Ethical Knowing in Nursing: How Nurses Tackle Moral Dilemmas in Everyday Care

What types of ethical conflicts did Florence Nightingale face more than 200 years ago? How did she handle these dilemmas in a time when nursing was still finding its professional identity?

Nightingale, widely known as the pioneer of modern nursing, confronted institutional resistance, advocated for hygiene reform, and fought for the recognition of women in healthcare. Her actions weren’t just clinical decisions, they were moral decisions, laying the groundwork for what we now call ethical knowledge in nursing.

Fast forward to today, and ethical knowing continues to shape nursing practice across hospitals, clinics, and community care settings. Whether guiding end-of-life care conversations or addressing staffing challenges, ethical knowing equips nurses with the tools to balance clinical judgment with moral clarity.

What Is Ethical Knowing in Nursing?

Ethical knowing is one of the four fundamental ways of knowing in nursing, as introduced by Barbara Carper, RN, EdD, in her landmark article, Fundamental Patterns of Knowing in Nursing. These four ways are:

• Empirical knowing (scientific knowledge)

• Aesthetic knowing (the art of nursing)

• Personal knowing (self-awareness and relationships)

• Ethical knowing (moral reasoning and values)

Unlike empirical knowledge, which is based on evidence and data, ethical knowing focuses on doing what is right, guided by principles like:

• Beneficence (doing good)

• Nonmaleficence (avoiding harm)

• Autonomy (respecting individual choice)

• Justice (ensuring fairness)

This way of knowing helps nurses navigate the moral complexities of healthcare, from policy conflicts to individual patient rights.

Everyday Ethical Dilemmas Nurses Face

Nurses are often on the front lines of difficult decisions, where clinical care meets emotional and ethical tension. Here are five common scenarios that require ethical knowing:

1. Balancing Patient Autonomy and Beneficence

One of the most frequent ethical dilemmas in nursing involves supporting a patient’s right to choose, even if the decision contradicts medical advice.

For instance, a patient with advanced cancer may refuse treatment, opting for comfort care instead. In this case, nurses must:

• Ensure the patient understands the consequences (informed consent)

• Respect the decision, even if it conflicts with their personal beliefs

• Act as advocates while adhering to legal and ethical frameworks

2. Resource Allocation and Staffing Shortages

Chronic nurse shortages and limited resources create tough choices, such as prioritizing which patients receive care first. Nurses may experience moral distress when they feel unable to provide the level of care every patient deserves.

Ethical knowing helps guide decisions that:

• Promote equity in patient care

• Advocate for systemic improvements

• Maintain integrity amid external pressures

  
  

3. Informed Consent and Truth-Telling

According to the National Library of Medicine, informed consent is the process where healthcare professionals explain risks, benefits, and alternatives of treatments.

Nurses play a key role in:

• Ensuring that patients receive clear, honest information

• Supporting them through complex, emotional decisions

• Upholding the ethical principle of veracity (truthfulness)

4. End-of-Life Care Decisions

Ethical challenges around DNR (do-not-resuscitate) orders, palliative care, and treatment withdrawal require nurses to balance emotional sensitivity with professional duties.

Using ethical knowing, nurses can:

• Facilitate open communication with patients and families

• Honor the patient's values and preferences

• Collaborate with interdisciplinary teams to ensure ethical care

5. Maintaining Professional Boundaries

In emotionally charged situations, especially in long-term care, nurses may become personally invested in a patient’s life.

For example, a nurse may feel compelled to offer support beyond their scope of practice when caring for a lonely, elderly patient. Ethical knowing helps nurses:

• Identify boundary crossings

• Maintain professional integrity

• Protect themselves and their patients from ethical complications

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How to Develop Ethical Knowing in Nursing

Ethical knowing is not just learned in a classroom, it’s cultivated through practice, reflection, and support. Here are ways to strengthen it:

1. Ethics Education and Formal Training

Many healthcare organizations and nursing schools offer ethics courses to help nurses:

• Understand core ethical principles

• Learn real-world applications

• Improve confidence in decision-making

2. Engage in Ethical Case Discussions

Talking through dilemmas with colleagues fosters:

• Moral reasoning development

• Empathy for diverse viewpoints

• A shared culture of accountability

3. Consult Ethics Committees

Most hospitals have ethics committees that:

• Provide non-biased guidance on complex cases

• Help resolve conflicts between patients, families, and providers

• Ensure ethical standards are maintained

4. Practice Self-Reflection and Moral Courage

Reflecting on difficult situations, and having the courage to speak up, strengthens a nurse’s ethical compass. Regular reflection can help nurses:

• Clarify their own values

• Evaluate past decisions

• Build confidence in advocating for what is right

Ethical Knowing in a Modern Context

As healthcare continues to evolve, ethical knowing is more important than ever. Issues like:

• AI in diagnostics

• Racial and social health disparities

• Privacy in digital health records

• Vaccine mandates and public health policies

...all require a strong foundation in ethical reasoning, empathy, and a commitment to patient-centered care.

A Legacy That Still Guides Us

Florence Nightingale didn’t just improve patient outcomes; she challenged authority, questioned outdated systems, and stood firmly for ethical care. Her legacy lives on in every nurse who uses ethical knowing to make compassionate, morally sound decisions.

By continuing to build on that legacy with education, courage, and reflection, nurses can ensure that ethical care remains at the heart of the profession, today, tomorrow, and for generations to come.