Basic Safety Concepts
Ernstmeyer & Christman- Nursing Fundamentals 2e- OpenRN
Safety: A Basic Need
Safety is a basic foundational human need and always receives priority in client care. Nurses typically use Maslow’s Hierarchy of Needs to prioritize urgent client needs, with the bottom two rows of the pyramid receiving top priority. See Figure 5.1[1] for an image of Maslow’s Hierarchy of Needs. Safety is intertwined with basic physiological needs.
Consider the following scenario: You are driving back from a relaxing weekend at the lake and come upon a fiery car crash. You run over to the car to help anyone inside. When you get to the scene, you notice that the lone person in the car is not breathing. Your first priority is not to initiate rescue breathing inside the burning car, but to move the person to a safe place where you can safely provide CPR.

In nursing, the concept of client safety is central to everything we do in all health care settings. As a nurse, you play a critical role in promoting client safety while providing care. You also teach clients and their caregivers how to prevent injuries and remain safe in their homes and in the community. Safe client care also includes measures to keep you safe in the health care environment; if you become ill or injured, you will not be able to effectively care for others.
Safe client care is a commitment to providing the best possible care to every client and their caregivers in every moment of every day. Clients come to health care facilities expecting to be kept safe while they are treated for illnesses and injuries. Unfortunately, you may have heard stories about situations when that did not happen. Medical errors can be devastating to clients and their families. Consider the true story in the following box that illustrates factors affecting client safety.
The Josie King Story
In 2001, 18-month-old Josie King died as a result of medical errors in a well-known hospital from a hospital-acquired infection and an incorrectly administered pain medication. How did this preventable death happen? Watch this video of her mother, Sorrel King, telling Josie’s story and explaining how Josie’s death spurred her work on improving client safety in hospitals everywhere.[2]
Reflective Questions:
- What factors contributed to Josie’s death?
- How could these factors be resolved?
Never Events
The event described in the Josie King story is considered a “never event.” Never events are adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable. In 2007 the Centers for Medicare and Medicaid Services (CMS) discontinued payment for costs associated with never events, and this policy has been adopted by most private insurance companies. Never events are publicly reported, with the goal of increasing accountability by health care agencies and improving the quality of client care. The current list of never events includes seven categories of events:
- Surgical or procedural event, such as surgery performed on the wrong body part
- Product or device, such as injury or death from a contaminated drug or device
- Client protection, such as client suicide in a health care setting
- Care management, such as death or injury from a medication error
- Environmental, such as death or injury as the result of using restraints
- Radiologic, such as a metallic object in an MRI area
- Criminal, such as death or injury of a client or staff member resulting from physical assault on the grounds of a health care setting
Sentinel Events
Sentinel events are very similar to never events although they may not be entirely preventable. They are defined by The Joint Commission as an “A client safety event that reaches a client and results in death, permanent harm, or severe temporary harm requiring interventions to sustain life.” Such events are called “sentinel” because they signal the need for immediate investigation and response. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission.[3] It is helpful to facilities to self-report sentinel events so that other facilities can learn from these events and future sentinel events can be prevented through knowledge sharing and risk reduction. Investigations into sentinel events are typically achieved through a process called root cause analysis.
Root cause analysis is a structured method used to analyze serious adverse events to identify underlying problems that increase the likelihood of errors, while avoiding the trap of focusing on mistakes by individuals. A multidisciplinary team analyzes the sequence of events leading up to the error with the goal of identifying how and why the event occurred. The ultimate goal of root cause analysis is to prevent future harm by eliminating hidden problems within a health care system that contribute to adverse events. For example, when a medication error occurs, a root cause analysis goes beyond focusing on the mistake by the nurse and looks at other system factors that contributed to the error, such as similar-looking drug labels, placement of similar-looking medications next to each other in a medication dispensing machine, or vague instructions in a provider order.
Root cause analysis uses human factors science as part of the investigation. Human factors focus on the interrelationships among humans, the tools and equipment they use in the workplace, and the environment in which they work. Safety in health care is ultimately dependent on humans – the doctors, nurses, and health care professionals – providing the care.
Near Misses
In addition to investigating sentinel events and never events, agencies use root cause analysis to investigate near misses. Near misses are defined by the World Health Organization (WHO) as, “An error that has the potential to cause an adverse event (client harm) but fails to do so because of chance or because it is intercepted.” Errors and near misses are rarely the result of poor motivation or incompetence of the health care professional but are often caused by key contributing factors such as poor communication, less-than-optimal teamwork, memory overload, reliance on memory for complex procedures, and lack of standardization of policies and procedures. In an effort to prevent near misses, medical errors, sentinel events, and never events, several safety strategies have been developed and implemented in health care organizations across the country. These strategies will be discussed throughout the remainder of the chapter.
Incident Reports and Client Safety
Recall from the previous discussion in Chapter 2.5 that an incident report is a specific type of documentation performed when there is an error, near miss, or other unexpected occurrence that occurs during client care. Incident reports are used to identify process problems or other areas that could benefit from safety and quality improvement and are not included in the client’s medical record. They are a component of an agency’s culture of safety and are used during investigations like root cause analysis to help improve the safety and quality of client care.
- “Maslow's hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0 ↵
- Healthcare.gov. (2011, May 25). Introducing the partnerships for patients with Sorrel King [Video]. YouTube. https://youtu.be/ak_5X66V5Ms ↵
- The Joint Commission. (2024). Sentinel event. https://www.jointcommission.org/resources/sentinel-event/ ↵
Learning Activities
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)
Visit the TeamSTEPPS® Instructor Manual: Specialty Scenarios for multiple AHRQ scenarios requiring application of TeamSTEPPS® to client scenarios.
Scenario 1
Read this scenario and answer the following questions.
Jill and Neil are both nurses working the same shift. Jill is responsible for clients in Rooms 1–6, and Neil is responsible for clients in Rooms 7–12. Over the course of their shift, both nurses routinely visit their clients’ rooms to take vitals and deliver medication.
On one of his rounds, Neil attends to his client in Room 8. He reads the chart and notices Jill’s initials signaling that she had already checked on this client. A bit confused, he continues on to his next client. After another hour goes by, Neil returns to Room 8 and again notices Jill’s initials on the chart. Neil thinks to himself, “What is she doing? I’ve got it covered. She’s checking my work. She must think I’m incompetent.” Neil decides to approach Jill and see what is going on.
Questions:
a) What might have been the initial cause of the conflict?
b) What kind of conflict did it turn into?
c) If Neil provides Jill with a copy of the room assignments, would that resolve the conflict?
Scenario 2
Read this scenario and answer the following questions.
A nursing team is having a routine meeting. One of the nurses, Stephen, is at the end of a 12-hour shift, and another nurse, Tanya, is just beginning hers. Tanya is a senior nurse in the unit with over ten years’ experience on this specific unit. Stephen is new to the unit with fewer than three years’ experience in nursing. Tanya has been asked to present information to the team about effective time management on the unit. During Tanya’s presentation, Stephen is seen rolling his eyes and talking to other members of the team. Tanya breaks from her presentation and asks, “Stephen, do you have anything to add?” Stephen replies, “No, I just don’t know why we need to talk about this again.” Tanya chooses to avoid engaging with Stephen further and finishes her presentation. Stephen continues to be disruptive throughout the presentation.
After the meeting concludes, Tanya approaches Stephen and asks if he had anything to add from the meeting. Stephen replies, “No, I don’t have anything. I just think we all know what the procedure is because we just learned it all during orientation training. Maybe if you don’t remember the training, you should take it again.” Tanya is shocked by his reply and quickly composes herself. She states, “Stephen, I have worked on this unit for over ten years. I was asked to present that information because there are current issues going on among the staff. Next time please respect my authority and listen to those who come before you.”
Questions:
a) What types of conflict are present?
b) What will need to happen to resolve this issue between Tanya and Stephen?
c) Take a moment to think about what your preferred approach to conflict may be. How might you adapt your approach to conflict when working with others?
Scenario 3
Read this scenario and answer the following questions.
Connie, the head nurse on Unit 7, is a respected member of the team. She has been working on this unit for a number of years and is seen by the other nurses as the “go to” person for questions and guidance. Connie is always thorough with clients and demonstrates excellence and quality in her work. Dr. Smith is a well-respected member of the medical profession and an expert in his field of medicine. He has a reputation for excellent bedside manner and is thorough in his approach with clients.
Connie is four hours into her 12-hour shift when she is approached by Dr. Smith. He asks, “Connie, why has the client in Room 2 not received his blood pressure medication over the past few days? I was not notified about this!”
Connie, trying to find a quick solution, replies, “I didn’t know that client had been missing medication. I’ll go check on it and get back to you.”
Dr. Smith is persistent, saying, “You don’t need to go check anything. I know this client and should have been informed about the withholding of medication and the reasons why.”
Connie, again attempting to find a resolution, states, “Well, there must be some communication about this change somewhere . . .”
“There isn’t!” Dr. Smith interrupts.
Connie becomes upset and decides to leave the conversation after declaring, “Fine, if you know everything, then you figure it out; you’re the one with the medical degree, aren’t you?” She storms off.
Connie makes her way to the nurses’ station where Dan and Elise are assessing charts and says to them, “You will not believe what Dr. Smith just said to me!”
Dan and Elise look shocked and ask “What?”
Connie explains, “Well, he thinks I don’t do my job, when really we nurses are the ones that keep this unit going. Who is he to question my ability to look after clients? I am the most knowledgeable person on this unit!”
Dan and Elise don’t know how to reply and decide to avoid the interaction with a simple, “Oh yeah.”
Meanwhile, Dr. Smith has made his way to the doctor’s lounge and finds his colleague Dr. Lee. Dr. Smith tells him, “That head nurse on Unit 7 is useless. She doesn’t know what she is doing and doesn’t understand that we must be informed about changes to our clients’ medications, does she?” Dr. Lee nods quickly and returns to reviewing his file.
About three hours later, Connie and Dr. Smith have each spoken to several people about the interaction. Connie bumps into another nurse, Jessie, one of her best friends. Connie pulls Jessie aside and says, “You will not believe what I just saw. I was going into the admin office to file my holiday requests and out of the corner of my eye, I saw Dr. Smith lurking around the corner, pretending to look at a chart, spying on me!”
“What? Are you serious? That’s not safe,” replies Jessie.
Connie is relieved that Jessie is taking her side—it makes her feel as if she is not going crazy. “Yeah, I’m really getting worried about this. First, that creep is accusing me of not doing my job, and then he is wasting his time spying on me. What a loser! Maybe what I should do is file a complaint. That’ll show the ‘big man’ that he isn’t that big around here and maybe take him down a notch.”
When Jessie gives her an apprehensive look, Connie continues, “Oh Jessie, don’t worry. I have a perfect record and this won’t affect me. Even if it does, I will have done something good for all the other nurses around here. It is the principle of the matter at this point.”
Meanwhile, Dr. Smith has run into an old classmate of his, Dr. Drucker, and says, “Wow! You got hired! So happy to have you in the hospital. I do need to tell you though to be careful of the head nurse on Unit 7 . . .” Dr. Smith describes his troubles with Connie and adds, “She’s a real snitch! She makes trouble out of nothing. I was reviewing a chart down the corridor from the admin office, minding my own business and actually getting my work done, when I saw her slip into the admin office to squeal about me to the top bosses! This is something that needs to be watched! We can’t have people reporting doctors to administration over nothing. I think I’m going to write her up and get a black mark on that perfect record of hers. I will be fine—everyone knows I’m right. There will be consequences for her.”
Questions:
a) Using the scenario above, identify the stages of the conflict escalation.
b) What suggestions might you give to Dan, Elise, Jessie, Dr. Lee, and Dr. Drucker about how to respond to Connie and Dr. Smith?
c) How do you think this conflict will be resolved?
Test your knowledge using this NCLEX Next Generation-style Case Study. You may reset and resubmit your answers to this question an unlimited number of times.[1]
Conflicts are inevitable when working on a team composed of members with different personalities, roles, and responsibilities. It is essential for all nurses to develop conflict resolution skills.
Common Sources of Interpersonal Conflict
Common sources of interpersonal conflict in health care settings are passive-aggressiveness, horizontal aggression, defensiveness, peer informer behavior, and victimization behaviors.[2]
Passive-Aggressiveness
Passive-aggressiveness is a behavior that shows disconnection between what a person says and does. Many times, a passive-aggressive person will agree with another person’s request, but later express feelings of frustration or anger to others and not comply with the request.
As an example, a charge nurse informs the team of RNs in a team meeting that a new policy requires bedside rounding. A nurse responds enthusiastically during the meeting but then complains to others about the policy and refuses to do it. The best method of managing passive-aggressive behavior is to confront it calmly and directly. For this example, it would be helpful for the charge nurse to say, “I was disappointed to hear you are upset about the new bedside rounding policy because you didn’t express any concerns directly to me. It would be helpful for you to directly communicate concerns to me so we can discuss them and make a plan for going forward.”[3]
Horizontal Aggression
The nursing literature describes diffuse incivility, lateral/horizontal violence, and bullying among nurses in the workplace.[4] Horizontal aggression refers to hostile behavior among one’s peers. It is not acceptable and should be directly confronted in a constructive manner or it will get worse. A suggested approach to a peer displaying horizontal aggression is to respond calmly and sincerely, “I value your expertise and experience and am looking for your help and support.” If the negative behavior continues after an attempt to address the individual directly, the nurse supervisor should be notified according to the agency’s chain of command.[5]
Defensiveness
It can be difficult to receive negative feedback. Some people respond by becoming defensive. Defensiveness puts the blame for one’s shortcomings on another person to make oneself appear better.
As an example, a charge nurse addresses a nurse about not turning on the bed alarm after repositioning a client and leaving the room. The nurse responds defensively by inaccurately blaming others, stating, “The nursing assistants are always sloppy with their responsibilities.” It is helpful to confront defensiveness by restating the facts in a calm manner and redirecting the conversation to the problem, its resolution, and the risk of jeopardizing client safety. For example, the charge nurse could reply, “In this situation, I saw you leave the room after repositioning the client, and when I went into the room to answer the client’s call light, the bed alarm was off.”[6]
Peer Informer Behavior
Peer informer behavior is similar to gossip. Peer informers relay information about fellow team members to the nurse leader, and this information often lacks objective evidence. It is often best to respond to the informer by asking them to speak to their team member directly about their concerns unless it is an urgent matter that must be dealt with immediately. However, keep in mind that if concerns are shared about a staff member by more than one team member, it may be a pattern of behavior, and the nurse leader should follow up with that staff member.[7]
As an example, a nurse approaches the charge nurse and says, “Everyone is concerned about how much time Nancy is spending in the room with her clients. She gets behind in her work and the rest of us have to make up for it.” The charge nurse could reply, “Have you addressed your concerns directly with Nancy?” If the nurse replies, “No,” then the charge nurse could state, “Please talk to Nancy directly with your concerns first.” However, if another nurse shares a similar concern with the charge nurse, then the charge nurse should address this pattern of behavior with Nancy and obtain her perspective.
Victimization
Victimization occurs when a team member feels they are being singled out unfairly or held to higher expectations than their peers. Comments may include, “Why am I getting called out on this when other people are doing this and aren’t getting in trouble?” or “I was never told this; why am I always the last to know?” Team members who feel victimized should be reminded by the nurse leader they are held to the same standards as the other members. However, keep in mind that sharing information about other staff members’ performance breaches confidentiality, so do not include another employees’ performance information in conversations but instead focus on policies and procedures that apply to everyone.[8]
Types of Conflict
There are various sources of conflict that nurses may encounter in their work environment.
Role Conflict: Role conflict arises when individuals have multiple, often conflicting, expectations associated with their roles. In professional settings, an employee may face role conflict when their job responsibilities are unclear or when there are conflicting demands from different supervisors. For example, a project manager might experience tension if their role requires them to enforce strict deadlines while also being expected to accommodate frequent changes in project scope. This type of conflict can lead to stress, decreased job satisfaction, and reduced productivity. Role conflict can be mitigated by clear communication, well-defined job descriptions, and regular feedback to ensure alignment of expectations.[9]
Communication Conflict: Communication conflict occurs when there is a failure in the exchange of information. Misunderstandings, misinterpretations, and lack of effective communication can lead to disputes and frustrations. For instance, in a team setting, if one member interprets a directive differently from others, it can result in duplicated efforts or missed tasks. Communication conflict is often exacerbated by differences in communication styles, cultural backgrounds, or language barriers. Addressing this type of conflict involves fostering an environment of open and clear communication, utilizing active listening techniques, and ensuring that all parties have a mutual understanding of the messages being conveyed.[10]
Goal Conflict: Goal conflict happens when the objectives of individuals or groups are incompatible. In organizations, different departments might pursue goals that are in opposition, such as a sales team aiming for maximum customer satisfaction while a production team focuses on minimizing costs. These conflicting goals can hinder overall progress and lead to tension among team members. To resolve goal conflicts, it is crucial to align individual and departmental goals with the broader objectives of the organization. This can be achieved through strategic planning, cross-functional collaboration, and regular goal-setting meetings that ensure all efforts are directed towards a common purpose.[11]
Personality Conflict: Personality conflict arises from differences in individual temperaments, attitudes, and behaviors. Such conflicts are common in any setting where diverse personalities interact, such as workplaces, schools, or social groups. For example, a highly extroverted person might clash with a reserved colleague, leading to friction in their interactions. Personality conflicts can negatively impact team cohesion and productivity. Managing these conflicts involves fostering a culture of respect and understanding, providing training in emotional intelligence and conflict resolution, and encouraging individuals to appreciate and leverage the strengths of diverse personalities.[12]
Ethical/Values Conflict: Ethical or values conflict occurs when individuals or groups have fundamentally different beliefs and values. These conflicts are often deeply rooted and can be particularly challenging to resolve. In a corporate environment, an ethical conflict might arise if one employee believes in strict adherence to company policies while another prioritizes flexibility and personal judgment. Values conflicts can also occur over issues such as diversity, environmental responsibility, and corporate social responsibility. Addressing ethical or values conflicts requires creating an environment of mutual respect, where different perspectives are valued. Organizations can benefit from having clear ethical guidelines and fostering an inclusive culture that encourages open dialogue and ethical decision-making.[13]
Conflict Management
Individuals manage conflict differently. During conflict, a person’s behavior is typically driven by their commitment to their goals or their commitment to relationships[14]:
- Commitment to goals: The extent to which an individual attempts to satisfy their personal concerns or goals.
- Commitment to relationships: The extent to which an individual attempts to satisfy the concerns of another party or maintain the relationship with the other party.
Most people use different methods to resolve conflict depending on the situation and what strategy best applies. One approach is not necessarily better than another, and all approaches can be learned and used effectively with practice. However, to effectively manage conflict, it is important to first analyze the situation and then respond accordingly.
A long-standing conflict resolution model created by Thomas and Killmann describes five approaches to dealing with conflict: avoiding, competing, accommodating, compromising, and collaborating. Each of these steps is further described in the following subsections.[15]
Avoidance Approach
An avoidance approach to conflict resolution demonstrates a low commitment to both goals and relationships. This is the most common method of dealing with conflict, especially by people who view conflict negatively. See Table 7.7a for types of avoidance, potential results, and situations when this strategy may be appropriate.[16]
Table 7.7a. Avoidance Approach[17]
Types of Avoidance Approaches | Potential Results | Appropriate Use |
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Application to Nursing
In a clinical setting, there may be times when it is appropriate to avoid confrontation. For example, on a particularly busy day in the emergency department, a client in a life-threatening condition was recently received. The attending physician shouts orders to the nurse in a disrespectful manner. The nurse avoids addressing the conflict until after the client has been stabilized and then shares their concerns. However, if the physician continues to bark orders to nursing staff in nonemergency situations, avoidance is no longer appropriate, and the conflict must be addressed to establish a positive and respectful working environment.[18]
Competitive Approach
A competitive approach to conflict management demonstrates a high commitment to goals and a low commitment to relationships. Individuals who use the competitive approach pursue their goals at other individuals’ expense and will use whatever power is necessary to win. A competitive approach may be displayed when an individual defends an action, belief, interest, or value they believe to be correct. Competitive approaches may also be supported by infrastructure (agency promotion procedures, courts of law, legislature, etc.).[19] See Table 7.7b for types of competitive approaches, potential results, and appropriate uses.
Table 7.7b. Competitive Approach[20]
Types of Competitive Approaches | Potential Results | Appropriate Use |
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Application to Nursing
A competitive approach to conflict resolution may be appropriate in a clinical setting if a nurse leader realizes a nurse has made an error while preparing to administer IV medication to a client. The nurse leader may stop the nurse from inaccurately administering the medication and take over completing the procedure. In this case, the goal of client safety outweighs the commitment to the relationship with that nurse. However, after client safety is maintained, it would be inappropriate to continue the competitive approach when debriefing the nurse about a simple human error. Debriefing should focus on educating the nurse about policy and procedures to improve their performance. However, if it is determined the nurse was acting recklessly and disciplinary measures must be instituted by a manager, then the competitive approach may be appropriate.[21] This approach to responding to errors is often referred to as “Just Culture.”
Read more about Just Culture in the “Legal Implications” chapter.
Accommodating Approach
An accommodating approach to conflict management demonstrates a low commitment to goals and high commitment to relationships. This approach is the opposite of the competitive approach. It occurs when a person ignores or overrides their own concerns to satisfy the concerns of the other party. An accommodating approach is often used to establish reciprocal adaptations or adjustments, but when the other party does not reciprocate, conflict can result. Accommodators typically do not ask for anything in return but can become resentful when a reciprocal relationship isn’t established. If resentment grows, individuals relying on the accommodating approach may shift to a competitive approach from a feeling of “being used” that can lead to conflict.[22] See Table 7.7c for types of the accommodating approach, potential results, and appropriate uses.
Table 7.7c. Accommodating Approach[23]
Types of Accommodating Approaches |
Potential Results | Appropriate Use |
---|---|---|
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|
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Application to Nursing
It may be appropriate to use an accommodating approach when one of the nurses on your team has a challenging client who is taking up a lot of time and effort. By being situationally aware and noticing the nurse has been involved in that client’s room for a long period of time, you offer to provide task assistance in an effort to provide mutual support. You are aware this will increase your workload for a short period of time, but it will assist your colleague and promote a strong team. However, the accommodating approach is no longer appropriate if the nurse continues to expect you to cover their tasks after the situation has been resolved.[24]
Compromising Approach
A compromising approach to conflict resolution strikes a balance between commitment to goals and commitment to relationships. The objective of a compromising approach is a quick solution that will work for both parties. It typically involves both parties giving up something in return for something, thereby “meeting in the middle."[25] See Table 7.7d for types of compromising approaches, potential results, and appropriate uses.
Table 7.7d. Compromising Approach
Types of Compromising Approaches |
Potential Results | Appropriate Use |
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Application to Nursing
Compromise is an appropriate approach to conflict in many clinical settings. For example, you are working with another nurse who rarely assists other team members. The nurse asks you for assistance with a blood draw for a client. You hesitate because you are searching for a lunch tray that has not yet been delivered for a client with diabetes. You ask your colleague to obtain the client’s lunch tray while you complete their request for assistance with a blood draw. It would be inappropriate to refuse to assist the nurse based on their reputation because this could impact safe, effective care for the client.[26]
Collaborative Approach
The collaborative approach to conflict resolution demonstrates a high commitment to goals, as well as a high commitment to relationships. The collaborative approach attempts to meet the concerns and priorities of all parties, but trust and willingness for risk are required for this approach to be effective.[27] See Table 7.7e for types of collaborative approaches, potential results, and appropriate uses.
Table 7.7e. Collaborative Approach[28]
Type of Collaborative Approaches |
Potential Results | Appropriate Use |
---|---|---|
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|
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Application to Nursing
An example of appropriately using the collaborative approach in conflict management in a clinical setting is when discussing vacation time off with team members. During a team meeting, time is available to discuss and focus on what is important and a priority for each member of the team. However, the collaborative approach to conflict management would be inappropriate when discussing the implementation of a new agency policy if the team has little influence in making adjustments.[29]
All approaches to conflict can be appropriate for specific situations, but they can also be inappropriate or overused. When conflict occurs, take time to consider which approach is most beneficial for the situation. Keep in mind that using wrong approaches can escalate conflict, damage relationships, and reduce your ability to effectively meet team goals. Correct conflict management approaches build trust in relationships, accomplish goals, and de-escalate conflict.[30]
Everyone has the capacity to use any of these approaches for managing conflict and can shift from their natural style as needed. We tend to react with our most dominant natural style when under stress, but other approaches can be learned and applied with practice and self-awareness. When dealing with others who have not developed their capacity to shift from their natural style of conflict management, it is important to consider their underlying needs. By understanding individuals’ needs existing beneath the surface of the conflict, you can work with the other person toward achieving a common goal.[31]
Addressing Individual Needs and Approaches
There are times when other individuals take an approach that is not helpful to resolving the conflict. It is important to remember the only person you can control during a conflict is yourself. Be flexible with your approach according to the situation and the team members with whom you are working. If someone is taking an approach that is not beneficial to resolving conflict, it can be helpful to try to understand the needs that underlie their decision to take that approach.[32]
Here are some examples of needs underlying their approaches to conflict and suggested ways to address them[33]:
- People using the avoidance approach may need to feel physically and emotionally safe. Take the time to reassure them that their needs will be heard.
- People taking the competitive approach often feel the need for something to be accomplished to meet their goals. It may be helpful to say, “We will work out a solution, but it may take some time to get there.”
- People using the accommodating approach may need to know that no matter what happens during the conversation, your relationship will remain intact. It may be helpful to say, “This decision will not affect our relationship or how we work together.”
- People using the compromising approach may need to know that they will get something in return. It may be helpful to say, “We will do Action A first, and then we will do Action B for you.” However, be sure to be true to your word.
- People using the collaborative approach may need to know what you want before they are comfortable sharing their needs. It may be helpful to say, “I need this, this, and this...What do you need?”
Take free online Conflict Quizzes and Assessments to identify your preferred conflict management styles.
Escalating and De-Escalating Conflict
An approach taken to manage conflict can escalate (increase) or de-escalate (decrease) the conflict. Conflict on a team can take a life of its own and escalate beyond reason if not managed appropriately by nurse leaders. When conflict is not managed appropriately, negative consequences within the team often occur, and client safety can be compromised. Increased rates of absenteeism and turnover may also occur.[34]
Conflict tends to escalate under the following conditions[35]:
- There is an increase in emotions like anger, frustration, etc.
- An individual feels that they are being threatened (i.e., the fight-or-flight response is triggered).
- Other people get involved and choose sides.
- The individuals were not friendly prior to the conflict.
- The individuals desire to engage in conflict.
However, conflict can be de-escalated under the following conditions[36]:
- Attention is focused on solving the problem.
- There is a decrease in emotion and perceived threat.
- The individuals were friendly prior to the conflict.
- The individuals desire to reduce conflict.
Read an example of escalating conflict in the following box.
Example of Escalating Conflict[37]
A conflict begins between two team members who became short-tempered with each other while caring for a client experiencing a medical emergency.
- The parties become aware of the conflict but attempt to deal with it sensibly. Often, they will attribute the problem to “a misunderstanding” and indicate “we can work it out.”
- If an appropriate conflict management approach is not used, the parties begin to move from cooperation to competition. (“I’ll bend - but only if they bend first.”) They begin to view the conflict as resulting from deliberate action on the part of the other. (“Didn’t they know this was going to happen?”) Positions begin to harden and defensiveness sets in, creating adversarial encounters. Parties begin to strengthen their positions and look to others on the team for support. (“Don’t you feel I’m being reasonable?” or “Did you know what that idiot did to me?”)
- As communication deteriorates, parties rely on assumptions about the other individual and attribute negative motives to them. (“I bet they did that on purpose.”) Groupthink can take over the subgroups as each individual seeks others to take on their side. (“We have to appear strong and make a united front.”)
- Parties believe that cooperation cannot resolve the problem because of the assumed negative actions of the other. (“I’ve tried everything to get them to see reason,” “It’s time to get tough,” or “I’m going to put a stop to this.”)
- Parties begin to feel righteous and blame the other for the entire problem. Generalizing and stereotyping begin. (“I know what those kinds of people are like. . . We can’t let them get away with this.”) Parties begin to be judgmental and moralistic and believe they are defending what is “right.” (“It’s the principle of the matter” or “What will others say if we give in to this?”)
- Severe confrontation is anticipated and planned, thus making it inevitable. The parties view this confrontation as acceptable. The objective of the conflict becomes to hurt the other more than being hurt, and the dispute is beyond rational analysis. (“I’m going to make you pay even if we both go down over this,” “There is no turning back now,” or “They won’t make a fool out of me.”)
There are positive steps to take to de-escalate conflict with another individual before it gets out of control. See Figure 7.9[38] for steps to de-escalate conflict and implement change.

Conflict Management Tips
Nurses must develop their own tool kit to manage conflict in a productive, positive way. Due to rapid turnover in the health care environment at this time, new nurses may find themselves in a "charge nurse" position within their first year of practice. See Table 7.7f for tips on managing conflict constructively.[39]
Table 7.7f. Conflict Management Tips[40]
Tip | Description |
---|---|
Be Consistent | Convey to the team that expectations are consistent and implemented fairly across the team. Set expectations and make sure the team knows those expectations via department meetings and visual reminders. Follow up to ensure expectations are met. This sets a clear picture of what is required. |
Be Team-Focused | Be aware of team members' strengths and weaknesses. Address poor performance and negative attitudes. Teamwork and team dynamics impact client safety and staff retention. Ask team members what they need from you as a leader. Coach team members and staff on a regular basis. |
Convey Trust and Integrity | Trustworthiness and integrity are powerful when managing conflict. Team members are more likely to handle difficult situations constructively if they know they are supported by an approachable and supportive team leader. Stay focused on the individual and remind them that you value them and want them to feel heard. It may be helpful to include a statement such as, “As health care members, we are held accountable for positive behaviors with team members.” |
Lead with Truth | If you need to have a difficult conversation, lead with the tough message and be clear. For example, try saying, “There's something difficult I need to talk with you about. I'm concerned about the feedback I've been receiving from clients.” Even in conveying a tough message, you can build trust by showing the employee that you'll be honest with them and share feedback openly.
Don't leave the team member guessing about the problem or what they need to do to improve. Clearly state the performance gap, your expectations, the reason it matters, and the timeline for improvement, including a future meeting to review feedback and give a progress update. Provide support and available resources to help them make the needed change. |
Anticipate Reactions | Knowing how a team member will respond when conflicts arise can be a challenge. Common negative reactions to conflicts are defensiveness, deflection, and denial. Defensive comments may include, “No one's ever brought this to me before.” You can reply, “I'm invested in you and want to see you succeed. I owe it to you and our department to be transparent with you and share these concerns.”
Deflection can take the form of an employee asking you why a coworker didn't directly bring up the concern. Often, it's because others are too intimidated by the individual or situation to speak up. Your reply can be, “Accountability between colleagues is always encouraged, but as your leader, I owe it to you to share this feedback. Do you feel your colleagues perceive you as approachable and open to feedback?” Denial may include the employee refuting that the incident of concern ever happened. You can calmly remind the employee that we own others' perceptions of our behaviors and you want to help them understand where some actions may be giving people the wrong impression. |
Use Available Resources | Engage in professional development for managing conflicts when they arise. Share knowledge and experiences with other nurse leaders to build networks, partner with other teams within the organization, and use the human resources department when needed. |
The American Nurses Association (ANA) defines morality as “personal values, character, or conduct of individuals or groups within communities and societies,” whereas ethics is the formal study of morality from a wide range of perspectives.[41] Ethical behavior is considered to be such an important aspect of nursing the ANA has designated Ethics as the first Standard of Professional Performance. The ANA Standards of Professional Performance are "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently." See the following box for the competencies associated with the ANA Ethics Standard of Professional Performance[42]:
Competencies of ANA's Ethics Standard of Professional Performance[43]
- Uses the Code of Ethics for Nurses With Interpretive Statements as a moral foundation to guide nursing practice and decision-making.
- Demonstrates that every person is worthy of nursing care through the provision of respectful, person-centered, compassionate care, regardless of personal history or characteristics (Beneficence).
- Advocates for health care consumer perspectives, preferences, and rights to informed decision-making and self-determination (Respect for autonomy).
- Demonstrates a primary commitment to the recipients of nursing and health care services in all settings and situations (Fidelity).
- Maintains therapeutic relationships and professional boundaries.
- Safeguards sensitive information within ethical, legal, and regulatory parameters (Nonmaleficence).
- Identifies ethics resources within the practice setting to assist and collaborate in addressing ethical issues.
- Integrates principles of social justice in all aspects of nursing practice (Justice).
- Refines ethical competence through continued professional education and personal self-development activities.
- Depicts one's professional nursing identity through demonstrated values and ethics, knowledge, leadership, and professional comportment.
- Engages in self-care and self-reflection practices to support and preserve personal health, well-being, and integrity.
- Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care.
- Collaborates with other health professionals and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity and congruence, and reduce health disparities.
- Represents the nursing perspective in clinic, institutional, community, or professional association ethics discussions.
Reflective Questions
- What Ethics competencies have you already demonstrated during your nursing education?
- What Ethics competencies are you most interested in mastering?
- What questions do you have about the ANA’s Ethics competencies?
The ANA's Code of Ethics for Nurses With Interpretive Statements is an ethical standard that guides nursing practice and ethical decision-making.[44] This section will review several basic ethical concepts related to the ANA's Ethics Standard of Professional Performance, such as values, morals, ethical theories, ethical principles, and the ANA Code of Ethics for Nurses.
Values
Values are individual beliefs that motivate people to act one way or another and serve as guides for behavior considered “right” and “wrong.” People tend to adopt the values with which they were raised and believe those values are “right” because they are the values of their culture. Some personal values are considered sacred and moral imperatives based on an individual’s religious beliefs.[45] See Figure 6.1[46] for an image depicting choosing right from wrong actions.

In addition to personal values, organizations also establish values. The American Nurses Association (ANA) Professional Nursing Model states that nursing is based on values such as caring, compassion, presence, trustworthiness, diversity, acceptance, and accountability. These values emerge from nursing practice beliefs, such as the importance of relationships, service, respect, willingness to bear witness, self-determination, and the pursuit of health.[47] As a result of these traditional values and beliefs by nurses, Americans have ranked nursing as the most ethical and honest profession in Gallup polls since 1999, with the exception of 2001, when firefighters earned the honor after the attacks on September 11.[48]
The National League of Nursing (NLN) has also established four core values for nursing education: caring, integrity, diversity, and excellence[49]:
- Caring: Promoting health, healing, and hope in response to the human condition.
- Integrity: Respecting the dignity and moral wholeness of every person without conditions or limitations.
- Diversity: Affirming the uniqueness of and differences among persons, ideas, values, and ethnicities.
- Excellence: Cocreating and implementing transformative strategies with daring ingenuity.
Morals
Morals are the prevailing standards of behavior of a society that enable people to live cooperatively in groups. “Moral” refers to what societies sanction as right and acceptable. Most people tend to act morally and follow societal guidelines, and most laws are based on the morals of a society. Morality often requires that people sacrifice their own short-term interests for the benefit of society. People or entities that are indifferent to right and wrong are considered “amoral,” while those who do evil acts are considered “immoral.”[51]
Ethical Theories
There are two major types of ethical theories that guide values and moral behavior referred to as deontology and consequentialism.
Deontology is an ethical theory based on rules that distinguish right from wrong. See Figure 6.2[52] for a word cloud illustration of deontology. Deontology is based on the word deon that refers to “duty.” It is associated with philosopher Immanuel Kant. Kant believed that ethical actions follow universal moral laws, such as, “Don’t lie. Don’t steal. Don’t cheat.”[53] Deontology is simple to apply because it just requires people to follow the rules and do their duty. It doesn’t require weighing the costs and benefits of a situation, thus avoiding subjectivity and uncertainty.[54],[55],[56]
The nurse-client relationship is deontological in nature because it is based on the ethical principles of beneficence and maleficence that drive clinicians to “do good” and “avoid harm.”[57] Ethical principles will be discussed further in this chapter.

Consequentialism is an ethical theory used to determine whether or not an action is right by the consequences of the action. See Figure 6.3[59] for an illustration of weighing the consequences of an action in consequentialism. For example, most people agree that lying is wrong, but if telling a lie would help save a person’s life, consequentialism says it’s the right thing to do. One type of consequentialism is utilitarianism. Utilitarianism determines whether or not actions are right based on their consequences with the standard being achieving the greatest good for the greatest number of people.[60],[61],[62] For this reason, utilitarianism tends to be society-centered. When applying utilitarian ethics to health care resources, money, time, and clinician energy are considered finite resources that should be appropriately allocated to achieve the best health care for society.[63]

Utilitarianism can be complicated when accounting for values such as justice and individual rights. For example, assume a hospital has four clients whose lives depend upon receiving four organ transplant surgeries for a heart, lung, kidney, and liver. If a healthy person without health insurance or family support experiences a life-threatening accident and is considered brain dead but is kept alive on life-sustaining equipment in the ICU, the utilitarian framework might suggest the organs be harvested to save four lives at the expense of one life.[64] This action could arguably produce the greatest good for the greatest number of people, but the deontological approach could argue this action would be unethical because it does not follow the rule of “do no harm.”
Read more about Decision making on organ donation: The dilemmas of relatives of potential brain dead donors.
Interestingly, deontological and utilitarian approaches to ethical issues may result in the same outcome, but the rationale for the outcome or decision is different because it is focused on duty (deontologic) versus consequences (utilitarian).
Societies and cultures have unique ethical frameworks that may be based upon either deontological or consequentialist ethical theory. Culturally derived deontological rules may apply to ethical issues in health care. For example, a traditional Chinese philosophy based on Confucianism results in a culturally acceptable practice of family members (rather than the client) receiving information from health care providers about life-threatening medical conditions and making treatment decisions. As a result, cancer diagnoses and end-of-life treatment options may not be disclosed to the client in an effort to alleviate the suffering that may arise from knowledge of their diagnosis. In this manner, a client’s family and the health care provider may ethically prioritize a client’s psychological well-being over their autonomy and self-determination.[66] However, in the United States, this ethical decision may conflict with HIPAA Privacy Rules and the ethical principle of client autonomy. As a result, a nurse providing client care in this type of situation may experience an ethical dilemma. Ethical dilemmas are further discussed in the "Ethical Dilemmas" section of this chapter.
See Table 6.2 comparing common ethical issues in health care viewed through the lens of deontological and consequential ethical frameworks.
Table 6.2. Ethical Issues Through the Lens of Deontological or Consequential Ethical Frameworks
Ethical Issue | Deontological View | Consequential View |
---|---|---|
Abortion | Abortion is unacceptable based on the rule of preserving life. | Abortion may be acceptable in cases of an unwanted pregnancy, rape, incest, or risk to the mother. |
Bombing an area with known civilians | Killing civilians is not acceptable due to the loss of innocent lives. | The loss of innocent lives may be acceptable if the bombing stops a war that could result in significantly more deaths than the civilian casualties. |
Stealing | Taking something that is not yours is wrong. | Taking something to redistribute resources to others in need may be acceptable. |
Killing | It is never acceptable to take another human being’s life. | It may be acceptable to take another human life in self-defense or to prevent additional harm they could cause others. |
Euthanasia/physician- assisted suicide | It is never acceptable to assist another human to end their life prematurely. | End-of-life care can be expensive and emotionally upsetting for family members. If a competent, capable adult wishes to end their life, medically supported options should be available. |
Vaccines | Vaccination is a personal choice based on religious practices or other beliefs. | Recommended vaccines should be mandatory for everyone (without a medical contraindication) because of its greater good for all of society. |
Ethical Principles and Obligations
Ethical principles are used to define nurses’ moral duties and aid in ethical analysis and decision-making.[67] Although there are many ethical principles that guide nursing practice, foundational ethical principles include autonomy (self-determination), beneficence (do good), nonmaleficence (do no harm), justice (fairness), fidelity (keep promises), and veracity (tell the truth).
Autonomy
The ethical principle of autonomy recognizes each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences. See Figure 6.4[68] for an illustration of autonomy. The American Nurses Association (ANA) defines autonomy as the “capacity to determine one’s own actions through independent choice, including demonstration of competence.”[69] The nurse’s primary ethical obligation is client autonomy.[70] Based on autonomy, clients have the right to refuse nursing care and medical treatment. An example of autonomy in health care is advance directives. Advance directives allow clients to specify health care decisions if they become incapacitated and unable to do so.

Read more about advance directives and determining capacity and competency in the “Legal Implications” chapter.
Nurses as Advocates: Supporting Autonomy
Nurses have a responsibility to act in the interest of those under their care, referred to as advocacy. The American Nurses Association (ANA) defines advocacy as “the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for persons (whether an individual, group, population, or society) or for an issue, such as potable water or global health.”[71] See Figure 6.5[72] for an illustration of advocacy.

Advocacy includes providing education regarding client rights, supporting autonomy and self-determination, and advocating for client preferences to health care team members and family members. Nurses do not make decisions for clients, but instead support them in making their own informed choices. At the core of making informed decisions is knowledge. Nurses serve an integral role in client education. Clarifying unclear information, translating medical terminology, and making referrals to other health care team members (within their scope of practice) ensures that clients have the information needed to make treatment decisions aligned with their personal values.
At times, nurses may find themselves in a position of supporting a client’s decision they do not agree with and would not make for themselves or for the people they love. However, self-determination is a human right that honors the dignity and well-being of individuals. The nursing profession, rooted in caring relationships, demands that nurses have nonjudgmental attitudes and reflect “unconditional positive regard” for every client. Nurses must suspend personal judgement and beliefs when advocating for their clients’ preferences and decision-making.[73]
Beneficence
Beneficence is defined by the ANA as “the bioethical principle of benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law.”[74] See Figure 6.6[75] for an illustration of beneficence. Put simply, beneficence is acting for the good and welfare of others, guided by compassion. An example of beneficence in daily nursing care is when a nurse sits with a dying client and holds their hand to provide presence.

Nursing advocacy extends beyond direct client care to advocating for beneficence in communities. Vulnerable populations such as children, older adults, cultural minorities, and the homeless often benefit from nurse advocacy in promoting health equity. Cultural humility is a humble and respectful attitude towards individuals of other cultures and an approach to learning about other cultures as a lifelong goal and process.[76] Nurses, the largest segment of the health care community, have a powerful voice when addressing community beneficence issues, such as health disparities and social determinants of health, and can serve as the conduit for advocating for change.
Nonmaleficence
Nonmaleficence is defined by the ANA as “the bioethical principle that specifies a duty to do no harm and balances avoidable harm with benefits of good achieved.”[77] An example of doing no harm in nursing practice is reflected by nurses checking medication rights three times before administering medications. In this manner, medication errors can be avoided, and the duty to do no harm is met. Another example of nonmaleficence is when a nurse assists a client with a serious, life-threatening condition to participate in decision-making regarding their treatment plan. By balancing the potential harm with potential benefits of various treatment options, while also considering quality of life and comfort, the client can effectively make decisions based on their values and preferences.
Justice
Justice is defined by the ANA as “a moral obligation to act on the basis of equality and equity and a standard linked to fairness for all in society.”[78] The principle of justice requires health care to be provided in a fair and equitable way. Nurses provide quality care for all individuals with the same level of fairness despite many characteristics, such as the individual's financial status, culture, religion, gender, or sexual orientation. Nurses have a social contract to “provide compassionate care that addresses the individual’s needs for protection, advocacy, empowerment, optimization of health, prevention of illness and injury, alleviation of suffering, comfort, and well-being.”[79] An example of a nurse using the principle of justice in daily nursing practice is effective prioritization based on client needs.
Read more about prioritization models in the “Prioritization” chapter.
Other Ethical Principles
Additional ethical principles commonly applied to health care include fidelity (keeping promises) and veracity (telling the truth). An example of fidelity in daily nursing practice is when a nurse tells a client, “I will be back in an hour to check on your pain level.” This promise is kept. An example of veracity in nursing practice is when a nurse honestly explains potentially uncomfortable side effects of prescribed medications. Determining how truthfulness will benefit the client and support their autonomy is dependent on a nurse’s clinical judgment, self-reflection, knowledge of the client and their cultural beliefs, and other factors.[80]
A principle historically associated with health care is paternalism. Paternalism is defined as the interference by the state or an individual with another person, defended by the claim that the person interfered with will be better off or protected from harm.[81] Paternalism is the basis for legislation related to drug enforcement and compulsory wearing of seatbelts.
In health care, paternalism has been used as rationale for performing treatment based on what the provider believes is in the client’s best interest. In some situations, paternalism may be appropriate for individuals who are unable to comprehend information in a way that supports their informed decision-making, but it must be used cautiously to ensure vulnerable individuals are not misused and their autonomy is not violated.
Nurses may find themselves acting paternalistically when performing nursing care to ensure client health and safety. For example, repositioning clients to prevent skin breakdown is a preventative intervention commonly declined by clients when they prefer a specific position for comfort. In this situation, the nurse should explain the benefits of the preventative intervention and the risks if the intervention is not completed. If the client continues to decline the intervention despite receiving this information, the nurse should document the education provided and the client’s decision to decline the intervention. The process of reeducating the client and reminding them of the importance of the preventative intervention should be continued at regular intervals and documented.
Care-Based Ethics
Nurses use a client-centered, care-based ethical approach to client care that focuses on the specific circumstances of each situation. This approach aligns with nursing concepts such as caring, holism, and a nurse-client relationship rooted in dignity and respect through virtues such as kindness and compassion.[82],[83] This care-based approach to ethics uses a holistic, individualized analysis of situations rather than the prescriptive application of ethical principles to define ethical nursing practice. This care-based approach asserts that ethical issues cannot be handled deductively by applying concrete and prefabricated rules, but instead require social processes that respect the multidimensionality of problems.[84] Frameworks for resolving ethical situations are discussed in the “Ethical Dilemmas” section of this chapter.
Nursing Code of Ethics
Many professions and institutions have their own set of ethical principles, referred to as a code of ethics, designed to govern decision-making and assist individuals to distinguish right from wrong. The American Nurses Association (ANA) provides a framework for ethical nursing care and guides nurses during decision-making in its formal document titled Code of Ethics for Nurses With Interpretive Statements (Nursing Code of Ethics). The Nursing Code of Ethics serves the following purposes[85]:
- It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
- It is the profession’s nonnegotiable ethical standard.
- It is an expression of nursing’s own understanding of its commitment to society.
The preface of the ANA’s Nursing Code of Ethics states, “Individuals who become nurses are expected to adhere to the ideals and moral norms of the profession and also to embrace them as a part of what it means to be a nurse. The ethical tradition of nursing is self-reflective, enduring, and distinctive. A code of ethics makes explicit the primary goals, values, and obligations of the profession.”[86]
The Nursing Code of Ethics contains nine provisions. Each provision contains several clarifying or “interpretive” statements. Read a summary of the nine provisions in the following box.
Nine Provisions of the ANA Nursing Code of Ethics
- Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
- Provision 2: The nurse’s primary commitment is to the client, whether an individual, family, group, community, or population.
- Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the client.
- 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 to provide optimal care.
- Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
- Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
- Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
- Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
- Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
Read the free, online full version of the ANA's Code of Ethics for Nurses With Interpretive Statements.
In addition to the Nursing Code of Ethics, the ANA established the Center for Ethics and Human Rights to help nurses navigate ethical conflicts and life-and-death decisions common to everyday nursing practice.
Read more about the ANA Center for Ethics and Human Rights.
Specialty Organization Code of Ethics
Many specialty nursing organizations have additional codes of ethics to guide nurses practicing in settings such as the emergency department, home care, or hospice care. These documents are unique to the specialty discipline but mirror the statements from the ANA’s Nursing Code of Ethics. View examples of ethical statements of specialty nursing organizations using the information in the following box.
Sample Ethical Statements of Selected Specialty Nursing Organizations
Nurses frequently find themselves involved in conflicts during client care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.
An ethical dilemma can involve conflicting client’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.
Table 6.3a. Examples of Ethical Issues Involving Nurses
Workplace | Organizational Processes | Client Care |
---|---|---|
|
|
|
Read more about Ethics Topics and Articles on the ANA website.
According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors[87]:
- Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
- An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements[88]
- Knowledge of ethical principles and their application to ethical decision-making
- Motivation and skills to implement an ethical decision
Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.”[89] See Figure 6.7[90] for an illustration of nurses’ moral courage.

Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.[91] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during client care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.
Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.[92] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.[93] Read more about self-care strategies to address feelings of burnout in the "Burnout and Self-Care" chapter.
Frameworks for Solving Ethical Dilemmas
Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.[94] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.
Nursing Process Model
The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.[95]
Table 6.3b. Using the Nursing Process in Ethical Situations[96]
Nursing Process Stage | Considerations |
---|---|
Assessment/Data Collection |
|
Assessment/Analysis |
|
Diagnosis |
|
Outcome Identification |
|
Planning |
|
Implementation |
|
Evaluation |
|
Four-Quadrant Approach
The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.[97] See Table 6.3c for sample questions used during the four-quadrant approach.
Table 6.3c. Four-Quadrant Approach[98]
Health Care Indications
(Beneficence and Nonmaleficence)
|
Individual and Family Preferences
(Respect for Autonomy)
|
Quality of Life
(Beneficence, Nonmaleficence, and Respect for Autonomy)
|
Contextual Features
(Justice and Fairness)
|
MORAL Model
The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.[99],[100]
Table 6.3d. MORAL Model
M: Massage the dilemma | Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal. |
---|---|
O: Outline options | Generate several effective alternatives to reach the goal. |
R: Review criteria and resolve | Identify moral criteria and select the course of action. |
A: Affirm position and act | Implement action based on knowledge from the previous steps (M-O-R). |
L: Look back | Evaluate each step and the decision made. |
PLUS Ethical Decision-Making Model
The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:
- P: Policies, procedures, and guidelines of an organization
- L: Laws and regulations
- U: Universal values and principles of an organization
- S: Self-identification of what is good, right, fair, and equitable[101]
The seven steps of the PLUS Ethical Decision-Making model are as follows[102]:
- Define the problem using PLUS filters
- Seek relevant assistance, guidance, and support
- Identify available alternatives
- Evaluate the alternatives using PLUS to identify their impact
- Make the decision
- Implement the decision
- Evaluate the decision using PLUS filters
In addition to using established frameworks to resolve ethical dilemmas, nurses can also consult their organization’s ethics committee for ethical guidance in the workplace. Ethics committees are typically composed of interdisciplinary team members such as physicians, nurses, allied health professionals, administrators, social workers, and clergy to problem-solve ethical dilemmas. See Figure 6.8[103] for an illustration of an ethics committee. Hospital ethics committees were created in response to legal controversies regarding the refusal of life-sustaining treatment, such as the Karen Quinlan case.[104] Read more about the Karen Quinlan case and controversies surrounding life-sustaining treatment in the “Legal Implications” chapter.

After the passage of the Patient Self-Determination Act in 1991, all health care institutions receiving Medicare or Medicaid funding are required to form ethics committees. The Joint Commission (TJC) also requires organizations to have a formalized mechanism of dealing with ethical issues. Nurses should be aware of the process for requesting guidance and support from ethics committees at their workplace for ethical issues affecting clients or staff.[105]
Institutional Review Boards and Ethical Research
Other types of ethics committees have been formed to address the ethics of medical research on clients. Historically, there are examples of medical research causing harm to clients. For example, an infamous research study called the “Tuskegee Study” raised concern regarding ethical issues in research such as informed consent, paternalism, maleficence, truth-telling, and justice.
In 1932 the Tuskegee Study began a 40-year study looking at the long-term progression of syphilis. Over 600 Black men were told they were receiving free medical care, but researchers only treated men diagnosed with syphilis with aspirin, even after it was discovered that penicillin was a highly effective treatment for the disease. The institute allowed the study to go on, even when men developed long-stage neurological symptoms of the disease and some wives and children became infected with syphilis. In 1972 these consequences of the Tuskegee Study were leaked to the media and public outrage caused the study to shut down.[106]
Potential harm to clients participating in research studies like the Tuskegee Study was rationalized based on the utilitarian view that potential harm to individuals was outweighed by the benefit of new scientific knowledge resulting in greater good for society. As a result of public outrage over ethical concerns related to medical research, Congress recognized that an independent mechanism was needed to protect research subjects. In 1974 regulations were established requiring research with human subjects to undergo review by an institutional review board (IRB) to ensure it meets ethical criteria. An IRB is group that has been formally designated to review and monitor biomedical research involving human subjects.[107] The IRB review ensures the following criteria are met when research is performed:
- The benefits of the research study outweigh the potential risks.
- Individuals’ participation in the research is voluntary.
- Informed consent is obtained from research participants who have the ability to decline participation.
- Participants are aware of the potential risks of participating in the research.[108]