Ethical Awareness: What It Is and Why It Matters

Aimee Milliken, PhD, RN


Online J Issues Nurs. 2018;23(1) 

In This Article


These three scenarios highlight the importance of recognizing that even routine and seemingly mundane nursing actions can have major implications for patients. As noted, nurses have professional goals and related ethical obligations that should guide nursing practice. However, routine practice actions may not always be viewed through this lens. This lack of recognition is in no way malicious or intentional; it stems from lack of awareness. Consequently, it becomes clear that increasing nurses' ethical awareness to include the implications of everyday decisions is important to maximize safe, ethical patient care.

An awareness of the ethical components of a situation ideally should prompt nurses to take action (Milliken, 2016; Milliken & Grace, 2015). The scenarios above demonstrate how heightened ethical awareness may have helped clarify the way that these nurses thought about the implications of their decisions. This perspective may have helped them view the scenarios more completely, and be sensitive the possible range of actions they might have taken (Rest, 1982). In other words, had the nurses in these cases recognized that their patients were at risk, they may have been more likely to intervene or take proactive measures.

Such a proactive measure, or intervention, is called "moral agency." The nurse recognizes a potential ethical issue, and acts to resolve it. In addition to willingness and ability to take action, moral agency requires that nurses embody this perspective in practice, recognizing that as a profession, we have an obligation to act as agents on behalf of patients (Liaschenko & Peter, 2016; Musto & Rodney, 2016). Embracing one's role as a moral agent in this way can facilitate resilience, or an individual nurse's ability to learn and grow from challenging clinical situations that may cause distress (Rushton, 2016b). Consequently, ethical awareness is an important first step in sustainable, optimal ethical practice.

The important role of ethical awareness in patient care suggests that individual nurses, as well as nurse leaders and healthcare organizations, hold the responsibility to develop this important skill. Strategies to heighten ethical awareness in the clinical setting have been discussed in depth elsewhere (Milliken, 2017b). Briefly, these include interventions targeted at the individual, unit, and organizational level. For example, individual nurses can improve ethical awareness by developing ethical competence, or overall ethical understanding and skill-set (Kulju et al., 2016; Lechasseur et al., 2016). Participating in ethics-related discussions, utilizing available ethics resources (Milliken, 2017b), and becoming familiar with the ANA Code of Ethics for Nurses with Interpretive Statements (Code of Ethics) are several ways of developing ethical competence.

The ANA Code of Ethics (2015) establishes the "ethical standard for the profession" (p. vii) and serves as the profession's "non-negotiable ethical standard" (p. viii). The nine provisions outline the expectations to which nurses, as professionals, must adhere. The Code of Ethics emphasizes that the scope of ethical nursing practice extends far beyond the nurse's role in challenging dilemmas. Recent work suggests that many nurses may be unfamiliar with the Code of Ethics document (Heymans, Arend, & Gastmans, 2007; Milliken, 2017a). Nevertheless, familiarity with this document has been identified as an essential part of preparation for ethical practice and should serve as a foundational step to develop ethical awareness (Grace & Milliken, 2016).

At the unit and organizational-level, nurse leaders can create opportunities for individual nurses to develop moral agency and resilience (Milliken, 2017b). These opportunities may include unit-based ethics rounds; in-services; formal and informal ethics training; and participation in interprofessional education (Hamric & Wocial, 2016; Milliken, 2017b; Rushton, 2016b). Nurse leaders can also model and contribute to shifting values toward an organizational culture that supports ethical awareness and ethical practice (Hamric & Epstein, 2017; Liaschenko & Peter, 2016). This requires attention to unit-specific issues (e.g., complex patient populations and staffing issues) and creation of platforms for nurses and other healthcare providers to participate in regular discussions about ethics and ethical issues (Hamric & Wocial, 2016; Liaschenko & Peter, 2016; Milliken, 2017b).

Interventions such as these can foster individual and collective ethical awareness. Keeping ethics at the forefront of conversation, in this way, can help to better ensure that patient needs are met. It may also help nurses facing everyday, yet challenging situations, like those in the case scenarios, to feel more confident in decision making and in their ability to access ethics-related resources at the moment of concern.