EMBRACING NEW NURSES: Clinical and Applied Ethics in Nursing Practice

Angela Babaev, DNP, CNS, RN, Assistant Vice President Education & Nursing Recruitment

The minute “Jennifer” begins her shift as a critical care nurse, she is swept into a whirlwind. “When you hit the door, everything starts happening,” she says. “People are handing you phones and reports. Somebody needs immediate help, and there is no easing into the workday.”

That’s a far cry from nursing school when you are calmly led by the instructor to the patient floor.

Today’s fast-paced health care environment can be challenging for nurses new to the profession. New RN graduates enter the work force with excitement and anticipation of their new role, even though they have demonstrated minimal competence to practice in meeting legal and professional requirements. Many experience anxiety, role conflict, and decreased confidence when making clinical judgments while transition to practice occurs.

Current nursing literature reports that the new graduate nurse turnover rate is 35 – 60 percent in the first year. This is particularly problematic in that new graduate nurses now comprise approximately 30 – 50 percent of typical hospital staff, if not more considering the recent staffing surges.

A Profession of Caring

Often, nursing is described as a profession of caring. Helping people or patients and families and giving back to the community are some of the reasons one becomes a nurse. There are many books on nursing ethics that refer to professional etiquette. The International Code of Ethics (ICN 2005), updated by the International Council of Nurses in Geneva, addresses nurse’s duties, obligations, and rights. As per the Code of Ethics, nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. The Code emphasizes that the nurse’s primary professional responsibility is to the people requiring nursing care. Each nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning to maintain the highest standards of nursing care possible. Nurses play the major role in determining and implementing desirable standards of nursing practice and nursing education in developing a core of professional knowledge. Through professional organizations, nurses participate in establishing and maintaining equitable social and economic working conditions in nursing.

To ease the reality shock among new graduate nurses, a large responsibility must be placed on preceptors to “embrace” them in order to ease the initial jolt. To help buffer the shock and keep nurses from running for the exits, we must look beyond the traditional orientation process. Ethical issues, dilemmas and questions confronted nurses even before the founding of modern nursing by Florence Nightingale. Nurses make clinical judgments every day that affect human lives at most critical moments of their patients’ lives. Many of these situations involve relationships and choices in which there are conflicts of values, duties, and ideals related to what is “good” or “right” for people. Frequently, there are many ethical matters surrounding daily choices made and influenced by nurses. These include: transition to clinical setting, acceptance into the professional role and environment, trying to fit in, maintaining professional standards, inter/intrapersonal dynamics, cultural competence, integration into the culture of the environment and unit, and nurse preceptor relationships.

Preceptor/Nurse Relationships is one matter that stands out and truly makes a difference during the learning experience the new nurse receives. As per the ICN Code of Ethics, “a professional relationship is based on collegial and reciprocal actions and behavior that aims to achieve certain agreed goals.” Many times, the initial learning experience is the deal breaker for anyone starting a new profession. Any nurse will thrive and blossom with the right preceptor surrounded with a positive environment – especially a newly-graduate nurse – so embracing new nurses in good will is essential.

Immanuel Kant (1724-1804), a Deontologist and philosopher, lived during the years of enlightenment, the Age of Reason, which influenced his philosophy. “Deon” in the Greek language means Duty and “Ontology” means the “study of.” Kant’s Deontology has often been associated with what is called “The Good Will” – not just be good, but to be good by its virtue. Morality is grounded in reason, not in tradition, intuition, conscience, emotion or such attitudes as sympathy. According to Kant, “good will” in essence is one’s intentions of the act, not the result. Moral worth of an action depends exclusively on the rule of obligation. One acts not just in accordance with, but for the sake of obligation. In hoping to create the proper society, Kant’s philosophy has been associated with Categorical Imperative, which consists of three steps: 1.) whatever decision that you make, think of it being set to maximum; 2.) whatever decision that you make consider yourself and those around you always at the same time and as an end, never as a means to an end; 3.) if the decision that you make is the one that you would want others to make now and for all eternity then do so. If not, then don’t do it. Kant focused on adherence to the rules, but not the consequences of the adherence. Many authors emphasize Kant’s rules to be universally accepted, meaning one’s actions should be such that they serve as a model for universal obligation for everyone to adopt.

Ethical predicaments in the health care system are deep-seated in every step of the way. There are many codes of ethics that guide health care, which shares a history with the research codes of ethics. According to Peirce, Smith, the first general code of ethics grew out of the Nuremberg trials following World War II. This came after the world learned of the human devastation wrought by Nazi doctors and nurses based on evidence of horrible experimentation performed on humans. As a result, this code was developed and is still being used today. With the evolution of time, the development of bioethics was driven by the technological advances of the last and current centuries.

Major Bioethical Principles

There are four major bioethical principles identified as critical in health care: autonomy, beneficence, non maleficence and justice. These are foundational, according to the authors Peirce, Smith. The first three are named “bedside principles.” They are the language of the institutional ethics committees. The principle of respect for persons is a principle that speaks to respect for individual autonomy and self-determination. It also recognizes that individuals are interrelated and interconnected members of the human community. Beneficence is a positive duty in that it requires that one takes an action. The beneficence principles require the provision of benefits and a balancing of harms and benefits as well.

How does this principle reflect in daily work on the unit? Do we as nurses understand the in-depth impact nurses are making? The nurse’s responsibility? Are we aware of the duties and obligations each nurse has to each other as colleagues? The demonological or Kantian theoretical approach focuses on the moral significance of the values of the moral agents or decision makers, and on duties and obligations guided by specific rules and principles without regard to consequences. The values and morals of the nurse preceptor are in alliance with the Code of Ethics with the principle of beneficence “to do no harm.” Preceptorship training, working culture of the unit and organization, and a “just culture” approach are the crucial elements that will provide a more successful learning experience for the new nurse who is transitioning into clinical practice. The key element is a positive nurse/preceptor relationship that makes a difference in embracing the new nurse during the transition into the clinical professional role.

Today, it is with confidence I can say that a professional collegial relationship with my preceptor was foundational to my future role as a nurse. The professional obligation using the beneficence principle of “to do no harm” applied to me by my preceptor was fully in effect for many years to come as my professional career developed and flourished. The nurse preceptor’s ability to distinguish ethical obligations to the patients from the obligations to the peers and the profession is a more complex individual process for each nurse preceptor. The explicit and implicit obligations must be used and maintained towards coworkers, colleagues and the nursing profession. In many circumstances, many obligations should be examined – in terms of collaborative practice, continuing education, mentoring, and knowledge development. The ideal preceptor is responsible for guiding, supporting, teaching, and evaluating the new nurse. Getting a commitment from the nurse preceptor supported not only by education, but by a willingness to precept will assure success to the nurse/preceptor relationship during the new nurse transition from student nurse into clinical practice.

Learning in the clinical setting is a complex phenomenon. There are many extrinsic and intrinsic components that influence the nurse/preceptor relationship and the teaching/learning experience in the clinical setting. Key elements that will impact the nurse/preceptor relationship is ethics applied and positive unit culture.

Nurse Residency Program

In our hospital, we offer a Nurse Residency Program where we provide mentorship resources for newly graduated nurses. The Nurse Residency Program is part classroom seminars and part support groups where nurses share their experiences and learn from each other, too. The program goes beyond reinforcing clinical skills. It teaches the new nurses how to be a hospital nurse, how to apply the knowledge to clinical practice, and how to integrate critical thinking, prioritization, and time management into their daily work. Creating an environment and encouraging ethical conduct; establishing, maintaining and promoting positive working conditions while engaging nurses to practice; and developing a set of values and beliefs to assure practice/policy is in alliance with the values of professional care delivery model we introduce and reinforce during the learning period.

Today, philosophers and bioethics offer many different theoretical positions which look at ethical dilemmas and problems in a richer and more comprehensive way than the use of abstract principles alone. People’s characters, clinical expertise, moral integrity, gaining knowledge and maintaining the code of ethics for nursing care are the points for ethical discussion and decision-making. An ethic of caring with the focus on relationships and responsibilities is one aspect of the broader field of ethics. The idea of an ethic of caring is the foundation of our practice to be about caring; caring for people; caring for the environment; caring for society; and caring for the profession. Caring is a fundamental value of nursing ethic. This core notion of caring is reflected and evident in the ANA Code of Ethics, which emphasizes respectful care of individuals as a major principle.

In an ethic of care, decision making focuses on identifying decisions and action that promote and maintain relationships as an individual responsibility. As nurses, it is our obligation to create healing environments for the patients, and a collegial professional environment for each other. This includes all aspects of ethics to develop positive relationships for social interactions, and to incorporate such socially-oriented principles as mutual respect, community, empathy, solidarity, and integrity, and connect them all to use in our everyday life. Embracing new nurses during the most vulnerable initial experience in their new professional role is momentous to the development of a great start and will contribute to the humanity of all participants in the health care system.

New baccalaureate nurse graduates require mentoring to become competent professionals. Creative approaches to new nurses’ practice initiation to complex, high-acuity patient care environments are needed to support workplace retention.