BackgroundSymptoms of mental disorder that impair decision-making capacity in inpatient psychiatric units increase the ethical tension between patient autonomy and paternalistic responsibility. Practices such as involuntary admission, compulsory treatment, and physical restraint further intensify this tension, while nursing students are more vulnerable to these ethical dilemmas because of their limited clinical experience.AimThis study aimed to describe nursing students' ethical experiences regarding the autonomy-paternalism tension in inpatient psychiatric units.Research designA qualitative descriptive design was used. Data were collected through reflective journals kept during the clinical placement and semi-structured individual interviews conducted at the end of the placement. These data were analysed using thematic analysis.Participants and research contextThe study was conducted in the nursing department of a public university in Türkiye. Thirty nursing students undertaking clinical practice in inpatient psychiatric units kept reflective journals, and 17 of them participated in individual interviews.Ethical considerationsEthical approval was obtained from the Sakarya University Social and Human Sciences Ethics Committee, and written informed consent was obtained from all participants.FindingsThe findings showed that students experienced the ethical tension between patient autonomy and paternalistic practices both explicitly and implicitly. Three main themes were identified: Experiencing Restrictions on Patient Autonomy, Ethical Silence in Response to Ethical Conflict, and Professional Ethical Development. Students identified the lack of adequate information and insufficient consideration of patients' concerns as ethical problems that undermined patient autonomy. They also reported remaining silent, primarily because of hierarchical structures and their role as students.ConclusionsThe autonomy-paternalism dilemma in inpatient psychiatric units constitutes a multidimensional experiential field for nursing students, intertwined with ethical silence, emotional burden, and processes of professional ethical development.
BackgroundIt is projected that the annual number of deaths will increase from 57 to 70 million between 2015 and 2030, placing increased demands on healthcare professionals in end-of-life care. Providing end-of-life care poses significant challenges for healthcare professionals, especially alleviating patients' suffering. Compassion, which is a foundational concept in caring science, is essential for easing suffering and can transform the caring experience for patients at the end of life and their families. According to the theory of caritative caring, compassion is the source of true caring.AimThe aim of this integrative review is to explore healthcare professionals' compassion in end-of-life care.DesignAn integrative review design was chosen. The literature searches were conducted in the CINAHL, Scopus and PubMed databases and 12 studies were included. As this was a review of published literature, ethical approval was not required.Quality appraisalThe Critical Skills Appraisal Programme (CASP) for qualitative research was used to evaluate the quality of the included studies.FindingsThe analysis revealed one overarching theme; Embracing the patient at the end of life and three categories; Being with the patient in the present moment, Being in a caring communion and Being available and attuned to the patient.ConclusionA healthcare professional's compassion can be key to achieving end-of-life care which unites evidence-based practice and the patient's voice as a human being. It is through compassion that healthcare professionals' caring can evolve at the end of life. This integrative review shows the importance and significance of a healthcare professional's compassion in caring for a patient at the end of life.
The use of restraint in psychiatric care remains one of the most ethically contested practices in mental health services, reflecting an enduring tension between the duty to ensure safety and the obligation to respect patient autonomy. Although coercive interventions are often justified as necessary responses to risk, their ethical legitimacy remains uncertain, particularly when examined through deontological frameworks. This theoretical paper provides a philosophical and legal analysis of restraint practices, drawing on the ethical theory of Immanuel Kant to critically evaluate the moral boundaries of coercion. Focusing on the Turkish context, the paper examines how reliance on Article 432 of the Turkish Civil Code, together with the absence of a comprehensive mental health law, shapes the use and justification of coercive interventions. The analysis suggests that current practices are largely grounded in risk-based and paternalistic models that may conflict with the Kantian imperative to treat individuals as ends in themselves. From this perspective, the routine use of restraint risks instrumentalizing patients, thereby undermining their dignity and moral agency. Integrating ethical theory, legal critique, and clinical considerations, the paper argues that restraint can only be justified under highly restrictive conditions, including strict necessity, proportionality, and use as a last resort; however, existing legal and clinical frameworks do not consistently meet these standards. The paper advances a rights-based alternative grounded in supported decision-making and psychiatric advance directives as mechanisms for preserving autonomy. By offering an interdisciplinary and normative framework that links philosophical principles with clinical practice and policy, this study contributes to nursing ethics and highlights the central role of nurses in transforming coercive care practices.
This paper argues that competence in nursing education is ethically incomplete without epistemic agency. Contemporary nursing programmes are increasingly shaped by competencies, assessment rubrics, curriculum mapping and audit-ready evidence. These mechanisms are legitimate and necessary for accountability, but they may become ethically insufficient when they make professional formation visible mainly as performance, compliance or documentation. Epistemic agency refers to the capacity to interpret experience, justify claims, question assumptions and participate as a legitimate knower in nursing practice. Although the term may be unfamiliar to some nurse educators, its absence is visible when students are trained to enact standards without being equally supported to reason about uncertainty, credibility, patient testimony and the knowledge claims embedded in care. Existing commitments to reflection, critical thinking, evidence-based practice, person-centred care and student voice provide important educational values, yet they often lack a sufficiently explicit account of the epistemic harms that occur when credibility, intelligibility and authority are unequally distributed. They do not fully explain how some knowers are believed while others are doubted, how some forms of knowledge become authoritative while others are treated as anecdotal and how nursing knowledge itself may be positioned as practical implementation rather than disciplinary contribution. Epistemic agency cannot be secured merely by asking students to think critically or nurses to listen more attentively. Such responses underestimate the social, institutional and curricular conditions through which knowledge is made credible, intelligible and actionable. Drawing on social epistemology, nursing ethics and nursing knowledge development, this discussion paper reframes epistemic agency as a condition of ethical professional formation beyond competence alone. No empirical data are reported. Practical reflexive prompts are offered for curriculum leaders, nurse educators, clinical supervisors and students.
BackgroundRespectful maternity care (RMC) is a fundamental human right and ethical obligation that includes women's dignity, autonomy, emotional support, and protection from harm during childbirth. Despite the increasing global attention to RMC, limited research has explored how women subjectively conceptualize respectful care through metaphors, particularly in the Turkish context.AimThis study explored women's metaphorical perceptions of respectful maternity care and identified the underlying ethical themes reflected in these metaphors.Research designThis qualitative study employed a metaphor analysis. Data were collected online from February to March 2026. Participants completed the prompt: "For me, respectful maternity care is like … because …." The data were analyzed using content analysis.Participants and research contextThe study included 109 women aged 21-78 years who had experienced vaginal childbirth in Türkiye. A total of 106 valid metaphors derived from 109 responses were analyzed.Ethical considerationsEthical approval was obtained from the Hacettepe University Faculty of Nursing Research Ethics Committee. Participation was voluntary, electronic informed consent was obtained from all participants, and anonymity and confidentiality were guaranteed.ResultsWomen's metaphors for respectful maternity care were grouped into four conceptual categories: dignified, supportive, protective, and guiding care. The findings showed that women perceive respectful maternity care as a multidimensional and ethically grounded experience extending beyond clinical safety to include dignity, emotional support, protection, and professional guidance.Conclusions: Women's metaphorical perceptions suggest that respectful maternity care is not merely the absence of mistreatment but a moral, relational, and rights-based form of care that recognizes women's dignity, vulnerability, autonomy, and personhood during childbirth. The findings highlight the importance of maternity care practices and professional education that actively promote respectful communication, emotional support, ethical sensitivity, and woman-centered care.
Respect for patient autonomy is a cornerstone of modern bioethics, yet the gap between ethical ideals and clinical practice remains pronounced. To bridge this divide, Björk and Hirsch have proposed the introduction of a new professional role: autonomy consultants. This essay critically examines the applicability of such a role within dementia care, a context characterized by progressive cognitive decline and irreversible alterations of personal identity. Using a philosophical and theoretical analysis, illustrated through a hypothetical clinical case study, this essay examines the conflict between a patient's historical autonomy and their situated well-being in the present. The results indicate that a strict bioethical focus on autonomy risks producing unintended consequences, including situations where attempts to preserve historical autonomy may contribute to distress for individuals with advanced dementia. Consequently, this essay argues for a conceptual reformulation of the role into a well-being consultant within dementia care. Rather than focusing primarily on autonomy, this role, grounded in care ethics and person-centered care, is proposed to function as a relational mediator who supports ethical reflection by integrating the patient's life history, present experiences, relationships, and well-being when conflicts arise between historical values and current care needs.
BackgroundNursing ethics is enacted through everyday clinical relationships as well as through formal standards. Perceived patient gratitude may function as a relational moral cue, but its association with nurses' ethically relevant workplace behaviour remains unclear.Research aimTo examine whether perceived patient gratitude was associated with nurses' workplace prosocial behaviour through moral efficacy and going beyond compliance.Research designA multicentre cross-sectional survey was conducted, and mediation analyses were performed using Hayes' PROCESS macro.Participants and research contextData were collected from 793 registered nurses working in hospitals in Henan, Hubei and Shaanxi provinces, China.Ethical considerationsEthical approval was obtained from the relevant institutional ethics committee. Participation was voluntary and anonymous, and electronic informed consent was obtained before questionnaire completion.FindingsPerceived patient gratitude was positively associated with workplace prosocial behaviour. Moral efficacy and going beyond compliance each independently mediated this association. A significant sequential indirect effect was also identified, in which perceived patient gratitude was associated with stronger moral efficacy, which was in turn associated with greater willingness to go beyond minimum professional expectations and, subsequently, higher workplace prosocial behaviour.ConclusionsPerceived patient gratitude may be associated with ethically relevant workplace conduct when relational recognition strengthens nurses' moral capability and professionally bounded ethical initiative. However, gratitude should not be regarded as a patient obligation, a condition of appropriate care or a substitute for organisational support. Longitudinal and relational research is needed to clarify these processes and their implications for equitable nursing practice.
BackgroundIn healthcare, patients are inherently required to undress, expose their bodies, and entrust themselves to others at their most vulnerable states. However, the potential sexual dignity discomfort (SDD) during these moments remains an underexplored dimension of patient dignity in healthcare settings. Unaddressed SDD can erode patients' trust in providers, prompt avoidance of necessary care, and ultimately compromise health outcomes.Research aimThis study aimed to develop and validate a culturally grounded clinical protocol to prevent patients' SDD in South Korean healthcare settings.Research designA multistep protocol-development design was employed, comprising protocol development, Delphi validation, and interview-informed refinement.Participants and research contextA total of 26 healthcare professionals from diverse clinical settings in South Korea participated in the Delphi surveys, and nine experts participated in in-depth interviews.Ethical considerationsThis study was approved by the Institutional Review Board of Chung-Ang University, and all participants provided informed consent.FindingsThe initial Delphi survey demonstrated high perceived necessity and importance of the protocol items but relatively lower feasibility and practice, revealing a gap between ethical awareness and practical implementation. Qualitative interviews identified several barriers to implementation, including sociocultural norms, defensive clinical attitudes, structural constraints, and hierarchical power dynamics. Based on these findings, the protocol was refined and finalized with 7 domains and 24 items.ConclusionsThe protocol developed in this study offers an evidence-based and culturally feasible framework not only as a practical guide for healthcare providers but also as an affirmation that every patient who exposes their body in clinical care deserves to have their dignity recognized, respected, and actively protected.
BackgroundMoral distress is common among ICU nurses and has been linked to burnout, diminished care quality, and turnover. Which factors matter most - and how they combine to shape individual risk - remains poorly characterised.Research objectiveTo identify factors associated with moral distress in ICU nurses and develop a parsimonious, exploratory risk-profiling model.Research designMulticentre cross-sectional survey with machine learning analysis.Participants and research contextA total of 318 registered nurses were recruited from ICUs of multiple tertiary hospitals across China between January and June 2025. Participants completed the Chinese-validated Moral Distress Assessment in Professional Practice Scale, the Connor-Davidson Resilience Scale, and the Pittsburgh Sleep Quality Index. High moral distress was present in 28.6% of participants. Data were split into training (n = 223) and test (n = 95) sets. LASSO regression selected 12 predictors from 29 variables, and 11 machine learning algorithms were compared. SHapley Additive exPlanations (SHAP) analysis guided feature reduction.Ethical considerationsApproved by the Ethics Committee of Jinzhou Medical University (No. JZMULL2025136). All participants gave written informed consent.FindingsGradient boosting machine (GBM) achieved the best balanced performance among all models (F1 = 0.767). SHAP-guided reduction to six features preserved full discriminative accuracy (AUC = 0.907, 95% CI: 0.834-0.980; DeLong p = 0.969 vs the 12-feature model). The six predictors, in order of importance, were monthly night shifts, financial responsibility role, psychological resilience, sleep quality, nurse-to-patient ratio, and weekly working hours. The model was well-calibrated (Hosmer-Lemeshow p = 0.220; Brier score = 0.097) and demonstrated net clinical benefit in decision curve analysis. Night shift frequency exhibited a nonlinear relationship with moral distress risk.ConclusionsSix modifiable or assessable factors accounted for most of the predictive signal. These exploratory findings suggest directions for future research and potential intervention - night-shift arrangements, financial strain, and resilience- and sleep-focused support - but the model requires external validation before any clinical application.
BackgroundAuthority and hierarchy shape nursing practice, influencing professional relationships, decision-making, advocacy and patient care. Although these concepts are widely present in healthcare, they are often examined indirectly through issues such as communication, bullying, professional status or organisational culture, rather than as phenomena in their own right.Research question/aim/objectivesThe aim of this study was to explore how nurses and midwives in the United Kingdom and Australia experience authority and navigate hierarchy in their work, and the consequences of these dynamics for ethical practice.Research designA qualitative study was conducted using online semi-structured interviews. Data were analysed inductively using reflexive thematic analysis, following COREQ reporting guidance.Participants and research context10 registered nurses and midwives from the United Kingdom and Australia participated. Participants worked across clinical, educational and academic contexts, with some still in full-time clinical practice and others having moved into non-clinical roles.Ethical considerationsEthical approval was granted by an institutional ethics committee. Participants provided informed consent. Given the sensitivity of the topic and the small sample, detailed demographic information was not collected or reported to protect confidentiality.Findings/resultsFive interconnected forms of authority were identified: professional, regulatory, theoretical, institutional and political. Authority was experienced as dynamic, relational and context-dependent, shifting across roles, relationships and settings. Participants described nursing as often positioned as subordinate within healthcare hierarchies, while also exercising authority through advocacy, expertise, influence and everyday resistance. Regulatory and institutional structures were experienced as both enabling and constraining, legitimising professional action while also limiting what could be said or done.ConclusionsAuthority in nursing is not fixed or determined solely by role or position, but it is continually negotiated in everyday practice. Nurses both reproduce and resist hierarchical structures while managing tensions between advocacy, compliance, professional risk and patient care, with authority and hierarchy shaping a range of ethical features of practice, including autonomy, communication and moral distress. Greater recognition of these dynamics may support safer, more ethical and more responsive healthcare systems.
BackgroundHealthcare is a heavily regulated environment in which nurses must navigate the delivery of therapeutic care while also managing their legal responsibilities. Appropriate care may appear ambiguous when the person who has experienced domestic or family violence is also experiencing mental health issues.AimThis study aims to present a case study, with learning objectives aligned to core legal, ethical, and clinical decision-making considerations and then demonstrate how students can be guided to analyse the case study, identify legal concerns, and address the arising issues to provide appropriate mental healthcare.Research DesignA simulated, constructed teaching case was analysed against relevant Australian legislation, professional standards, and organizational policy to identify key legal and practice issues at the intersection of domestic and family violence and mental healthcare.Ethical ConsiderationsSimulated case studies include realistic details that mirror practice environments. This case, designed for educational purposes, does not reproduce or disclose any real patient information, thereby avoiding confidentiality and ethical concerns.ResultsRecommendations surrounding lawful information sharing and the use of least-restrictive practices have been made. There is a need to support nurses with relevant education aligned with clear policies that reflect legislation.ConclusionsThis article highlights how legislation underpins and influences the provision of safe trauma-informed healthcare. Where domestic and family violence intersect with mental deterioration nursing staff need to navigate between their legal and ethical role and responsibilities. Using a simulated case study this article provides recommendations for care for these often-complex presentations.
BackgroundPower imbalances between supervisors and students can hinder graduate students from expressing concerns, potentially affecting academic progress and well-being. This issue may be more pronounced in nursing education due to the hierarchical culture.AimDrawing on boundary work theory, this study explores postgraduate nursing students' experiences of expressing concerns in power-imbalanced supervisory relationships, and examines whether informal peer support serves as an alternative channel when formal supervisory communication is constrained.DesignA descriptive qualitative design was employed. Data were collected through semi-structured interviews and analyzed using thematic analysis.Participants and research contextBetween November 2025 and January 2026, 18 postgraduate nursing students were recruited from four universities in Sichuan and Chongqing, China.Ethical considerationsEthical approval for this study was obtained from the Institutional Review Board of the First Affiliated Hospital of Chongqing Medical University (Approval Number: 2026-0423-01).ResultsThree main themes were identified: (1) Attempting formal feedback: exploring and defining supervisor-student boundaries; (2) Encountering obstacles in formal feedback: the narrowing and reinforcement of supervisor-student boundaries; (3) Shifting to informal peer support: alternative expressions within constrained boundaries.ConclusionPostgraduate nursing students commonly experience dissatisfaction in supervisory relationships. Within power-imbalanced contexts, their expression of concerns is often constrained and redirected toward informal peer support. The interviews indicate that peer support can provide emotional support and advice, but it does not fully address the underlying issues. Therefore, it is necessary to foster a more open and egalitarian communication climate among supervisors and to improve institutional feedback and communication mechanisms at the school level.
BackgroundGeneration Z is entering healthcare education and the early career during a period of workforce strain and rapid digital transformation. Ethical values may shape how this cohort engages with training, work environments, and professional roles, yet ethical perspectives are often addressed indirectly in existing studies.MethodsA scoping review following JBI guidance and PRISMA-ScR was conducted. MEDLINE (PubMed), CINAHL, PsycINFO, Embase, and ProQuest Dissertations & Theses were searched, with no date limits and inclusion of English, Italian, Spanish, and Portuguese sources. Screening and extraction followed a structured approach. Study characteristics were summarized descriptively, and ethics-related findings were synthesized using a thematic narrative approach.ResultsTwenty-eight were included, focused mainly on medicine and nursing area. The evidence base was heterogeneous and dominated by cross-sectional surveys, qualitative descriptive studies, and discursive papers, with few theory-driven designs and no consistent use of formal ethical frameworks. Ethical values were rarely the primary focus and more often appeared as embedded orientations within broader discussions. Recurring ethical themes encompassing education, career decisions, professional practice, and health-related behaviours included well-being and boundaries; meaningful work and purpose; empathy, teamwork, and supportive supervision; equity and fairness; autonomy and flexibility; and digital/technological ethics, including privacy, trust, diagnostic reliability, and human connection.ConclusionsEthics-related orientations among Generation Z in healthcare are consistently present but commonly implicit. Greater attention to value-context alignment in learning environments, leadership practices, and digital implementation may help inform strategies to support strengthen engagement and retention. Further research should strengthen conceptual clarity and broaden the contexts and professions studied.
This article offers a comprehensive analysis of the representations of nursing and healthcare in contemporary and classic dystopian literature and film. It explores how these narratives employ the professional figure of the caregiver to critique mechanisms of social, biopolitical, technological, and patriarchal control within healthcare systems. Using a qualitative approach to critical narrative discourse analysis, it examines foundational works, including One Flew Over the Cuckoo’s Nest, Brave New World ), the film adaptation of 1984, The Handmaid’s Tale, The Grief Nurse, and One Widow’s Healing. These texts are analyzed alongside recent theoretical contributions in posthumanism, critical nursing theory, and the ethics of care. The findings demonstrate that dystopian nursing operates as a powerful metaphor for the tension between an ethics of care and structures of domination, also revealing gendered and racialized dimensions of oppression. These narratives reflect urgent contemporary concerns about dehumanization, the commodification of health, the erosion of privacy, neoliberal bureaucratization, and the growing role of artificial intelligence in healthcare systems. It is concluded that these fictions offer a critical antidote to transhumanist and technocratic ideologies, reaffirming shared vulnerability, embodied empathy, and relational justice as irreducible foundations of nursing practice. The study advocates for collectivized political resistance in nursing, the integration of narrative competence in nursing education, and a critical engagement with the discipline’s historical complicities.
BackgroundAdvance directives (ADs) document the patient's preferences regarding future medical care and are used to ensure goal-concordant care and patient autonomy when the patient becomes incapacitated. In a clinical setting, goals of care (GOC) discussions are a tool that helps health care providers (HCPs) provide goal-concordant care. A lack of documentation of the patient's wishes, either as AD or following GOC discussions, can, especially in emergency or critical situations, lead to moral distress among HCPs, a psychological disequilibrium that stems from the perceived inability to act in the best interests of the patient.ObjectivesThis study aimed to (1) assess attitudes toward GOC discussions among patients and HCPs in general wards at Vienna General Hospital, (2) identify barriers and facilitators for their implementation, and (3) measure and compare moral distress between HCPs.MethodsA cross-sectional survey was conducted between October 2022 and June 2023 across six wards (cardiology, pulmonology, infectious diseases, maxillofacial surgery, palliative care, and chronic haemodialysis). Paper-based questionnaires were administered to patients (n = 47) and HCPs (n = 75). Moral distress among HCPs was assessed using a culturally adapted German translation of the Measure of Moral Distress - Health Care Professionals (MMD-HP).Ethical considerationsThe study was approved by the ethics committee and the data protection commission of the Medical University of Vienna. Informed consent was obtained from all participants. The questionnaires contained no identifying information. Participation was voluntary and not participating carried no disadvantages.ResultsMost patients (70.5%) considered GOC discussions appropriate during hospitalisation, 71.4% considered them relieving, and 79.1% considered them helpful. Only 10.9% had ever been asked about ADs during a hospital stay. Among HCPs, the majority considered GOC discussions suitable for patients with multimorbidity (80.0%) and life-shortening conditions (86.7%) as well as those with a simple medical condition (54.7%). However, the majority (51.4%) of HCPs practice GOC discussions for less than 10% of their patients. The lack of standard operating procedures (SOPs), personnel, time, translators, and material were reported as the most relevant barriers. The mean MMD-HP total score was 105.0. Nurses scored significantly higher than physicians (125.7 vs 86.9, p = 0.020).ConclusionsBoth patients and HCPs expressed strong support for GOC discussions, yet the implementation is hindered by resource limitations and the lack of standardised protocols. At the same time, nurses experience high levels of moral distress. There seems to be a need for organisational and policy measures to facilitate structured GOC discussions and goal-concordant care.
Background Nursing students encounter ethically complex situations in culturally diverse healthcare settings where ethical decision-making requires more than the application of ethical principles alone. Cultural humility and ethical sensitivity may play a critical role in shaping ethical decision-making competence in nursing education and practice. Aim This study aimed to examine the relationship between cultural humility, ethical sensitivity, and ethical decision-making competence among undergraduate nursing students in Egypt and to investigate whether ethical sensitivity mediates this relationship. Research design A descriptive cross-sectional survey design was used. Data were analyzed using descriptive statistics, Pearson’s correlation, multiple linear regression, and structural equation modelling. Participants and research context A total of 900 undergraduate nursing students were recruited from three public universities representing lower, middle, and upper regions of Egypt. Participants completed Arabic-translated versions of the Cultural Humility Scale for Nursing Students (CHSNS), Ethical Sensitivity Questionnaire for Nursing Students (ESQ-NS), and Ethical Decision-Making Competence Scale (EDM-CS). Ethical considerations Ethical approval was obtained from the Institutional Review Board of the Faculty of Nursing, Zagazig University (Approval No. 313). Written informed consent was obtained from all participants, and confidentiality and anonymity were maintained throughout the study in accordance with the Declaration of Helsinki. Findings Students demonstrated moderate-to-high levels of cultural humility and ethical sensitivity. Cultural humility was positively associated with ethical sensitivity and ethical decision-making competence. Multiple regression analysis revealed that cultural humility and ethical sensitivity significantly predicted ethical decision-making competence. Mediation analysis further showed that ethical sensitivity partially mediated the relationship between cultural humility and ethical decision-making competence. Conclusions Cultural humility directly and indirectly enhances ethical decision-making competence through ethical sensitivity among nursing students. Integrating cultural humility and ethical sensitivity into nursing ethics education may strengthen students’ moral awareness, ethical reasoning, and culturally responsive nursing practice.
BackgroundWhen patients refuse basic nursing care in the hospital setting, ethical tension arises between promoting patient dignity by providing hygiene and honoring bodily autonomy by respecting patient refusal of interventions.Research AimTo describe patient factors, clinical context, and the role of ethics consultation when basic care is refused to identify implications for future practice and/or policy.Research DesignWe conducted a retrospective qualitative content analysis of adult and pediatric ethics consultation documentation between January 2015 and December 2025 at a quaternary academic medical center, screening 2,381 consultations to identify cases involving refusal of basic nursing care. We collected patient demographics, admission and clinical information, reasons for ethics consultation, and actions taken by the ethics consultation service. Data were summarized via descriptive statistics, and categories were abstracted to develop a framework.Participants and Research ContextPatients receiving inpatient care at an academic medical center in the Midwestern United States.Ethical ConsiderationsUniversity of Michigan IRBMED deemed the study exempt (HUM00256591).Findings34 ethics consultations for 29 unique patients involved refusal of basic nursing care. Patients were adults (100%), with an average LACE score of 12.8; 15 (44%) had decision-making capacity. Care over objection was provided in 16 (47%) of cases, and physical restraints were used in 2 (6%) cases. Refusals involved hygiene (18, 53%), wound care (15, 44%), and repositioning (9, 26%), and occurred across nursing units and clinical services. Refusals were addressed through persuasion (9, 26%), soft paternalism (13, 38%), hard paternalism (3, 9%), or permitted refusal (9, 26%).DiscussionEthics consultation involvement resulted in four approaches to refusal of basic nursing care based on patient agency, decision-making capacity, and clinical context.ConclusionsWhen refusal results in dignitary or physical harm, healthcare teams should address barriers and encourage participation. In rare circumstances, care over objection is ethically permissible with multidisciplinary input.
