Module

 2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

The  purpose  of  this  module  is  to  educate  the  participant  about  ethics  in  relation  to  the  nursing  
profession  and  to  teach  important  aspects  of  ethical  decision  making  involving  patient  care.    
This  module  also  provides  examination  and  discussion  of  concepts  related  to  ethical  theories  
and  guidelines  for  the  practicing  nurse  in  today’s  healthcare  environment.  
 
Ethics  and  Ethical  Dilemmas  
Ethics  is  a  generic  term  that  covers  several  different  ways  of  understanding  and  examining  the  
moral  life  (Beauchamp  &  Childress,  2009).  Bioethics  is  the  study  of  moral  and  social  implications  
of  developments  in  the  biological  sciences  and  related  technology  (Beauchamp  &  Childress,  
2009).    Bioethics  first  emerged  as  an  academic  interdisciplinary  field  in  the  1960’s  (Beauchamp  
&  Childress,  2009).    Beauchamp  and  Childress  published  the  first  American  textbook  of  
bioethics  titled  Principles  of  Biomedical  Ethics  in  1977.    Bioethics  addresses  a  broad  range  of  
human  inquiry,  ranging  from  debates  over  the  boundaries  of  life,  surrogacy,  to  the  allocation  of  
limited  healthcare  resources  (e.g.,  healthcare  rationing,  organ  donations)  to  the  right  to  refuse  
medical  care  for  religious  or  cultural  reasons  (Beauchamp  &  Childress,  2009).      
 
Morality  describes  the  norms  of  right  and  wrong  human  conduct  that  are  so  widely  shared  they  
form  a  stable  social  agreement  (Beauchamp  &  Childress,  2009).    Morality  encompasses  many  
standards  of  conduct,  moral  principles,  rules,  ideals,  rights,  and  virtues  (Beauchamp  &  
Childress,  2009).    One  learns  about  morality  while  growing  up,  and  the  universal  norms  may  
differ  for  different  groups  such  as  physicians,  nurses,  lawyers,  teachers,  or  public  health  officials  
(Beauchamp  &  Childress,  2009).      
 
Common  morality  refers  to  the  set  of  norms  shared  by  all  persons  committed  to  morality  
(Beauchamp  &  Childress,  2009).    Examples  of  the  norms  include  to  tell  the  truth,  prevent  evil  or  
harm  from  occurring,  do  not  cause  pain  or  suffering,  keep  your  promises,  and  many  more  
(Beauchamp  &  Childress,  2009).    Common  morality  also  includes  traits  such  as  integrity,  
nonmalevolence,  kindness,  and  fidelity,  to  name  a  few  (Beauchamp  &  Childress,  2009).    If  a  
person  lacks  these  personality  traits,  it  is  believed  that  he  or  she  lacks  moral  character  
(Beauchamp  &  Childress,  2009).  
 
Approaches  to  ethics  are  classified  as  either  normative  or  non-­‐normative  (Beauchamp  &  
Childress,  2009).    
• Normative  ethics  describes  values,  behaviors,  and  ways  of  being  that  are  considered  right  
or  wrong  when  deciding  what  to  do  in  a  specific  situation  (Butts  &  Rich,  2013).      Examples  
include  the  actions  of  being  honest,  lying,  or  stealing.    Ethical  principles  are  theories  that  
are  commonly  used  in  an  attempt  to  identify  and  justify  these  norms  (Beauchamp  &  
Childress,  2009).  
• Practical  (Applied)  ethics  falls  under  the  normative  category.  It  applies  general  concepts  to  
address  particular  problems  (Beauchamp  &  Childress,  2009).    It  is  the  use  of  norms  and  
other  moral  resources  in  deliberating  about  problems,  practices,  and  policies  in  professions,  
institutions,  and  public  policy  (Beauchamp  &  Childress,  2009).    Although  there  is  no  
straightforward  movement  from  general  norms  and  principles  to  particular  judgments,  they  

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

serve  as  a  starting  point  for  the  development  of  norms  of  conduct  (Beauchamp  &  Childress,  
2009).  
 
Descriptive  ethics  and  meta-­‐ethics  are  two  types  of  non-­‐normative  ethics  (Beauchamp  &  
Childress,  2009).      
• Descriptive  ethics  is  the  factual  investigation  of  moral  beliefs  and  conduct  that  uses  
scientific  techniques  (anthropology,  sociology,  psychology  e.g.)  to  study  how  people  reason  
and  act  (Beauchamp  &  Childress,  2009).    Descriptive  ethics  studies  the  phenomena  of  
surrogate  decision-­‐making  (Beauchamp  &  Childress,  2009).  
• Meta-­‐ethics  involves  an  analysis  of  the  language,  concepts,  and  methods  of  reasoning  in  
normative  ethics  (Beauchamp  &  Childress,  2009).    This  includes  addressing  the  meaning  of  
terms  such  as  right,  virtue,  obligation,  morality,  justification,  and  responsibility  (Beauchamp  
&  Childress,  2009).  Meta-­‐ethics  is  also  concerned  with  moral  epistemology  (the  theory  of  
moral  knowledge),  the  logic  and  patterns  of  moral  reasoning  and  justification,  and  the  
possibility  and  nature  of  moral  truth  (Beauchamp  &  Childress,  2009).    Important  questions  
in  meta-­‐ethics  are  whether  morality  is  objective  or  subjective,  relative  or  nonrelative,  and  
rational  or  non-­‐rational  (Beauchamp  &  Childress,  2009).  
 
An  ethical  dilemma  is  a  situation  in  which  an  individual  feels  compelled  to  choose  between  
two  actions  that  will  affect  the  welfare  of  a  sentient  being,  and  both  actions  are  reasonably  
justified  as  being  good,  neither  action  is  readily  justified  as  being  good,  or  the  goodness  of  the  
actions  is  uncertain  (Butts  &  Rich,  2013).    Since  one  action  must  be  chosen,  the  decision  
making  process  often  burdens  the  person  or  group  who  must  decide  (Butts  &  Rich,  2013).    
Quite  often  when  a  person  is  facing  an  ethical  dilemma,  both  choices  may  feel  wrong  (Butts  &  
Rich,  2013).  
 
Leadership  Roles  
In  the  past,  the  nursing  profession  focused  on  female  traits  (Garesche,  1944;  Denesford,  1946;  
&  Way,  1962)  that  included  respect  for  authority  figures,  being  faithful  to  duty,  being  tactful,  
cultivating  a  meek  and  mild  disposition,  loyalty,  and  cleanliness  (as  cited  in  Begley,  2010).    
Begley  (2010)  now  credits  modern  day  codes  of  ethics  and  standards  of  conduct  for  creating  a  
shift  in  the  traditional  understanding  and  characteristics  expected  of  a  nurse.      
 
Modern  codes  rely  on  the  expectation  that  nurses  will  possess  the  intellectual  capacity  to  
practice  effectively  and  to  advance  the  knowledge  base  of  the  discipline  (Begley,  2010).    Baley  
(1986)  states  that  Florence  Nightingale,  English  nursing  pioneer  and  reformer,  believed  that  to  
be  a  good  nurse,  one  must  first  be  a  good  person  (as  cited  in  Begley,  2010).    According  to  
Beauchamp  (1995),  being  a  good  person  does  not  mean  simply  following  the  rules  but  instead  
considering  what  sort  of  person  one  ought  to  be  rather  than  what  one  ought  to  do  (as  cited  in  
Begley,  2010).      
 
Codes  of  ethics  are  more  virtue-­‐based  and  focus  more  on  the  characteristics  of  a  good  practice  
and  the  character  of  the  agents  than  on  simple  rules  and  statements  (Begley,  2010).    

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

 
The  International  Council  of  Nurses  (ICN)  Code  of  Ethics  (2013)  for  nurses  was  first  adopted  in  
1953  and  revised  in  2012.    Its  purpose  is  to  serve  as  a  standard  for  nurses  worldwide  by  making  
clear  that  inherent  in  nursing  is  respect  for  human  rights,  including  the  rights  to  life,  to  dignity,  
and  to  be  treated  with  respect  (ICN,  2013).    The  Code  of  Ethics  is  reviewed  regularly  and  revised  
in  response  to  the  realities  of  nursing  and  health  care  in  a  changing  society  (ICN,  2013).    The  ICN  
Code  of  Ethics  reflects  a  shift  in  nursing  responsibility  from  a  focus  on  obedience  to  physicians  
to  a  focus  on  patient  needs  (Butts  &  Rich,  2013).      
 
It  is  used  to  guide  nurses  every  day  in  their  choices,  and  it  supports  their  refusal  to  participate  
in  activities  that  conflict  with  caring  and  healing  (ICN,  2013).    The  International  Council  of  
Nurses  Code  of  Ethics  is  based  on  four  responsibilities  of  the  nurse:  to  promote  health,  prevent  
illness,  restore  health,  and  alleviate  (Chism,  2013).  
 
The  International  Council  of  Nurses  (ICN)  Code  of  Ethics  is  composed  of  four  principle  elements  
that  outline  the  standards  of  ethical  conduct.    These  elements  are  1)  Nurses  and  people,  2)  
Nurses  and  practice,  3)  Nurse  and  the  profession,  and  4)  Nurses  and  co-­‐workers  (ICN,  2013).  
 
• Element  1-­‐  Nurses  and  People:  The  nurse’s  primary  professional  responsibility  is  to  the  
people  requiring  nursing  care  (ICN,  2013).      When  providing  care,  the  nurse  should  promote  
an  environment  in  which  human  rights,  values,  customs,  and  spiritual  beliefs  of  the  
individual,  family,  and  community  are  respected  (ICN,  2013).    The  nurse  ensures  that  
individuals  receive  accurate,  sufficient,  and  timely  information  in  a  culturally  appropriate  
manner  on  which  to  base  their  consent  for  care  and  related  treatment  (ICN,  2013).    The  
nurse  should  hold  in  confidence  personal  information  and  use  judgment  in  sharing  this  
information  (ICN,  2013).    Nurses  share  with  society  the  responsibility  for  initiating  and  
supporting  action  to  meet  the  social  and  health  needs  of  the  public,  especially  those  of  
vulnerable  populations  (ICN,  2013).    Nurses  should  serve  as  advocates  for  equity  and  social  
justice  in  resource  allocation,  access  to  health  care,  and  other  social  and  economic  services  
(ICN,  2013).    Lastly,  the  nurse  demonstrates  professional  values  such  as  respectfulness,  
responsiveness,  compassion,  trustworthiness,  and  integrity  (ICN,  2013).  
 
• Element  2-­‐  Nurses  and  Practice:  The  nurse  carries  personal  responsibility  and  accountability  
for  nursing  practice,  and  for  maintaining  competence  by  continual  learning  (ICN,  2013).    The  
nurse  should  also  maintain  a  standard  of  personal  health  so  that  the  ability  to  provide  care  
is  not  compromised  (ICN,  2013).    Judgment  should  always  be  used  by  the  nurse  regarding  
individual  competence  when  accepting  and  delegating  responsibilities  (ICN,  2013).    At  all  
times,  the  nurse  is  to  maintain  a  standard  of  personal  conduct  that  reflects  well  on  the  
profession  and  enhances  its  image  and  public  confidence  (ICN,  2013).    The  nurse,  in  
providing  care,  ensures  that  the  use  of  scientific  advances  and  technology  are  compatible  
with  the  safety,  dignity,  and  rights  of  the  people  (ICN,  2013).    Nurses  should  strive  to  foster  
and  maintain  a  practice  culture  promoting  ethical  behavior  and  open  dialogue  (ICN,  2013).    
 
• Element  3-­‐  Nurses  and  the  Profession:  Nurses  assume  the  major  role  in  determining  and  

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

implementing  acceptable  standards  of  clinical  nursing  practice,  management,  research,  and  
education  (ICN,  2013).    The  nurse  should  be  active  in  developing  a  core  of  research-­‐based  
professional  knowledge  that  supports  evidence-­‐based  practice.    Nurses  should  similarly  be  
active  in  developing  and  sustaining  a  core  of  professional  values  (ICN,  203).    Also,  the  nurse,  
acting  through  the  professional  organization,  participates  in  creating  positive  practice  
environments  and  maintains  safe,  equitable  social  and  economic  working  conditions  in  
nursing  (ICN,  2013).    Nurses  practice  to  sustain  and  protect  the  natural  environment  and  are  
aware  of  its  consequences  on  health  (ICN,  2013).    The  nurse  is  to  contribute  to  an  ethical  
organizational  environment  and  be  willing  to  challenge  unethical  practices  and  settings  
(ICN,  2013).  
 
• Element  4-­‐  Nurses  and  Coworkers:  The  nurse  should  sustain  a  collaborative  and  respectful  
relationship  with  co-­‐workers  in  nursing  and  other  fields  (ICN,  2013).    The  nurse  should  take  
appropriate  action  to  safeguard  individuals,  families,  and  communities  when  their  health  is  
endangered  by  a  co-­‐worker  or  any  other  person  (ICN,  2013).    Appropriate  action  should  be  
taken  by  the  nurse  to  support  and  guide  co-­‐workers  to  advance  ethical  conduct  (ICN,  2013).  
 
The  International  Council  of  Nurses  Code  of  Ethics  for  Nurses  (2006)  as  well  as  the  American  
Nurses  Association  (ANA,  2001)  focus  on  the  importance  of  compassionate  patient  care  aimed  
at  alleviating  suffering  (Butts  &  Rich,  2013).    Nurses  should  support  patients’  self-­‐determination  
and  protect  the  moral  space  where  patients  receive  care  (Butts  &  Rich,  2013).      
 
Principles  of  Ethical  Reasoning  
Ethical  principles  are  based  on  the  concepts,  theories,  literature,  and  techniques  of  moral  
philosophy  and  are  central  to  bioethics  (Beauchamp  &  Childress,  2009).    The  four  categories  of  
ethical  principles  are  respect  for:  1.  Autonomy,  2.  Nonmaleficence,  3.  Beneficience,  4.  Justice  
 
• Autonomy  is  the  respect  for  individuals  to  make  their  own  decisions  (Beauchamp  &  
Childress,  2009).    Respecting  one’s  autonomy  includes  obtained  informed  consent  for  
treatment;  facilitating  and  supporting  patients’  choices  regarding  treatment  options;  
allowing  patients  to  refuse  treatments;  disclosing  comprehensive  and  truthful  information,  
diagnoses,  and  treatment  options  to  patients;  and  maintaining  privacy  and  confidentiality  
(Butt  &  Rich,  2013).    A  surrogate  decision  maker  must  determine  the  highest  net  benefit  
among  the  available  options,  assigning  different  weights  to  interests  the  patient  has  in  each  
option  and  discounting  or  subtracting  inherent  risks  of  costs  (Beauchamp  &  Childress,  
2009).  
• Nonmaleficence  imposes  the  obligation  not  to  inflict  evil  or  harm  on  others  (Beauchamp  &  
Childress,  2009).    In  medical  ethics,  this  concept  is  phrased  as  “first,  do  no  harm”  
(Beauchamp  &  Childress,  2009).    Issues  that  may  arise  when  studying  nonmaleficence  
Nonmaleficence  include  negligence  and  standards  of  care,  withholding  and  withdrawing  
treatment,  ordinary  and  extraordinary  treatment,  killing  and  allowing  to  die,  and  quality  of  
life  considerations  (Beauchamp  &  Childress,  2009).  Nonmaleficence    supports  moral  rules  
such  as  do  not  kill,  do  not  cause  pain  or  suffering,  do  not  incapacitate,  do  not  cause  offense,  

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

and  do  not  deprive  others  of  the  goods  of  life  (Beauchamp  &  Childress,  2009).    The  goal  of  
the  ethical  principle  of  nonmaleficence  is  that  we  should  avoid  causing  harm  to  people  
(Beauchamp  &  Childress,  2009).    
 
The  Rule  of  Double  Effect  distinguishes  between  intended  effects  and  merely  foreseen  
effects  (Beauchamp  &  Childress,  2009).    Four  conditions  must  be  met  for  an  act  with  a  
double  effect  to  be  justified:    
1.   The  nature  of  the  act  must  be  good.    
1. The  agent’s  intent  must  be  good,  the  bad  effect  can  be  foreseen  but  not  
intended.  
2. The  distinction  between  means  and  effects,  meaning  the  bad  effect  must  
not  be  a  means  to  the  good  effect.  
3. The  proportionality  between  the  good  effect  and  the  bad  effect,  meaning  
the  good  effect  must  outweigh  the  bad  effect  (Beauchamp  &  Childress,  
2009).    Looks  at  the  relationship  between  optional  treatments  and  
obligatory  treatments.      
 
There  are  several  conditions  for  overriding  the  obligation  to  treat,  such  as  whatever    
1. Physicians  or  providers  cannot  perform;    
2. Will  not  produce  physiological  effect;  
3. Is  highly  unlikely  to  be  efficacious;  
4. Probably  will  produce  only  low  grade,  insignificant  outcomes;    
5. Is  highly  likely  to  be  more  burdensome  than  beneficial;  
6. Is  completely  speculative  because  it  is  untried;  
7. In  balancing  the  effectiveness,  potential  benefit,  and  potential  burden,  
warrants  withdrawing  or  withholding  treatment  (Beauchamp  &  Childress,  
2009).    Justification  for  overriding  treatment  is  usually  granted  when  the  
burden  of  treatment  outweighs  the  benefits  (Beauchamp  &  Childress,  
2009).  
 
• Beneficence,  in  terms  of  bioethics,  refers  to  the  moral  obligation  to  act  for  the  benefit  of  
others  (Beauchamp  &  Childress,  2009).    The  rules  of  obligation  for  the  ethical  principles  of  
beneficence  are  to:    
1. Protect  and  defend  the  rights  of  others  
2. Prevent  harm  from  occurring  to  others  
3. Remove  conditions  that  will  cause  harm  to  others    
4. Help  persons  with  disabilities  
5. Rescue  persons  in  danger  (Beauchamp  &  Childress,  2009).    Beneficence  
demands  more  than  maleficence  because  it  requires  that  we  take  positive  
steps  to  help  others,  provide  benefits  to  others,  and  rescue  others  
(Beauchamp  &  Childress,  2009).    Benefits  are  measured  by  cost  
effectiveness  analysis  (CEA),  cost  benefit  analysis  (CBA),  and  the  value  of  
the  quality-­‐adjusted  life  years  (QALY)  (Beauchamp  &  Childress,  2009).      

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

 
• Justice  describes  fairness,  what  is  deserved  and  entitled  (Beauchamp,  2009).      
Distributive  justice  refers  to  fair,  equitable,  and  appropriate  distribution  of  benefits  or  
burdens  justified  by  norms  that  structure  the  terms  of  social  cooperation  (Beauchamp  &  
Childress,  2009).      Justices  states  people  are  entitled  to  an  equal  share  according  to:  
1. Their  need  
2. Their  effort  
3. Their  contribution  
4. Their  merit  
5. Free  market  exchanges  (Beauchamp  &  Childress,  2009).    
 
Fair  opportunity  rule  states  that  individuals  should  not  receive  social  benefits  on  the  
basis  of  undeserved  advantageous  properties  and  should  not  be  denied  social  benefits  
on  the  basis  of  undeserved  disadvantageous  properties,  because  they  are  not  
responsible  for  the  properties  (Beauchamp  &  Childress,  2009).    These  properties  
include:    racial,  ethnic  and  gender  disparities,  and  vulnerable  and  exploited  populations  
(Beauchamp  &  Childress,  2009).    One  must  also  consider  issues  of  justice,  such  as  
looking  at  peoples’  access  to  care,  enrolling  economically  disadvantaged  individuals  in  
research,  the  moral  right  to  government–funded  healthcare,  the  right  to  a  decent  
minimum  of  healthcare,  the  right  to  forfeit  their  right  to  healthcare,  the  right  to  health,  
and  the  issue  of  rationing  and  setting  priorities  when  it  comes  to  resources  (Beauchamp  
&  Childress,  2009).    
   
Ethics  and  the  Nursing  Process  
An  important  part  of  clinical  reasoning  is  the  ability  to  work  up  the  ethical  aspects  of  a  case  
(Georgetown  University  Center  for  Child  and  Human  Development,  n.d.).  The  ethics  workup  
emphasizes  a  sensible  progression  from  the  facts  of  the  case  to  a  morally  sound  decision,  using  
a  five-­‐step  process  to  guide  the  thought  process  behind  morally  troubling  cases  as  follows  
(Georgetown  University  Center  for  Clinical  Bioethics).      
 
• Step  1:  What  are  the  facts?    This  stage  stresses  the  need  to  clarify  the  facts  of  the  case  in  
order  to  make  a  decision.    It  asks  questions  of  the  ‘who’  (persons  involved),  ‘what’  
(prognosis,  preferences,  therapeutic  options),  ‘when’  (time  constraints  or  chronology  of  
events),  ‘where’  (medical  setting),  and  ‘why’  (reasons  supporting  the  claims,  goals  of  
current  care.  
 
• Step  2:  What  is  the  issue?  Evaluates  whether  the  conflict  is  personal,  interpersonal,  
institutional,  or  at  a  societal  level.    Asks  if  there  is  a  question  at  the  level  of  thought  or  
feeling  (Georgetown  University  Center  for  Clinical  Bioethics).    Interprets  whether  the  
question  has  a  moral  or  ethical  component.      
 
• Step  3:  Frame  the  Issue?  Frames  the  ethical  issue  at  stake  in  terms  of  areas  of  concern:  

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

1. Identify  appropriate  decision  makers  (which  option  is  most  likely  to  benefit  
and  not  harm  the  patient?),    
2. Apply  criteria  to  be  used  in  reaching  clinical  decisions  (biomedical  good  of  
the  patient  and  goods  and  interests  of  other  parties),  and  
3. Establish  healthcare  professional’s  moral  and  professional  obligations.  
 
• Step  4:  Identify  and  weigh  alternative  courses  of  action  and  then  decide.    Realize  that  a  
decision  must  be  made  and  that  there  is  no  simple  formula.    This  step  requires  clinical  
judgment  for  doing  so,  practical  wisdom,  and  moral  argument.    Sources  of  justification  
include:    
1. Internal  morality  of  the  profession:  the  nature  of  healthcare  professional-­‐
patient  relationship;  compatibility  of  recommended  course  of  actions  with  
aims  of  profession  
2. Approaches  to  ethical  inquiry    
3. Grounding  and  source  of  ethics  
4. Ethically  relevant  considerations      
 
The  ethically  relevant  considerations  include  balancing  benefits  and  harms,  disclosure,  
informed  consent  and  shared  decision  making,  norms  of  family  life,  relationship  between  
clinicians  and  patients,  professional  integrity  of  clinicians,  cost  effectiveness  of  allocations,  
issues  of  cultural  and  religious  variations,  and  considerations  of  power.    
 
• Step  5:  The  critique.  The  fifth  step  of  the  Ethics  Workup  considers  the  major  objections  and  
the  ability  to  respond  adequately  or  change  your  decision.    It  stresses  the  importance  of  
seeking  input  of  ethics  of  doing  an  analysis  to  better  prepare  for  next  time  (Georgetown  
University  Center  for  Clinical  Bioethics).      
 
Essentials  of  Professionalism  in  the  Workplace  
Ethics  committees  are  formal  teams  composed  of  preselected  members  that  come  together  
regularly  to  discuss  ethical  issues  within  an  organization.    The  members  often  include  
physicians,  nurses,  an  on-­‐staff  chaplain,  social  worker,  and  facility  administrative  staff  member,  
and  sometimes  include  legal  representatives  as  well  as  local  community  representatives.    Times  
may  arise  when  nurses  do  not  agree  with  physician,  family  member,  or  surrogate  decisions  
regarding  treatment.  When  this  occurs,  nurses  often  seek  an  ethics  consultation.  This  act  is  part  
of  the  nurse’s  role  as  a  patient  advocate.  
 
The  role  of  the  professional  nurse  has  evolved,  as  there  has  been  a  shift  from  etiquette  to  
ethics,  from  obedience  to  moral  autonomy,  assertiveness,  accountability,  and  advocacy  (Begley,  
2010).    The  professional  nurse  is  also  an  autonomous  moral  practitioner  who  collaborates,  is  
assertive,  operates  in  partnership  with  patients,  and  acts  as  an  advocate  when  patients  are  
unable  to  speak  up  for  themselves  (Begley,  2010).  
 

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Module  2.  Ethics  and  the  Role  of  Nurse  as  Advocate    

The  ideal  ethical  nurse  should  possess  qualities  such  as  moral  integrity  and  concern,  and  should  
provide  culturally  sensitive  care  (Butts  &  Rich,  2013).    Moral  integrity  suggests  that  a  person  is  
often  described  as  being  honest,  truthful,  trustworthy,  courageous,  benevolent,  and  wise  (Butts  
&  Rich,  2013).  Moral  integrity  appears  to  represent  the  quality  of  one’s  character  (Butts  &  Rich,  
2013).    Nurses  can  show  concern  by  serving  as  patient  advocates  (Butts  &  Rich,  2013).    Nurses  
who  provide  culturally  sensitive  care  provide  care  that  acknowledges  and  respects  the  beliefs,  
values,  and  customs  of  the  person  receiving  the  care  (Butts  &  Rich,  2013).      
 
In  conclusion,  nurses  should  strive  to  uphold  the  moral  agreement  they  make  with  patients  and  
communities  when  they  joined  the  nursing  profession  (Butts  &  Rich,  2013).    Nursing  care  
includes  actions  such  as  promoting  health  and  preventing  illness,  but  the  most  important  
responsibility  of  nursing  care  involves  caring  for  patients  who  are  experiencing  varying  degrees  
of  physical,  psychological,  and  spiritual  suffering  (Butts  &  Rich,  2013).  
 

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