care. Learn how to create an effective treatment plan to optimize patient outcomes.

ABA Intake Form

Access a free PDF template of an ABA Intake Form to improve your initial touchpoint in the therapeutic process.

Speech Language Pathology Evaluation Report

Get Carepatron's free PDF download of a Speech Language Pathology Evaluation Report example to track therapy progress and communicate with team members.

Home Remedies for Common Diseases PDF

Explore natural and effective Home Remedies for Common Diseases with our guide, and educate patients and caretakers to manage ailments safely at home.

HIPAA Policy Template

Get a comprehensive HIPAA policy template with examples. Ensure compliance, protect patient privacy, and secure health information. Free PDF download available.

Health Appraisal Form

Download a free Health Appraisal Form for young patients. Streamline your clinical documentation with our PDF template and example.

Consent to Treat Form for Adults

Discover the importance of the Consent to Treat Form for adults with our comprehensive guide and example. Get your free PDF download today!

Nursing Skills Assessment

Know how to evaluate nursing skills and competencies with our comprehensive guide. Includes an example template for a Nursing Skills Assessment. Free PDF download available.

Medical Record Request Form Template

Discover how to streamline medical record requests with our free template & example. Ensure efficient, compliant processing. Download your PDF today.

Personal Training Questionnaire

Access a comprehensive Personal Training Questionnaire to integrate when onboarding new clients to ensure a personalized fitness plan.

Agoraphobia DSM 5 Criteria

Explore a helpful documentation tool to help screen for the symptoms of agoraphobia among clients. Download a free PDF resource here.

Dental Inventory List

Streamline your dental practice's inventory management with our Dental Inventory List & Example, available for free PDF download.

Personal Trainer Intake Form

Discover how to create an effective Personal Trainer Intake Form with our comprehensive guide & free PDF example. Streamline your fitness assessments now.

Healthy Liver Foods List

Explore our Healthy Liver Foods List to support liver health with the right diet. Learn how Carepatron aids healthcare professionals in managing nutrition plans.

Printable Family History Form

Streamline patient intake with our Family History Form template. Capture essential family medical history to enhance patient care and risk assessment.

Portable Medication List

Keep track of your prescription medicines, supplements, and vitamins with our Portable Medication List and take care of your health

Universal Health Form

Learn the importance of a Universal Health Form. Download a free PDF and template to guide parents and guardians when completing the form.

Skin Analysis Form

Need a skin analysis form? Download Carepatron's free PDF template and get an example to help you conduct comprehensive skin analyses effectively.

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