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Earn 2.3 Contact Hours
Empowering Nurses to Participate in Ethical
Decision-Making at the Bedside
Cara Bicking, RNC, MS
HOW TO OBTAIN CONTact hours BY
READING THIS ISSUE
Instructions: 2.3 contact hours will be awarded for this activity. A contact
hour is 60 minutes of instruction. This is a Learner-paced Program. Vindico
Medical Education does not require submission of the quiz answers. A
contact hour certificate will be awarded 4-6 weeks following receipt of your
completed Registration Form, including the Evaluation portion. To obtain
contact hours:
1. Read the article: Empowering Nurses to Participate in Ethical Decision-
Making at the Bedside, on pages 19-24, carefully noting the tables and
other illustrative materials that are provided to enhance your knowledge
and understanding of the content.
2. Read each question and record your answers. After completing all
questions, compare your answers to those provided within this issue.
3. Type or print your full name and address and your Social Security number in
the spaces provided on the Registration Form. Indicate the total time spent
on the activity (reading article and completing quiz). Forms and quizzes
cannot be processed if this section is incomplete. All participants are
required by the accreditation agency to attest to the time spent completing
the activity.
4. Forward the completed Registration Form with your check or money order
for $15 made payable to JCEN-CNE. Payment must be in U.S. dollars
drawn on a U.S. bank. Payment must be in U.S. dollars drawn on a U.S.
bank. This activity is valid from January 1, 2011, to December 31,
2012.
Vindico Medical Education is an approved provider of continuing nursing
education by the New Jersey State Nurses Association, an accredited
approver by the American Nurses Credentialing Centers Commission
on Accreditation. P188-6/09-12.
This activity is co-provided by Vindico Medical Education and The Journal
of Continuing Education in Nursing.
Objectives: After studying the article, Empowering Nurses to Participate in
Ethical Decision-Making at the Bedside, in this issue, the participant will:
1. Describe the importance of nurse involvement in ethical
decision-making.
2. Describe how a learning needs assessment was used to organize the
program described in this article.
3. Identify learning activities and teaching strategies that have been
shown to be successful in a continuing education (CE) program on
ethical decision-making.
4. Discuss ways in which the educational activity can be adapted to spe-
cialty areas other than neonatal nursing.
5. Discuss the benefits of a CE program about ethical decision-making.
AUTHOR DISCLOSURE STATEMENT
The author discloses that she has no significant financial interests in any
product or class of products discussed directly or indirectly in this activity,
including research support.
COMMERCIAL SUPPORT STATEMENT
All author(s) and planners have agreed that this activity will be free of bias.
There is no commercial company support for this activity. There is no
noncommercial support for this activity.
The Journal of Continuing Education in Nursing Vol 42, No 1, 2011
abstract
Nurses at the bedside have widely varied educational
backgrounds. Most bedside nurses have insufficient knowl-
edge in the area of ethical decision-making to feel confident
in their ability to participate in ethical decision-making along
with the health care team. Continuing education programs
for staff nurses should focus on ethical decision-making to
empower bedside nurses to participate. The effect of a suc-
cessful continuing education program in ethics could lead
to improved relationships among health care professionals,
improved communication with patients and families, and re-
duced stress-related burnout caused by ethical dilemmas.
This article describes a successful continuing education pro-
gram designed to improve knowledge of ethics and confi-
dence in ethical decision-making that can be adapted for any
nursing specialty.
J Contin Educ Nurs 2011;42(1):19-24.
T he need for nurses to participate in ethical decision-
making at the bedside increases exponentially as
the technology to support life advances. According to
the American Nurses Association (ANA) Code of Eth-
ics for Nurses, nurses have a duty to create and sustain
practice environments that are supportive of the ethical
obligations of nurses (2005). Practice environments that
are supportive of nurses ethical obligations cannot exist
if nurses are not properly educated in the basic concepts
of ethics. In a small study of first-year graduate-level
nursing students, Kalb and OConner-Von (2007) found
Ms. Bicking is Instructor, Penn State University School of Nursing,
Hershey, Pennsylvania.
The author discloses that she has no significant financial interests in
any product or class of products discussed directly or indirectly in this
activity, including research support.
The educational program described in this article was part of a syn-
thesis project required for the completion of a masters degree in nursing
education at Walden University, Minneapolis, Minnesota.
Address correspondence to Cara Bicking, RNC, MS, Penn State
University School of Nursing, 600 Centerview Drive, 1300 ASB/A110,
Hershey, PA 17033. E-mail: cbicking@hmc.psu.edu.
Received: March 11, 2009; Accepted: May 14, 2009; Posted: June
8, 2010.
doi:10.3928/00220124-20100601-03
19
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Sidebar 1
Learning Needs Assessment (n = 12)
The following topics were ranked in this order based on previ-
ous knowledge and what would be most beneficial to prac-
tice. They are listed from most important to least important.
The following example was provided: If something is very
important to practice but you already feel you have sufficient
knowledge, it would be ranked low. cess, education in the practice and theory of health care
Models to guide ethical decision-making in practice.
Stories from other neonatal intensive care unit nurses
regarding ethical decision-making.
Understanding ethical principles.
Court decisions in cases where ethical decisions had to be
made in a neonatal setting.
Statements from neonatal intensive care unit parents about
ethical decision-making.
that students had widely varied background education in
the area of ethics or bioethics. It may be further assumed
that nurses working at the bedside, who have completed
combinations of diploma, associates degree, or bacca-
laureate degree programs, may have even more varied
educational backgrounds.
This article describes a successful live continuing edu-
cation program on neonatal ethics and legal issues of-
fered to neonatal caregivers at a large university hospi-
tal. The article reviews the administrative details, course
content, and method of delivery, as well as student evalu-
ation outcomes. A discussion of the benefits of the pro-
gram and a recommendation for educators to implement
a similar program, regardless of specialty, is included.
The article provides nurse educators with a successful
model that can be adapted to any practice specialty and
used to empower nurses through knowledge of ethical
decision-making.
Educating nurses on the basics of ethics and ethical
decision-making will provide them with the support
they need to serve as patient advocates when an ethi-
cal dilemma arises in bedside nursing. Nurses are often
the first health care providers to whom patients express
their wishes (National Association of Neonatal Nurses
[NANN], 2006). Through compassionate bedside care,
nurses become familiar with the attitudes and values of
the patient and family. Nurses are also the profession-
als charged with implementing treatments in an ethically
challenging situation. These ethical dilemmas and the
tasks nurses are subsequently asked to perform are a sig-
nificant source of stress and burnout if the nurse has not
been involved in the process of decision-making (Braith-
waite, 2008).
To protect the bedside nurse from conflict and fur-
ther risk of burnout, nurses should be involved in ethical
20
decision-making at the bedside. NANN, in a 2006 po-
sition statement, explicitly stated that it supports the
inclusion of NICU [neonatal intensive care unit] nurses
in making ethical decisions in the care of critically ill
newborns. The position statement further asserts that,
for nurses to be involved in the decision-making pro-
ethics is essential. The author believes that these state-
ments have powerful implications, not only for neonatal
nurses, but also for all nurses involved in direct patient
care in all specialties. Continuing education in the area of
ethics and the nurses role in ethical decision-making can
have a positive effect on patient outcomes, family-cen-
tered care, and professional collaboration and can reduce
the growing problem of nurse burnout.
Program Details
According to the educational surveys completed by
the nurses on the neonatal unit, the most convenient
time for educational programs is one that allows nurses
to transition easily to working in direct patient care on
the same day. The program coordinators selected the
times of 7:30 a.m. to 11:00 a.m. and 11:30 a.m. to 3:00
p.m. to offer back-to-back programs. This time selection
has been the most successful in the past for offering edu-
cational programs to nurses working all shifts and yields
the highest number of participants.
The tentative plan to organize a continuing edu-
cation program based on neonatal ethical decision-
making was refined through the responses provided by
a unit-specific educational assessment. This assessment
showed a desire to learn more about the topic of ethics
as well as a desire to learn more about prenatal counsel-
ing performed by neonatologists for parents who were
expecting to have a child in the neonatal intensive care
unit (NICU). In an ethics-specific learning needs assess-
ment (Sidebar 1), staff nurses (n = 12) ranked models
to guide ethical decision-making in practice highest in
a list of topics. From the results of these educational as-
sessments, the program was organized into the following
four topics: the basics of ethics, ethical decision-mak-
ing in the NICU, the legal history of ethical decision-
making, and prenatal consult. Each portion of the pro-
gram is discussed separately, including the educational
activities and student evaluations for each.
The Basics of Ethics
The first portion of the program was designed to
introduce nurses who had not previously had formal
coursework in health care ethics to the principles of
ethics and to review the principles for those who had
completed this coursework (see Sidebar 2 for a list of
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the seven ethical principles). The percentage of program
attendees who had not had formal coursework or had
not attended an educational program specific to ethics
was approximately 50% (n = 11 of 21 total attendees).
The basics of ethics section began with a case study. The
participants were asked to read the case study and an-
swer the discussion questions that were also distributed.
Discussion about the case study followed and allowed
the students to interact, tell personal stories, and discuss
questions relevant to ethical decision-making. This ac-
tivity promoted active learning and was within the pa-
rameters of adult learning theory. Adult learning theory
is an ideal model in the context of continuing education
in nursing because it emphasizes the adult learners need
to participate, share personal and professional experi-
ence, and relate knowledge to practice (Billings & Hal-
stead, 2005). Starting the program with an activity, such
as discussion of the case study, helps to draw students
in and promote active participation.
This portion of the course continued with a didactic
presentation that described a nurses obligation to pro-
vide ethical practice and introduced the seven basic ethi-
cal principles. Issues specific to neonatal care were also
discussed and included the limit of viability, statistics on
death and disability, futility, parent authority, and influ-
ences on parents. Throughout the lecture, participants
were asked to discuss the information provided in terms
of the ethical principles or by providing examples from
their own practice. Participation and discussion were
generally enthusiastic and often provided varied view-
points for further consideration.
Finally, the participants knowledge of the basics of
ethics was evaluated using a five-question multiple-choice
quiz presented via a PowerPoint interface and using
audience response software. Each participant was able to
answer the multiple-choice questions anonymously us-
ing a personal clicker. The majority of responses gave
the correct answer to each question, and participants
verbally rated this activity highly; several stated that it
was fun and that they wanted to do more. Audience
response systems have been shown to improve student
motivation and encourage classroom participation (Me-
dina et al., 2007). Overall, achievement of the learning
objective for this lesson was rated as high or very high by
all but one participant, who rated it as moderate.
Ethical Decision-Making in the NICU
In an ethics-specific learning needs assessment in the
NICU, the respondents listed models to guide ethical
decision-making in practice as most valuable to learn-
ing (Sidebar 1). This lesson reflects the assessment results
and began with a didactic presentation on the theories of
The Journal of Continuing Education in Nursing Vol 42, No 1, 2011
Sidebar 2
The Seven Basic Ethical Principles
Autonomy
Beneficence
Non-maleficence
Veracity
Justice
Fidelity
Confidentiality
deontology and consequentialism and further expanded
with information on quality of life versus sanctity of
life. Throughout the didactic portion, students were
encouraged to provide examples from their own prac-
tice to support the ideas that were discussed. An ethical
decision-making model was then presented. The model
was adapted for simplicity from one published by Fasser
et al. (2007). Use of the model encourages decision-mak-
ing that is well reasoned and ethically justified, and it
can be used in any specialty area of nursing (Fasser et
al., 2007).
For any nursing specialty, case examples are available
in the literature that describe ethically challenging situa-
tions and can be used in conjunction with Fassers model
(2007). For example, in a 2008 report, Krueger described
a case study of a neurosurgical patient who presented her
own plan for physician-assisted suicide. For periopera-
tive nurses, Kuz (2006) described a case study in which
a 14-year-old girl provided her own consent for surgery
and the attending surgeon accepted this consent without
question. Experienced nurses may also have witnessed
cases in clinical practice that could serve as excellent ex-
amples of ethically challenging situations. Any of these
cases relevant to the clinical practice of the program par-
ticipants can be used with the decision-making model to
determine a course of action based on solid ethical rea-
soning.
Participants in this program were given a case study
published by Novak (1988) of a woman who was work-
ing in the United States as an illegal immigrant. She gave
birth to twins through cesarean section at 34 weeks ges-
tation; it was unknown why the obstetrician initiated
delivery before term gestation. One of the twins sub-
sequently had long-term neurological consequences of
premature birth. The participants were asked to use the
ethical decision-making model to decide whether a peer
review should be initiated against the obstetrician. They
were asked to consider the consequences of this action
to the mother and the infants as well as the consequences
of each action to society. Interestingly, the first program
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group decided that the principle of justice outweighed all
others and that a peer review must be initiated to protect
future patients of the obstetrician. The second program
group was unable to come to a consensus. In the case
presented by Novak (1988), the health care team decided
not to initiate a peer review at the request of the mother.
Participants engaged in active discussion in this por-
tion of the program and shared relevant clinical examples,
upholding the principles of adult learning, as previously
discussed. Meeting the learning objective for this portion
of the program was rated as high or very high by all but
one participant, who rated it as moderate.
The Legal History of Neonatal Decision-
Making
The portion of the program concerned with the legal
history of neonatal decision-making consisted of didac-
tic presentation, with participants encouraged to inter-
act with the content through questions, discussion, and
storytelling. Participants were presented with the case of
Baby Doe, which caused controversy and several legisla-
tive actions affecting the neonatal world. Several court
decisions involving neonates, as well as position state-
ments from the American Academy of Pediatrics and
the Presidents Council, were also presented. There was
also a short didactic presentation on the differences in
how society views resuscitation and life support for dif-
ferent age groups, using a study by Javier, Leblanc, and
Barrington (2008). Participants were shocked at the con-
clusions of this study, which would provide interesting
discussion and reflection for nurses in any specialty area.
Overall, this portion of the program was rated similarly
to the other portions, with all but one participant rating
the degree to which learning objectives were met as high
or very high.
Prenatal Consult
The final portion of the program was included in re-
sponse to learning needs assessment surveys in which re-
spondents listed what doctors tell parents of a premature
or sick baby prior to delivery as an additional relevant
educational topic believed to benefit their practice. For
this lecture, one of the university neonatologists gave a
short presentation that included the most recent available
statistics on outcomes for extremely premature infants as
well as information on the beliefs and values of the medi-
cal team when counseling parents before delivery. The
participants also used this opportunity to ask the neona-
tologist about biases in counseling as well as differences
between neonatologists and parents perceptions. This
portion of the program was a vital link between nurses
and physicians, serving to promote communication and
22
understanding between their roles. Achieving learning
outcomes for this portion of the course was rated as high
or very high by all but two participants.
Benefits and Outcomes
Indications of a successful educational program vary,
but the author aimed to provide information to partici-
pants that would be useful in practice and would improve
participants confidence in making ethical decisions. In
response to the statement I feel that this class provided
information I can use in my practice to evaluate clinical
situations from an ethical perspective, 32% (n = 6) of
classroom participants answered somewhat agree and
68% (n = 13) answered strongly agree (Table). There
were no neutral or negative responses to this statement.
Participants indicated that the program offered valuable
knowledge that could be used in practice.
In pre-class and post-class surveys, students were
asked to rate their confidence in providing input to both
the health care team and parents during difficult ethical
decision-making situations. Participants indicated an
increase in confidence after the completion of the edu-
cational program in both situations. In response to the
statement I am confident in providing input to the neo-
natal care team when ethical or end-of-life decisions are
made in the NICU, 33% (n = 7) of respondents had a
neutral or negative response, whereas 67% (n = 14) an-
swered positively in the pre-class assessment. On pro-
gram completion, 15% (n = 4) had a neutral response
to this statement; 80% answered positively (n = 16)
and only 5% (n = 1) answered negatively. In response
to a similar statement, I am confident in providing in-
formation to parents in the NICU when they are faced
with end-of-life decisions, participants also reported
improved confidence. The percentage of respondents
agreeing with the statement increased from 52% (n =
11) pre-class to 75% (n = 15) post-class. Twenty percent
(n = 4) of respondents had a neutral response after the
program. One respondent disagreed with the statement
after program completion (5%), compared with five who
disagreed with the statement (24%) before the program.
Increased confidence in providing input to health care
professionals as well as parents is essential for nurses to
become involved in the ethical decision-making process.
The benefits of an educational program on ethical
decision-making were explicitly described by NANN,
which stated, In order for nurses to contribute to the
decision making process in the most effective manner,
NANN (2006) recommends education for nurses in the
theory and practice of ethics in health care . . .. Individ-
ual nurses show increased confidence in providing input
during ethical discussions; in addition, a clinical unit as
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Table

Comparison of responses on the pre-class survey versus the post-class survey

No. of Respondents Who Chose Each Answer
Strongly Somewhat Somewhat Strongly Total No. of
Survey Statement Disagree Disagree Neutral Agree Agree Responses
I am confident in providing input to the neonatal
care team when ethical or end-of-life decisions
are made in the neonatal intensive care unit.
Pre-class survey 0 5 2 12 2 21
Post-class survey 0 1 3 13 3 20
I am confident in providing information to parents
in the neonatal intensive care unit when they are
faced with end-of-life decisions.
Pre-class survey 1 4 5 11 0 21
Post-class survey 0 1 4 14 1 20
I feel that I have a good understanding of what
the neonatologists discuss with parents during a
prenatal consult.
Pre-class survey 7 3 3 7 1 21
Post-class survey 0 2 1 9 7 19
I feel that this class provided information I can use
in my practice to evaluate clinical situations from
an ethical perspective.
Post-class survey 0 0 0 6 13 19
Note. Not all program participants responded to all questions.

a whole can benefit from this education. The contribu-
tion of nurses in ethical decision-making is essential be-
cause nurses are often the professional most aware of the
wishes and values of the patient and family (Braithwaite,
2008).
The continuing education program described in this
article can be adapted to any nursing specialty and can be
used to empower nurses all over the world to participate
in ethical decision-making at the bedside. For example,
the nurse educator for an adult critical care unit would
be able to present the basics of ethics in the same manner
as described in this article, perhaps including additional
information on advance directives, restraints, pain man-
agement, family presence during resuscitation, and end-
of-life care. The American Association of Critical-Care
Nurses maintains an ethics webpage (2009) that provides
information on these topics as well as an extensive selec-
tion of ethically challenging case studies that can be used
with the previously mentioned ethical decision-making
model. The educational program for ethics in the critical
care setting should be based on a learning needs assess-
ment, which may show the need for additional educa-
tion on the use of the ethics committee or other hospital-
based resources for which a guest speaker can provide
additional education. Additionally, the value of a criti-
cal care nurses experience with ethical decision-making
or the experience of a patient or patients family should
not be underestimated and can be considered a teach-
ing resource. Nurse educators in other specialty areas
should use the resources available to them from relevant
professional organizations, such as the Association of
periOperative Registered Nurses or the American Psy-
chiatric Nurses Association, to assist in the development
of an educational program to address ethical issues.
The use of this program could increase nurses respect
for ethical reflection and increase their ability to discuss
ethical standards. By reducing the moral distress caused
by complicated ethical dilemmas and a lack of input, em-
powerment of nurses in ethical decision-making could
decrease nurse burnout.
Limitations
Only two class presentations were made, with a rela-
tively small sample of nurses, 22 in total. The majority
of nurses attending the program were senior nurses,
many with more than 20 years of neonatal experience.
The process used for scheduling educational time in the
study institution is based on seniority, leaving nurses

The Journal of Continuing Education in Nursing Vol 42, No 1, 2011 23

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key points
Ethical Decision-Making
Bicking, C. (2011). Empowering Nurses to Participate in Ethi-
cal Decision-Making at the Bedside. The Journal of Continuing
Education in Nursing, 42(1), 19-24.
1 Educational programs designed to empower bedside nurses
to participate in ethical decision-making can improve relation-
ships among health care team members, improve relation-
ships with patients, and reduce the distress that occurs during
an ethical dilemma.
2 The program described here follows adult learning theory and
uses case examples, discussion, didactic presentations, and
audience response software to meet learning objectives.
3 The educational program on ethical decision-making can be
adapted to any specialty area of nursing using the adult learn-
ing principles and assuring that the case examples provided
are relevant to the specialty area.
with low seniority without the opportunity to attend
more desirable educational offerings, as was the case
for this program. A representative sample of neonatal
nurses, including new graduates or those with less expe-
rience, may have yielded different results.
Recommendations for Educators
To reap the benefits of nurse empowerment through
education, it is recommended that educators adapt the
educational program to the needs of their students.
Most continuing education programs are designed with
the needs of adult professionals in mind. It is important
for the principles of adult learning to be upheld, with
the use of case examples, discussion, storytelling, and
audience response interaction, as was used in this pro-
gram. In addition to a focus on adult learning, it is es-
sential to remember that information must be provided
that is directly applicable to the clinical area in which
the program is offered. To keep participants interested
and engaged in the content, case examples and court de-
24
cisions that are presented should be drawn from a famil-
iar practice area.
Nurse educators have a responsibility to ensure that
nurses at the bedside have a solid understanding of ethi-
cal principles, are able to logically discuss ethical dilem-
mas, and are confident in their ability as professionals
to support families during times of ethical questioning.
It is the authors hope that educators will continue to
adapt the educational program discussed in this article
to empower nurses to participate in ethical decision-
making.
References
American Association of Critical-Care Nurses. (2009). Ethics web-
page. Retrieved from www.aacn.org/WD/Practice/Content/ethic
mainpage.pcms?menu=Practice&lastmenu=
American Nurses Association. (2005). Code of ethics for nurses with
interpretive statements. Retrieved from www.nursingworld.org/
ethics/code/protected_nwcoe813.htm
Billings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A guide
for faculty (2nd ed.). St. Louis, MO: Elsevier Saunders.
Braithwaite, M. (2008). Nurse burnout and stress in the NICU. Ad-
vances in Neonatal Care, 8, 343-347.
Fasser, C., McGuire, A., Erdman, K., Nadalo, D., Scott, S., & Waters,
V. (2007). The ethics workup: A case-based approach to ethical
decision-making instruction. Journal of Physician Assistant Educa-
tion, 18, 34-41.
Javier, A., Leblanc, I., & Barrington, K. J. (2008). The best-interest
standard is not applied for neonatal resuscitation decisions. Pedi-
atrics, 121, 963-969.
Kalb, K. A., & OConner-Von, S. (2007). Ethics education in advanced
practice nursing: Respect for human dignity. Nursing Education
Perspectives, 28, 196-202.
Krueger, D. L. (2008). Ethical decision-making in neurosurgery: A case
study. Journal of Neuroscience Nursing, 40, 346-349.
Kuz, K. M. (2006). Young teenagers providing their own surgical con-
sent: An ethical-legal dilemma for perioperative registered nurses.
Canadian Operating Room Nursing Journal, 2, 6-15.
Medina, M. S., Medina, P. J., Wanzer, D. S., Wilson, J. E., Er, N., &
Britton, M. L. (2007). Innovations in teaching: Use of an audience
response system (ARS) in a dual-campus classroom environment.
American Journal of Pharmaceutical Education, 72, 38.
National Association of Neonatal Nurses. (2006). Position statement
#3015: NICU nurse involvement in ethical decisions (treatment
of critically ill newborns). Retrieved from www.nann.org/pdf/
3015rev0612.pdf
Novak, J. (1988). An ethical decision-making model for the neonatal
intensive care unit. Journal of Perinatal and Neonatal Nursing, 1,
57-67.
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