ethical nursing case study examples

20 Common Examples of Ethical Dilemmas in Nursing + How to Deal With Them

If you are a nurse, chances are you have faced situations where you had to make decisions based on your belief of whether something is right or wrong, safe or unsafe. This type of decision is based upon a system of ethical behavior. It is essential that all nurses develop and implement ethical values into nursing practice. If this sounds familiar, you may be asking, "What are the common examples of ethical dilemmas in nursing?" There are many things that could be considered an ethical dilemma in nursing, and it is important for nurses to know how to address them when they occur. In this article, I will share the 20 most common examples of ethical dilemmas in nursing and offer some insight into handling them.

What Is An Ethical Dilemma In Nursing?

5 main reasons why nurses face with ethical dilemmas in nursing.

1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing

How To Identify Ethical Dilemmas In Nursing?

What are the common examples of ethical dilemmas in nursing, example #1: pro-life vs. pro-choice, ethical dilemma:, how to deal with this ethical dilemma:, example #2: protecting the adolescent’s right to privacy, example #3: empirical knowledge vs. religious beliefs, example #4: parent refuses to vaccinate child, example #5: personal and professional boundaries related to social media, example #6: nurse is instructed to have patient with low literacy level to sign consent for treatment, example #7: end-of-life decision-making, example #8: inadequate resources to provide care, example #9: former patients - to date or not to date, example #10: informed consent, example #11: inadequate staffing, example #12: spirituality vs. science, example #13: patient addicted to prescription pain medication, example #14: duty and compassion do not align with facility safety protocols, example #15: patient does not have an advanced directive, example #16: incompetence among nursing peers, example #17: disclosing the seriousness of medical conditions, example #18: questioning physician orders, example #19: asked to work in a department without training, example #20: beneficence vs. autonomy, 4 consequences of avoiding ethical dilemmas in nursing, 1. nurses can quickly experience burnout., 2. avoiding ethical dilemmas in nursing can lead to legal issues., 3. nurses who avoid ethical dilemmas could lose their jobs., 4. loss of licensure:, my final thoughts.

Ethics case study: Poor staffing results in brain-damaged patient

Shirley Keck, age 61, was admitted to Kansas medical center. Because of understaffing of nurses in the hospital, Shirley’s nurse did not assess her often enough and did not monitor her oxygen level. Shirley’s deteriorating condition was not noticed by the nurse because the nurse was overworked. Shirley suffered a respiratory arrest with a resulting brain injury.

Shirley went to the hospital with what she thought was a bad cold, and was admitted with a diagnosis of pneumonia. Following admission, she became increasingly feverish and short of breath, but her family’s calls for help went unanswered. In fact, her daughter was unable to find anyone when she went to the nurses’ station looking for help. The patient eventually stopped breathing, and someone finally responded to the family’s desperate and frantic calls for help. Shirley was successfully resuscitated, but sustained brain damage due to oxygen deprivation. She was left unable to walk, talk, or care for herself.

At the time of this incident, there were 41 other patients on this unit. Although the hospital’s own staffing standards called for 5 registered nurses and 2 licensed practical nurses to staff this unit, only 3 registered nurses were on duty. The plaintiff’s attorneys contended that lack of monitoring by nurses—caused by short staffing—led directly to the permanent brain damage Keck suffered. Furthermore, the attorney claimed that the hospital’s staffing plan, calculated according to hours of care per patient per day, failed to account for patient acuity, resulting in one nurse caring for as many as 20 patients at a time. The hospital claimed that the unit was safely staffed at all times. However, when the records for the unit in question were subpoenaed, they indicated that the hospital failed to meet its own staffing standards for 51 out of 59 days before this incident. Moreover, during depositions, a staffing supervisor said that administration warned about the costs of scheduling extra nurses, and a staff nurse submitted copies of documents in which the staff expressed their concern about the impact short staffing was having on patient care safety. According to the American Trial Lawyers Association, this was the first case to target corporate level staffing decisions rather than individual provider negligence.

The defendant hospital blamed the doctors caring for the Shirley Keck, and denied any allegations of understaffing in order to increase profits. It would have been very interesting to see what a jury would have done with this case; however, the hospital agreed to a $2.7 million out-of-court settlement while still denying allegations of short staffing. To put this in perspective, in 2010 the median range for out of court settlement was approximately $125,000 versus $235,000 for jury verdicts–and the hospital settled for $2.7 million in 1999. Moreover, the family refused to agree to any conditions that the settlement remain confidential so that others people might not suffer injury as a result of poor staffing. Thus, Keck’s story became nationally news, and was presented on CBS – 60 minutes, NBC nightly news , and CNN , and published in Reader’s Digest, Chicago Tribune, Wichita Eagle , and other media.

About the same time a Kansas Court was considering this case, The Wall Street Journal (September 29, 1999) published an article about another corporation that chose to risk human lives to save money. On the front page in a bylined article the paper reports the stunning punitive damages—$4.9 billion—levied against GMC. Even though it was reduced to a “mere” $1.2 billion on appeal, GMC lost the case because of the “cold calculus” of life versus money. Patricia Anderson, her four children and family friend Jo Tigner were awarded $107 million to compensate them for their pain, suffering and disfigurement. As the fire consumed the Malibu, the adults were able to escape, but the four children were trapped in the back of the car. Young Alisha Parker was the most gravely injured. Her burns were so severe that she lost the fingers of one hand and has undergone more than 70 surgeries.

Jurors awarded $4.8 billion in punitive damages after finding that GM acted out of fraud or malice. The verdict was quick and unanimous, particularly after jurors heard evidence that GM chose not to spend $8.59 per car to relocate the Malibu fuel tank because it cost less to settle lawsuits from injuries and deaths in fuel fires. One piece of evidence was a 1973 internal “value analysis” memo which calculated that deaths from such accidents cost the company $2.40 per automobile. So the executives decided not to recall and repair the cars to save roughly $6.00/vehicle. Attorneys for the plaintiffs did not ask for a specific amount, but pointed out that GM paid one of its expert witnesses $3.5 million over four years and spent about $4 billion annually on advertising.

Case commentary

Why talk about Anderson v GMC or even Keck v Wesley Medical Center ? Because staffing is still an issue. It will become more of an issue as reimbursement continues to be curtailed. Moreover, as patient ratios are increasingly mandated, and studies of the impact of nurse staffing on patient outcomes are providing a growing body of knowledge, it is not only possible but likely that now that we can know what is safe hospital leadership will be held liable if they do not maintain safe staffing levels. Indeed, in the Keck case, it is important to note that Keck never filed a suit or even a claim against the nurse assigned to her care. Making a profit at the expense of human life and well-being is and always will be an issue that is directly impacted by staffing decisions. Indeed, the attorneys in the Keck case could easily have asked how much it would have cost the hospital to staff the unit according to its own standards!

Maintaining safe care is the first ethical and legal duty of any hospital, and of all health professionals. Setting and meeting its own staffing standards is a hospital’s regulatory and moral duty. Moreover, as researchers produce the data needed to ensure safe patient care (and as these data are introduced as evidence in malpractice cases), there will be more pushback from courts as judges and juries react to a cold calculus of profits over human life. Indeed, in many instances, it may be the healthcare executives who make staffing decisions who are dragged into court instead of harassed and overwhelmed staff nurses. What do you think?

Selected references

Keck v Wesley Medical Center, no. 99 –C20307 (D. KS 1999)

Medical Malpractice Settlements, onlinelawyersource.com/medical_malpractice/settlements.html . Accessed November 5, 2011.

Anderson v. General Motors Corp., BC116926 (Super. Ct., Los Angeles).

14 Comments .

To this day, professional nursing organizations continue to refuse discussion on the silencing of nurses via management retaliation. A recent study by a PhD candidate on unjust discipline of nurses has been effectively supressed. The media, who takes its cue from these organizations, has been complicit in this cover-up. When nurses see there is no accountability for manager retaliation, they are effectively silenced from reporting staffing and other safety issues. Licensing boards seem not to enforce unprofessional conduct when it applies to management. To wit, even instances where management loses or quietly settles retaliation or discrimination lawsuits.

As you discuss culpability of nurse vs hospital leadership, it is important to note this case is 13 years old. With changes like IHI and IOM report, the standard across the country has reinforced this case creating the expectation that leaders must create non punitive environments where safety is a priority.

Betty did you read the whole article? It was not the nurses fault that the hospital over a 2 month period failed to follow their own staffing numbers. Nurses are super human but no one can be in 2-3 places at once. Placing the blame once more on the nurse…with this kind of support I would not wonder why any nurse would care… for they are being held out to dry for things they have all the responsibility for but no authority to change…perfect storm for burnout and PTSD.

Leah Curtin makes the case for corporate responsibility in health care systems as well as at GM. Hospital budgets are decisions about people (staff) and things (physical plant, amenities, parking lots, etc.)The hospital had options, made conscious choices; there must be corporate consequences beyond the customary placing of blame on the individual nurse. That distinction was made in this case. This is a lesson to be learned throughout the health care “industry.”

It is obvious Betty did not read the entire article. The nurse/patient ratio was obviously too high for THE NURSE to make a judgement or the family would have sued THE NURSE. When’s the last time you worked as staff Betty?

Even wih short staffing, ignoring the symptoms this patient displayed amounts to nothing short of nursing malpractice!

Unfortunately short-staffing has always been a problem, and seems worse today. When greed and paperwork began to win over ethical and thorough patient care, I sadly took a break from nursing, and can’t see going back anytime soon.

There is mounting evidence that poor staffing negatively affects patient care. Isn’t it about time we demanded evidence-based staffing?

Nurses are always complaining about staffing….no matter how many are on duty

For KathyRN: This is a bill to amend title XVIII of the Social Security Act to provide for patient protection by establishing safe nurse staffing levels. It has been referred to the Committee on Finance for deliberation, investigation, and revision before it goes to general debate. So far as I know, it’s still there.

Kathy, RN, this particular case happened in 1999. ‘Safe staffing’has always been a concern. In the ’80’s I worked in L&D, management started to pull us to ICU…This upset many nurses who did nothing but complain. I wrote a letter to management and said I would only do basic nursing when sent to an area out of my expertise! The pulling stopped immediately! Nurses need to CYA, management is looking for the buck.

Staffing issues remain the number 1 issue for staff nurses. Leah’s article was refreshing reviewing cases where judgement was based on hospitals taking human risks to save money instead of providing appropriate staffing. Ohio must continue to explore next steps despite legislation requiring Staffing Committees in each hospital with x number of nurses from departments throughout the hospital. Thanks you Leah for this very helpful perspective. Michele Valentino

Whatever happened to the ‘Safe NUrse Staffing legislation introduced in Congress in 2010 and 2011?

Comments are closed.

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10 Examples of Ethical Dilemmas in Nursing

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

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

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

10 Common Ethical Dilemmas in Nursing 

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

1. Patient Autonomy vs. Beneficence

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

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

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

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

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

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

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

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

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

>> Related: What is Autonomy in Nursing?

2. Confidentiality vs. Duty to Warn 

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

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

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

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

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

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

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

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

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

3. End-of-Life Care

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

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

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

Here’s how the nurse might address this situation:

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

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

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

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

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

4. Resource Allocation

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

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

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

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

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

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

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

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

5. Informed Consent

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

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

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

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

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

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

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

6. Cultural and Religious Beliefs

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

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

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

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

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

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

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

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

7. Impaired Colleague

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

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

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

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

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

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

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

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

8. Professional Boundaries

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

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

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

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

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

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

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

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

9. Whistleblowing

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

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

Here are the steps the nurse should follow:

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

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

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

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

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

10. Ethical Use of Technology

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

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

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

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

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

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

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

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

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

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

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

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

Case Study in Nursing Ethics Human Rights and Human Dignity

This article appears on page 4 of

The Maryland Nurse Maryland February 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Case study: an ethical dilemma involving a dying patient

Affiliation.

• 1 Lehman College, City University of New York, Bronx, NY, USA.
• PMID: 19105511

Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life. This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and principles that apply to this situation.

Publication types

• Case Reports
• Blood Transfusion / ethics*
• Cesarean Section / ethics*
• Fatal Outcome
• Hemorrhage / therapy*
• Jehovah's Witnesses*
• Treatment Refusal / ethics*

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Nursing Case Study Examples and Solutions

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NursingStudy.org is your ultimate resource for nursing case study examples and solutions. Whether you’re a nursing student, a seasoned nurse looking to enhance your skills, or a healthcare professional seeking in-depth case studies, our comprehensive collection has got you covered. Explore our extensive category of nursing case study examples and solutions to gain valuable insights, improve your critical thinking abilities, and enhance your overall clinical knowledge.

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Discover a wide range of comprehensive nursing case study examples and solutions that cover various medical specialties and scenarios. These meticulously crafted case studies offer real-life patient scenarios, providing you with a deeper understanding of nursing practices and clinical decision-making processes. Each case study presents a unique set of challenges and opportunities for learning, making them an invaluable resource for nursing education and professional development.

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Nursing leadership is essential for driving positive change and ensuring high-quality patient care. Our nursing leadership case studies examine effective leadership strategies, change management initiatives, and interprofessional collaboration in healthcare settings. Gain insights into the qualities of successful nurse leaders, explore innovative approaches to leadership, and learn how to inspire and motivate your team to achieve excellence in nursing practice.

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Remember, success in nursing begins with knowledge and continues with lifelong learning. Explore our nursing case study examples and solutions today and embark on a journey of professional growth and excellence.

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

Ana luiza ferreira aydogdu.

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

Associated Data

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

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

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

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

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

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

Implications for nursing management

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

1. INTRODUCTION

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

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

2. BACKGROUND

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

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

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

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

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

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

4.1. Design

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

4.2. Search strategy

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

4.3. Inclusion and exclusion criteria

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

4.4. Search outcome

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

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

4.5. Quality appraisal

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

Critical Appraisal Skills Programme (CASP) a checklist

4.6. Data extraction

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

Reviewed articles and summary of results

4.7. Data synthesis

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

Categories and codes

Abbreviation: Protective Personal Equipment.

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

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

5.1. Concerns with beneficence—Nonmaleficence

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

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

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

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

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

5.2. Awareness of need for autonomy

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

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

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

5.3. Challenges to justice

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

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

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

5.4. Coping with ethical dilemmas

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

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

6. DISCUSSION

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

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

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

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

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

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

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

6.1. Limitations

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

7. CONCLUSIONS

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

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

8. IMPLICATIONS FOR NURSING MANAGEMENT

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

CONFLICT OF INTEREST

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

ETHICAL APPROVAL

No ethical approval was required for this integrative review.

ACKNOWLEDGEMENT

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

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• Open access
• Published: 18 March 2024

Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

• Maxine Kuczawski   ORCID: orcid.org/0000-0002-0774-8113 1 ,
• Suzanne Ablard 1 ,
• Fiona Sampson 1 ,
• Susan Croft 1 , 2 ,
• Joanna Sutton-Klein 1 , 3 &
• Suzanne Mason 1  

BMC Nursing volume  23 , Article number:  185 ( 2024 ) Cite this article

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Advanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role.

Five online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles.

Fourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability.

Conclusions

Appropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision.

Peer Review reports

Introduction

Advanced Clinical Practitioners (ACPs) are a relatively new role in the National Health Service (NHS), introduced to address the increasing complexity of healthcare needs and the growing demand for skilled professionals. They are becoming increasingly embedded within a wide range of NHS healthcare settings spanning community services, mental health wards and hospitals. ACPs play a vital role in expanding the scope of practice within healthcare teams, take on more advanced and complex levels of clinical work, including tasks historically carried out by doctors, with an aim to help alleviate the strain on medical professionals and enhance the efficiency of healthcare delivery. Their integration into the workforce has been shown to enhance patient care by providing timely access to high-quality services while also fostering interdisciplinary collaboration [ 1 ]. Studies have shown that ACPs contribute to improved patient outcomes, increased patient satisfaction, and cost-effective healthcare delivery [ 2 , 3 ]. Additionally, their presence supports the development of junior staff by providing mentorship and guidance, thus ensuring a sustainable healthcare workforce for the future [ 1 , 4 ]. As non-medical healthcare professionals, ACPS are required to undertake further education (Masters degree) and extended training in specific clinical areas such as nursing, pharmacy, or allied health professions to qualify as an ACP. According to the multi-professional framework advanced clinical practice, this training is underpinned by four pillars: clinical practice, leadership and management, education, and research [ 5 ]. However, there is wide variability in this practice and training of ACPs across the UK [ 6 ].

Recent years have seen attempts to standardise the training and practice of ACPs. A framework for advanced clinical practice in England was authored in 2017 by Health Education England (HEE) (NHS England) [ 5 ], which set out standards for advanced clinical practice. Within this framework, advanced clinical practitioners should be able to deliver care with a high degree of autonomy and undertake complex decision making. The knowledge and skills should be underpinned by a Master’s level award (or equivalent) that incorporates the Four Pillars of Practice: Clinical Practice, Leadership and Management, Education and Research [ 5 ]. In 2020, The Centre for Advancing Practice ( https://advanced-practice.hee.nhs.uk/ ) began accrediting some of the many advanced clinical practice Masters programmes available in the UK, which it deemed to have met the standards laid out in HEE’s framework [ 7 ]. This process of defining common standards remains in its early stages, and there remains little research on ACP training programmes and their structures or governance. In a further effort to improve and standardise advanced clinical practice, The Centre for Advancing Practice additionally created guidance on workplace supervision for ACPs, noting the crucial need for high-quality supervision [ 8 ]. The Nursing and Midwifery Council (NMC) published their 2020-25 corporate strategy also in 2020, and committed to explore the need for regulation in a comprehensive review of advanced nurse practice [ 9 ]. The review is still in progress but research undertaken in the early stages by The Nuffield Trust and BritainThinks as part of the review reported inconsistency in definitions, outcomes, standards of education and proficiency in advance practice [ 10 ], and support for regulation by health professionals [ 11 ]. Despite calls for improvements in the supervision of ACPs, there has been limited research in this area.

Studies have shown that ACPs have historically struggled with the transition from their previous career to their advanced practice roles [ 12 , 13 , 14 , 15 ]. The challenges of the transition have been exacerbated by a lack of clear professional identity for ACPs, which has been noted to be a source of tension and confusion, impacting on training, development and ultimately patient safety [ 6 , 16 , 17 , 18 , 19 , 20 ]. Recognising the importance of successful integration into the workforce will help ACPs to realise their full potential [ 21 , 22 ], impacting on role satisfaction [ 23 ], staff retention [ 24 ] and ultimately, building a more sustainable workforce.

As efforts to standardise and develop the ACP role continue, ACPs are becoming more widespread within the NHS. The proliferation of ACPs brings a need for a better understanding of all aspects of ACP training, both during and after qualification. We sought to explore the training experiences of ACPs with the aim of informing future models of education and support.

Theoretical framework

The theoretical framework of this study is based on the theories of Bourdieu, particularly his concept of Habitus [ 25 ], as it offers a valuable lens for examining the multifaceted identities, roles, and positionalities of ACPs. Habitus, ingrained dispositions and cultural knowledge shaped by social experiences, acts as a bridge between individual practitioners and the complex healthcare field they navigate. It influences how ACPs perceive and enact their roles, shaped by their educational background, professional training, and prior clinical experiences. Furthermore, Habitus interacts with the “field,” the social space within which ACPs operate, characterized by power dynamics, established hierarchies, and competing ideologies. This interaction influences the capital, both symbolic and material, that ACPs possess and wield within the field. Through this lens, we can understand how ACPs negotiate complex power dynamics within the healthcare system, navigate tensions between professional autonomy and institutional constraints, and ultimately construct their own sense of meaning and purpose within their evolving roles. By analyzing these interactions between Habitus, field, and capital, Bourdieu’s framework offers a rich and nuanced understanding of the experiences and challenges faced by ACPs, paving the way for further research and dialogue on optimizing their practice and impact.

We sought to explore the training experiences of ACPs as well as their perceptions on role identity, gaining clinical competency and future development of the role.

This exploratory study used a qualitative design to conduct focus groups with a purposive sample of ACPs currently working in South Yorkshire and Bassetlaw in the North of England. In 2022 there were 585 trainee ACPs and approximately 1200 qualified ACPs working in this region.

Participants

Qualified ACPs or trainee ACPs that have completed at least 1 year’s full time equivalent of Advanced Care Practitioners clinical training, and currently work in this role within either Mental Health, Community or Secondary Care within the South Yorkshire and Bassetlaw region. It was felt 12-month minimum training experience would ensure trainees were sufficiently embedded in the clinical and educational programmes.

Recruitment

The NHS England Regional Faculty for Advancing Practice– North East and Yorkshire (FACP-NEY) acted as gatekeepers for the recruitment, contacting all qualified and trainee Advanced Care Practitioners working in the region with an invitation to participate by email. The email included a brief outline of the study, dates and times of the focus groups, details of an incentive payment of £30 for participation, a participant information sheet and, a web link to a short online questionnaire and contact details form. Additionally, the study was also advertised on social media platforms (Twitter, Facebook), with those who expressed an interest sent the same study invitation email, documentation and web link. Recruitment was open between February and May 2021, with one reminder email sent from the FACP-NEY during this time.

ACPs that wished to participate in the study were required to complete the short online questionnaire built using the survey tool, Qualtrics ( www.qualtrics.com ). After confirming eligibility, basic details were recorded about the participant and their ACP training including name, contact details, gender, age group, ethnicity, length of experience in the ACP role, supervision routine, portfolio status and supernumerary time. A variety of dates and times (morning, afternoon and evening) were provided for the focus groups to maximise recruitment, and participants were asked to indicate their preference. A total of 14 participants took part across five focus groups.

Data collection

Focus groups took place online using the Google Meets platform, with a maximum of 3 participants per group. To ensure participants were confident in using the Google Meets platform, the focus group began with an overview of the main functions and how to use them, for example clicking the ‘hand-up’ icon to indicate a wish to speak and chat facility. A focus group schedule was designed and used to guide the discussion similar to that used by Macnaghten and Jacobs (1997) [ 26 ] with an emphasis on each topic followed by discussion amongst the participants. The topics covered included experiences of undertaking ACP training (including gaining competence), role identity and career progression. Data collection was discontinued once it was felt there was no new contributions to the analysis, and there had been full investigation of the developed themes.

Participants provided written informed consent prior to attending the focus group, and consent was also acquired verbally at the start of each focus group. Each focus group was facilitated by one of the two authors (SA and MK), both of whom are experienced qualitative researchers with no clinical background or experience. Google Meets was used to video and audio-record the focus groups. The focus groups were transcribed verbatim by a third party, and quality checked against the recordings for accuracy. The duration of the focus groups was 2 h with a 15-minute comfort break. On completion of the focus groups, participants were sent a £30 shopping voucher to compensate them for their time.

Data analysis

The data was thematically analysed by three researchers (MK, SA and JSK) following the six-phrase process of Braun and Clarke, commencing with familiarisation of the data and then line by line coding to identify preliminary categories [ 27 , 28 ]. The data was then ordered and synthesised, combining similar categories and exploring the relationships between them [ 29 ]. This process was repeated for three of the five transcripts at which point the main themes and sub-themes were identified forming a test model, this was then applied to the final two transcripts. Following discussion amongst the research team, the main themes and sub-themes were agreed. NVIVO Release 1.3 (QSR International) [ 30 ] was used to help organise the data. The Standards for Reporting Qualitative Research (SRQR) checklist was used to report the findings (see Additional file 1).

The focus groups highlighted significant variability in the training experience of ACPs, dependent on their role and place of work. Table  1 provides an overview of the participant characteristics of each of the focus groups, and an overview of the overarching themes and sub-themes that were developed are displayed in Table  2 .

Overarching themes

A number of overarching themes were identified in our analysis that appeared to be strongly linked to role identity. We found the experiences of the ACP training were influenced by internal and external perceptions of the ACP role, often acting as barriers, with structural aspects being significant contributory factors. These findings were revealed in four key themes - lack of structure and support in the clinical training, existing experience and knowledge as enablers and inhibitors to progress with implications for confidence, the poorly understood nature of the ACP role and associated responsibilities, and a need for change to provide security to the ACP role in the future.

Clinical training lacked structure and support

The data revealed a stark contrast between the academic and clinical training, with clinical training found to be lacking in structure and support. Experiences of the clinical training were often expressed negatively due to the lack of structure which was heavily reliant on supervision and placements. As a result, ACPs often had to take the lead on their training and having to identify their own supervisor(s) and/ or placements was felt to be challenging. Consequently, some ACPs reported they had no dedicated medical supervisor at all. Where supervisors were in place, the quality of supervision varied, from being ad hoc (p41) and chaotic (p52) to great ( p53). Some of the supervision issues raised by the ACPs included lack of supervisor knowledge in relation to the ACP training and their required responsibilities, accessibility of supervisor (available time) and little direct clinical oversight. ACPs felt they needed an experienced medical professional as their supervisor, providing similar support and advice to that received by junior doctors.

We have nursing supervision from the lead community matron who is our line manager, but we do miss that sort of medical supervision (p22, Trainee ACP– Primary care) . I’m line managed by a nurse who is the operational lead for the service. He is the right person, but I don’t go to him for clinical support. It would be nice to have a medical supervisor (p. 41, Trainee ACP– Community care) .

Good supportive supervision appeared to enhance the ACP training, conversely poor, unsuitable or no supervision was perceived to have a serious negative impact on training and well-being, with suggestions that ACPs had left during training because of it.

I’ve had free reign over my own training, and planned everything myself, and that’s a positive for me (p41, Trainee ACP– Community care) . So the positives, um, I think the academic and educational supervision’s been, err, accessible and supportive. So we have, um, supervision from [regional] ACP lead,…and then there’s, um, the course unit lead, which she’s there and she’s supportive. So yeah, the academic, err, supervision is good (p52, Trainee ACP– Secondary care) . I think, um, something that I haven’t touched upon is, which I realised, so I’ve got a, um, clinical supervisor, she’s a consultant *****, and…the module I’ve just done which is minor illness, you had to do like a learning log, so they had to see you do….a load of things. And it made me laugh cos they turned around and said, look, I haven’t assessed anybody’s abdomen in ten years…. (p53, Trainee ACP– Secondary care)

Similar to supervision, clinical placements were highly valued by the ACPs and recognised as an important part of the training to achieve competence and consolidate their academic learning. All of the ACPs reported obstacles in organising and undertaking such placements, with those working in the community or mental health facing particular difficulties due to placements needing to be in a different clinical setting to where they worked. Competition with other trainees, the need to ‘ beg ’ (p7) and insufficient time from trainers were highlighted as ongoing problems. Conflict with junior doctors was also described as a competition for training opportunities.

Completely unsupported by the Trust because they just weren’t set up for it, there was no one leading on it, there were no one for us to contact really to talk. And then, like you said, I got my placements from begging on a, on a forum on Facebook and a nurse set me up (p16, Trainee ACP– Secondary care) . To kind of fulfil the module requirements, it was pretty much, for minor illness basically phoning up GP surgeries, practice nurses, beg stealing and borrowing, you know, begging people can you help me out, to try and get the amount of hours that you needed (p7, Trainee ACP– Secondary care) . But sometimes, it’s a little bit of a fight to get to what you need when you need because there’s so many junior doctors that also need that same training. So, there are occasions where you have to sort of step up and say we are training the same as these guys, we also need to be able to have these opportunities and you kind of have to have a little bit of a voice to say, we’re here (p17, Trainee ACP– Secondary care) .

In contrast to the clinical training, the academic learning followed a traditional format of taught lessons which ACPs felt covered a wide breadth of knowledge. There was some feeling that modules might have been more useful if they had been tailored towards individuals’ specialisms such as mental health or physiotherapy, however on the whole it was described as a positive learning experience with good supportive academic supervision.

I found the dissection labs quite alien but they have really helped to develop my practice (p24, Qualified ACP– Secondary care) . It feels a lot like there’s university, which is one day a week, and you do that, and it’s really supportive, and I’ve made some really good friends there, and everybody supports each other. But then at work, it’s a bit of a try and find your own way (p53, Trainee ACP– Secondary care) .

ACPs did describe the two learning environments (clinical and academic) as disconnected, separate and discrete, even though the ACP training is a combination of academic and clinical learning.

From the course point of view it’s pretty straightforward but it’s marrying that up with the expectations of the employer. Willingness of the employer to be able to give you the time you need to do what you need to do (p. 38, Qualified ACP– Secondary care) . They’d learn something at University (e.g. Cardiology) but there was no way this could be built on within the Trust. They just don’t deal with the physical health side of things (p. 7, Trainee ACP– Community mental health) .

Existing knowledge and experience appeared to act as both an enabler and inhibitor for ACPs, with implications for confidence

As existing experienced clinical practitioners, ACPs felt they were able to recognise their knowledge gaps and work quickly towards filling them, however the training approach also led to declines in confidence when deficiencies in knowledge and skills were highlighted. ACPs reported learning ‘backwards’ compared to junior doctors, using pattern recognition rather than pathology as a starting point, for example, being able to identify the treatment based on a diagnosis, but not necessarily knowing how the diagnosis was made originally. Not being able to adequately answer questions sufficiently on such subjects when tested by clinicians, and as experienced clinical practitioners, ACPs perceived themselves as lacking competence with a subsequent drop in confidence.

ACPs are trained ‘bottom-up’– we learn pattern recognition and then work our way back, whereas doctors know the diseases better (p41, Trainee ACP– Community care) . I think about cases backwards compared to doctors– as they think about pathology first and then build on that (p9, Trainee ACP– Primary care) .

A comparison between the clinical training processes of junior doctors and ACPs was a common discussion between ACPs with suggestions that it would be more beneficial if ACPs were recognised in a similar manner to junior doctors. For example, ACPs felt they should not be ‘counted in the nursing numbers’ when working on a ward, and as a consequence should not be expected to undertake a dual role of managing a nursing shift and practicing as an advanced practitioner:-

So say for example, you’re sat with somebody talking about their prescription and trying, you know, looking to see if there needs to be a change made, and then you’ve got other people banging on the door saying, I want to go out on leave, and I need this and I need that, and you’re the nurse in charge and need to be doing that. The people that usually do those jobs, so say for example the doctors in the week, when they’re having those sorts of consultations with people, they’ve not got that stress, the pressure, the disruption and the responsibility of running a nursing shift or a completely other shift. So, us as novices, it just doesn’t make sense to me (p. 52, Trainee ACP– Secondary care)

ACPs spoke of being unsure of when they had reached clinical competency, and how they would maintain this. They worried that if they were not given sufficient time to practise the new clinical skills, their confidence would decline and that they would ultimately feel unsafe in their clinical practice. ACPs emphasised the importance of having sufficient time to practice new skills and consolidate knowledge, enabling autonomy and confidence building. It was also felt this provided essential opportunities for colleagues to observe progress.

I’ve got most of my competencies but I still wouldn’t see myself as an expert practitioner (p41, Trainee ACP– Community care) .

The ACP role and associated responsibilities are poorly understood by ACPs and the wider medical profession

Exploring the experiences of training and the process of developing clinical competence with ACPs revealed there was a lack of clarity regarding the job role depending on where the ACP worked, and this applied to the ACPs themselves as well as their colleagues. This uncertainty impacted the responsibilities the ACP undertook within the clinical environment, and the expectations on them from the staff that they worked with.

ACPs that worked within the Emergency Department reported that colleagues understood the ACP role and utilised the advanced skillset the ACPs gained as the training progressed. They described feeling fully immersed within the department as an advanced practitioner, yet they were also recognised as being in a transitional stage with appropriately allocated time to undertake the necessary training.

ACPs working in other areas of healthcare such as acute wards, outpatients, mental health and community care discussed a general lack of awareness about the advanced practitioner role by both healthcare staff and patients. It was felt this led to a lack of utilisation of the advanced skills of the ACPs and expectations that the ACP should fulfil multiple job roles, creating feelings of intense pressure and demoralisation. ACPs reported hearing discouraging comments from colleagues about their abilities and felt a need to justify their role. Some ACPs described struggling with how to introduce themselves to both staff and patients, with their uniform described as an important part of their identity and how they were perceived by others. Adding to these external perceptions, ACPs revealed their job description was not necessarily updated to reflect their ACP role and where it was, the job description could be vague further undermining their role identity and leading to feelings of conflict between their original healthcare professional role (e.g., nurse) and working at an advanced level.

There’s been a lot of ambiguity around the job description for ACPs and trainee ACPs, so that’s left wriggle room for everybody making their own assumptions about what you’re supposed to do and what you should be doing, and therefore you’re pulled into all different things that don’t tie in to on paper in terms of national, regional frameworks……. there’s just pressure on the role being categorised as an extension of the nursing team, and taking on classic nursing tasks, it’s what people are familiar with, it’s what they assume (p52, Trainee ACP– Secondary care) . The challenge is with our role, is the ACP is tagged on to the end of our existing job. So, we have all of our normal nursing duties, we’re bed managers, we triage nurse, we run the hospital. And then you’ve got ACP tagged on the end. (p25, Qualified ACP– Secondary care)

Inconsistencies in awareness of the role, experience, training and clinical practice were felt to be a reflection of the different professions undertaking ACP training, a lack of standardised job role and unclear expectations. The variation in financial remuneration within and across different organisations for ACPs was also felt to be a contributing factor to these identity issues.

The ACP role is important, but changes are required to provide security to the role in the future

There was consensus that the combination of experience and advanced skills made the ACP a unique and valued role in the NHS, fulfilling an important gap in patient care. ACPs reported uncertainty about their future in the role, and the need for change structurally to ensure the ACP role has a future. Accreditation was felt to be necessary as this would legitimise the ACP role and apply some professional control in respect to the role title. ACPs viewed this as an existing issue with ‘advanced’ used by a multitude of health professions that have not undertaken the accredited training.

I kind of feel that, certainly as an ACP title, it should be some sort of standardised title, and then people would probably understand it a little bit more. I think our colleagues would understand it, and I think you won’t get so much resistance, from some medical colleagues, maybe, if people were sort, if it were a bit more regulated. I mean, if there were talking about credentialing and looking at a directory for ACPs anyway, it should be a registered regulated title (p54, Qualified ACP– Primary care) . I think everybody should be under the same governing body and there should be a bit of standardised, training placement (p41, Trainee ACP– Community care) .

As well as increased knowledge and skills, ACPs discussed the additional benefits of the training including the broad range of opportunities offered both during and after the training, and the potential boost in future prospects. A key attraction to the ACP training route that was repeatedly highlighted was the fact that it offers career progression whilst maintaining clinical responsibilities, progressing through more traditional routes into a managerial role appears to involve considerably less clinical duties and contact with patients. However, there was also some feelings of insecurity regarding the future of the ACP role because of the general lack of awareness of how ACPs fitted and could contribute to the NHS. It was felt that the deficiency in formal structure for the ACP role contributed to this; ensuring job descriptions existed and reflected the responsibilities of the role, and there was a structure for career progression was proposed as a good starting point to improve understanding amongst staff.

In terms of where I see myself in five to ten years’ time, I’m not sure, it depends how that organisation I work for pans out, because…. I won’t be sat here in five years’ time saying the same stuff. If it’s still the same I won’t be there, I will have gone somewhere else cos there are places that fulfil the role (p52, Trainee ACP– Secondary care) . I don’t see much career progression within ACPs other than to become a lead ACP and there is nothing to define progression within that role from a banding point of view (p1, Trainee ACP– Secondary care) .

On the whole, the ACPs felt the role had great future potential but this was often caveated, that changes were needed in formalisation of the training and particularly, wider recognition of the role and its responsibilities. Without these changes, a number of ACPs felt they would not be in the ACP role in 5 years’ time.

The one thing that I do know is that I love the job, I love the role (p38, Qualified ACP– Secondary care) .

This qualitative study collected the perspectives of 14 ACPs from different specialties and at different stages of their career. The findings suggest that ACPs continue to face significant barriers, undermining their development, transition and integration into the healthcare workforce.

ACPs described a number of challenges experienced in their training within the clinical environment, notably with placements and supervision. Both of these elements appeared to suffer from a lack of formal structure; where some ACPs experienced a supportive clinical environment making their training experience ‘phenomenal’, others reported unsuitable supervision and having to identify their own supervisors and/ or placements. This lack of support was felt to have a serious negative impact on ACP training and well-being, which has been reported nationally and internationally [ 17 , 31 , 32 ]. It is recognised that a supportive environment is a healthy environment, aiding not only ACPs in their competency, role transition and job satisfaction but also helping to optimise quality patient care, recruitment and retention [ 13 , 24 ]. Additionally, a disconnect between academic and clinical training was highlighted. This lack of ‘joined-up’ working between educators, healthcare staff and managers has been described previously with suggestions that it can impede the development of ACPs and their fulfilment of the role [ 22 , 33 ].

The knowledge and experience already held by ACPs from their original professional training was perceived as both a strength and weakness. Whilst the ACPs felt they could provide improved holistic patient care and identify gaps in their own training, it influenced their approach to learning which was described as ‘bottom-up’ and ‘backwards’ compared to how junior doctors learnt. This had implications for confidence as ACPs often felt they could not adequately answer questions posed during training. Furthermore, if they were not given sufficient time to consolidate their new knowledge, this led to an additional drop in confidence and doubts about their competence. This was reported by MacLellan, Higgins and Levett-Jones (2017) [ 34 ] and has been referred to as Imposter Syndrome [ 35 ]. It links closely with role transition and identity which has been widely researched within the advanced practitioner community [ 12 , 13 , 14 ]. Increasing autonomy and responsibility is part of the transition for ACPs and whilst some of the ACPs in this study found this experience exciting, the majority conveyed mixed emotions including feeling stressed, pressured and uncertain. This was more prominent for those ACPs in areas where the role appeared to be less established and a lack of awareness among healthcare staff of the ACP role. For a smooth and successful transition, Barnes (2015) [ 12 ] identified a number of defining attributes including a shift from provider of care to prescriber of care, straddling two identities and mixed emotions. The experiences of our ACPs covered all of these attributes and suggest they have not experienced a smooth transitional journey.

Inconsistencies in the ACP training and lack of structure in relation to the clinical job role were discussed as contributing factors to role identity issues, which impacted their daily working lives. It appears the ACPs in our study are still experiencing the consequences of a role which was introduced without clear definition, standardisation, skills and scope [ 20 ], even though there has been significant development in recent years within advanced practice [ 5 ] of the ACP training. As a role introduced to work alongside doctors, nurses, pharmacists, and other healthcare professionals to deliver comprehensive and patient-centred care, ACPs play a pivotal role in fostering interprofessional collaboration within healthcare teams. However, with blurred definitions regarding the ACP role and responsibilities, it is unsurprising our ACPs reported a lack of understanding of their expertise and respect from their colleagues. Such barriers to interprofessional collaboration not only prevents ACPs from working to the full extent of their education and training [ 36 ] but impacts patients, on their outcomes and access to specialist care [ 21 , 37 , 38 ]. A review of 64 studies undertaken by Schot, Tummers and Noordegraaf (2020) of interprofessional collaboration among healthcare professionals described this as being multifaceted, and that for change to occur, individuals needs to work daily on tasks such as bridging gaps, negotiating overlaps and creating spaces [ 39 ].

There was agreement between the ACPs that accreditation of the role would help address some of the issues around role identity. The use of ‘advanced practice’ is widely applied within healthcare with little relationship to education level, often leading to confusion [ 18 ]. Accreditation would help protect the role by providing professional identity as well as providing more clarity to ACPs and those in the wider healthcare setting about the role and scope of practice [ 6 , 17 , 18 ]. It may also alieve fears of insecurity which were raised by the ACPs in relation to the future of the role. Improving and promoting knowledge brokering at both the individual and collective (system) levels would improve the transition process [ 40 ], whilst also encouraging change in an environment that is traditionally intransigent.

Although the ACPs reported challenges in their training and felt changes were necessary to ensure wider recognition of the ACP role, there was consensus among the ACPS that participated in this study that the training ‘boosted’ opportunities and allowed career progression whilst maintaining clinical responsibilities, an important factor to many of the ACPs in this study. Surprisingly, there was little discussion regarding the impact of the COVID-19 pandemic on ACP training, even though the focus groups took place during the pandemic. When it was discussed, it was generally in the context of placements and how they had been further limited.

This qualitative insight into the training experience of ACPs has highlighted that there are many challenges still to be overcome to ensure ACPs feel supported through their role transition journey and are recognised appropriately for their skills and experience in the healthcare workforce. These findings are not new [ 13 , 14 , 20 , 22 ] but after the release of the 2017 HEE multi-professional framework for advanced clinical practice [ 5 ], it would be expected that there would have been more clarity and structure in the ACP training and role, benefitting ACPs, wider healthcare professionals and employers. Progress may improve as a result of the NMC review on regulation of advanced nursing practice that is due in the next 12 months [ 9 ], however, at the time of this study, the ACPs appeared to feel progress was slow and more work was needed.

Strengths and limitations

The opinions and experiences provided in this study were from a group of ACPs, either during (> 1 year FTE) or post training, working in the South Yorkshire and Bassetlaw region. It is reasonable to suggest therefore that the results are not generalisable to other populations. Qualified and trainee ACPs were contacted about the study by email through the regional FACP-NEY who acted as gate keepers, as well as the study being advertised on social media platforms. It is assumed that this broad recruitment strategy helped to reach a wider population, although most respondents appeared to be as a result of the direct email. This approach may have introduced some bias but using a purposive sampling approach, participants from different specialties, professions and career stages were included. Information about the local ACP workforce such as size and individual characteristics was requested from the regional FACP-NEY but this was not provided thus an exact response rate cannot be calculated nor can any inferences be made regarding how representative the sample of ACPs were that participated in the study. The number of males that registered an interest in the study was low (three) and only one male participated in the focus groups; this is a limitation as there may be different perspectives and experiences of ACP training related to gender. Due to the COVID-19 pandemic focus groups had to be undertaken online. Adaptions were made to accommodate for this such as reducing the number of participants per focus group and creating time to build rapport [ 41 ]. One participant did experience technical issues, however using a digital approach did not appear to impede the participant-researcher interaction and compared favourably with traditional face to face focus groups [ 41 , 42 ]. There is a risk that views from participants were oversimplified due to the limited number of ACPs involved in the focus groups but findings from this study appear to align with previously published literature [ 6 , 17 , 19 , 21 ] providing some confidence in the results.

Future work

This was a small exploratory study in a rapidly evolving field, providing insights on ACP training, role identity and competence at one point in time. ACPs did report differences in their experiences due to their specialty thus a much larger study would provide an opportunity to explore this further and allow for more in-depth comparisons. The multi-professional framework was relatively new when this study was undertaken and since its publication, there has been much development in the guidance and practice of ACPs including the Royal College of Emergency Care ACP training [ 43 ] and the merger of Health Education England with NHS England. It would be useful to explore what impact, if any, these developments may have had on ACPs and if similar issues around role identity and competence still exist.

The ACP role is now integrated across many specialties both nationally and internationally, however challenges continue to persist in training, impacting on transition into the role. At a collective level, there remains a lack of structure and clarity around the ACP role, and individually ACPs appear to experience issues with supervision and support. This study has highlighted that the journey to advanced level practice is often turbulent, and changes are required to further embed the ACP training and role into the workplace. Ensuring ACPs have appropriate continuous support, allocated sufficient time to learn and practice, and wider recognition of the ACP role through accreditation would aid the training experience and a successful role transition.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the participants privacy being compromised but are available from the corresponding author on reasonable request.

Abbreviations

Advanced Clinical Practitioner

Faculty for Advanced Clinical Practice

Health Education England

National Health Service

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Acknowledgements

The authors would like to thank the Sheffield Emergency Care Forum (SECF) PPI group ( https://secf.org.uk/ ) for their helpful feedback on the recruitment materials (email invitation, information sheet and consent form) developed for this study to ensure they were suitable for a lay audience. For helping with the recruitment, we would also like to thank the Faculty of Advanced Practice, particularly Fran Mead. Lastly, we would like to thank our participants for giving up their valuable free time to share with us their experiences of developing clinical competence as an Advanced Clinical Practitioner, and for their opinions on role identity.

This manuscript is independent research funded by the National Institute for Health and Care Research, Yorkshire and Humber Applied Research Collaborations (NIHR200166). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research or the Department of Health and Social Care.

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Made substantial contributions to conception and design, or acquisition of data: MK, SA and JSK; Analysis and interpretation of data: MK, SA, SC and JSK; Manuscript draft: MK, SA and JSK; Manuscript critical revisions: MK; SA; SC; JSK; FS; SM. All authors approved the final version of the manuscript.

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Kuczawski, M., Ablard, S., Sampson, F. et al. Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study. BMC Nurs 23 , 185 (2024). https://doi.org/10.1186/s12912-024-01843-x

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DOI : https://doi.org/10.1186/s12912-024-01843-x

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The role of a nurse is often seen as one of care and compassion, providing support and medical treatment to those in need. However, there is another aspect to nursing that is equally important but often overlooked - that of the [...]

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