Running head: IMPORTANCE OF HAVING A NURSING CONSCIENCE

Importance of Having a Nursing Conscience: Moral Distress in the Clinical Setting

Nicole Rossi
James Madison University

Importance of Having a Nursing Conscience: Moral Distress in the Clinical Setting

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Introduction
As first semester nursing students, the idea of entering the clinical setting and learning
about our dream career is both exciting and stressful. Since we are starting to grow in our skills
and applying concepts from class, we rely on the guidance of nursing preceptors at our clinical
institutions. Much trust is employed into each of these clinical days as we novices follow the
more experienced preceptors patient care instructions. Although this unconditional reliance is
ideal, realistically, as students we need to apply our developing nursing conscience, which holds
our morals, ethical principles, and critical thinking skills, and not just blindly follow preceptors.
Nursing students may have a moral mindset, but not the courage to speak up in an ethical
situation where a preceptor acts as a poor example of moral nursing practice. Nursing students
were found to not act in ethical scenarios despite their nursing conscience because they felt
powerless as a student, lacked the confidence and knowledge to speak up, and did not want to
upset preceptors (Bickhoff, Sinclair, & Levett-Jones, 2015, pp. 6, 8). Students tended to fear
retribution and thus did not report when they observed nurses performing ethically questionable
actions (Epstein & Carlin, 2012, p. 900). However, if students reported the moral wrongdoing,
they addressed concerns to a manager instead of the nurse so that they were distanced from the
action (Bickhoff, Sinclair, & Levett-Jones, 2015, p. 11). Morally distressing situations have led
to feelings of shame for not advocating for the patient and even questioning of their place in
nursing (Epstein & Carlin, 2012, p. 900). Nurse preceptors are supposed to set an example for
evolving nurses, but students should employ confidence and courage to use their nursing
conscience and advocate for patients in morally compromising situations. Poor examples set by
preceptors are common and can affect the student nurse and the safety and rights of patients. The
findings in these scholarly articles relate to my first clinical experience of undergraduate nursing.

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Background
One scenario during my first clinical rotation tested my nursing conscience, which I
forwent in order to listen to an authority figure whose suggestion threatened patient safety. While
removing a tight cap to administer an injection, the needle tip skimmed my gloved finger. I
immediately stopped, looked at my glove, and asked the nurse what I should do. This was my
first medication injection, and I was nervous enough that I struggled with the cap, nonetheless
had the needle barely touch my glove. She examined my glove, stated that it was not punctured,
and ensured that it was fine to give the medication. I wrestled with the thought that maybe there
was a microscopic tear in the glove and that I could ask to get a different needle to be cautious. I
did not ask, lacked the courage to speak up, and believed that the nurses knowledge and
experience was enough to justify her suggestion. This scenario is a perfect example of moral
distress, especially since my nursing conscience directed me to the correct action, but feelings of
powerlessness and fear as being a new student nurse inhibited me from taking that action.
Methods/Findings
As a student nurse, I can use the Madison Collaborative 8 Key Questions with ethical
reasoning. According to this ethical decision-making model, it is important to consider outcomes,
character, liberty, authority, empathy, responsibility, rights, and fairness when faced with a moral
dilemma or distress situation. With outcomes, the short and long-term consequences of each
person in the situation must be deliberated carefully and objectively. In my scenario, by giving
the medication without changing the needle, my skin and blood could have transferred to the
patient if there was a microscopic hole in the glove, which may have caused infection in the
long-term and jeopardized the patients safety. I would experience guilt of the unknown and face
possible repercussions. The nurse would risk her career, especially if the patient was harmed. By

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using a new needle, patient safety is not endangered and medication administration would come
without additional risks. I would have felt no guilt or fear and instead accomplished in properly
administering my first injection. The nurse would have the satisfaction of demonstrating the
importance of patient safety even in uncertain situations. Character explores what actions are
congruent with ones desirable personal values. As a nurse and person, I want to be trusted,
compassionate, and uphold integrity. I did not follow my values by not changing the needle.
Instead, I adopted the nurses character and disregarded mine out of fear of disobeying authority.
When contemplating liberty, autonomy, freedom, and the harm principle are recognized. This
principle states that a person should do what they please and enact their liberties until it threatens
the harm and liberties of another. The patients safety was threatened once the needle skimmed
my glove, so I needed to change the needle to avoid endorsing the threat. It is wrong to expose
them to a potentially contaminated needle, even if instructed by an authority figure, to cause less
harm and protect the patients liberty (The Madison Collaborative, 2013).
The authority element speculates what legitimate authority figures would expect in a
scenario. Nursing students should obey preceptors to ensure safe, quality care. Conversely, my
authoritys judgement jeopardized patient safety. I would expect my nurse to be legitimate since
she has practiced for years, but her unethical decision clouded this idea. Empathy involves
putting yourself in others shoes in the situation. As a patient or family member, I would not want
to have my safety or that of my loved one compromised. The nurse may not want to be
disobeyed, but if she had imagined herself as the patient, then maybe she would have changed
her mind about letting me give the medication. Responsibility considers our duties as a nursing
professional to patients. According to the NSNA Code of Ethics, a student nurse must ensure
the safety of clients, self, and others and avoid any action that could cause unnecessary risk of

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injury (National Student Nurses Association, 2009, pp. 3, 8). Further, Provision 3 in the ANA
Code of Ethics states that the nurse must protect the rights, health, and safety of the patient
(American Nurses Association, 2015, p. 13). Considering these provisions, the threat of patient
safety was present, and it was our duty to be cautious and change the needle. With responsibility
come rights for another party involved. Since nurses hold the responsibility to provide safe,
quality patient care, the patient has the right to optimal care and protection. Giving the
medication without changing the needle violated that right because of the risk involved. Fairness
encompasses ensuring that a situation facilitates equality for all parties involved and doing what
is right or just. Equality is not an issue in my scenario, but if examined from a just outlook, it
would be right to the patient to change out the needle (The Madison Collaborative, 2013).
Conclusion
When considering the 8 Key Questions and both Codes of Ethics, there was a clear and
appropriate action in my moral distress situation. Patient safety is imperative and nurses are
expected to uphold this standard, especially given the high level of trust placed on the profession.
In retrospect, I should have acted differently in the scenario. I let the fear of going against
authority overrule my duty as a student nurse to advocate for the patients safety. I should have
addressed the issue to the nurse respectfully, asked for a new needle, and injected the patient with
an assured non-contaminated needle. When in doubt in the future, I will perform an action that
guarantees safety. I acknowledge the presence of my nursing conscience, but need to maintain
confidence when utilizing it in clinical. Current nurses should not doubt their nursing
consciences, need to withhold fears of authority figures, and handle situations with respect and
patient advocacy. I am still an excited and nervous student nurse that is learning every day, but
this scenario taught me that my moral and ethical knowledge will lead me on the right path.

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References
American Nurses Association. (2015). Code of ethics for nurses. Retrieved from
http://www.nursingworld.org/DocumentVault/Ethics_1/Code-of-Ethics-for-Nurses.html
Bickhoff, L., Sinclair, P.M., & Levett-Jones, T. (2015). Moral courage in undergraduate nursing
students: A literature review. Collegian, 22(4), 1-13. doi:10.1016/j.colegn.2015.08.002
Epstein, I. & Carlin, K. (2012). Ethical concerns in the student/preceptor relationship: A need for
change. Nurse Education Today, 32(8), 897-902. doi:10.1016/j.nedt.2012.03.009
The Madison Collaborative. (2013). The eight key questions handbook. Retrieved from
https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf
National Student Nurses Association. (2009). Code of ethics: part II. Retrieved from
http://www.nsna.org/Portals/0/Skins/NSNA/pdf/NSNA_CoC_Academic_Clinical_Interp
_Statements.pdf