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AACN Advanced Critical Care

Volume 21, Number 4, pp.380–384
© 2010, AACN

Ethics
in Critical Care Cynda Hylton Rushton, RN, PhD
Department Editor

Ethics of Nursing Shift Report

Cynda Hylton Rushton, RN, PhD

C larity and precision in sharing information among clinicians are essential

1
for quality and safe care. Nursing shift report is a common and powerful
vehicle for sharing private patient information, plans of care, tasks to be com-
pleted, and concerns and priorities during transitions between settings or services,
between shifts, and among clinicians in critical care settings. But breakdowns in
communication, inaccurate information, or unverified assumptions and conclu-
sions can lead to serious errors, undermine relationships,1 and create unhealthy
work environments.2 Without attention to the ethical foundations of common
practices, such as nursing shift report, critical care nurses may overlook impor-
tant opportunities to uphold their ethical commitments.

Nursing Shift Report

Traditionally, nursing shift report is designed as a method to provide the oncom-
ing nursing team relevant information to guide practice; to give updates on patient
progress, goals of treatment, and care plans; and to determine daily priorities. It
is a forum for sharing formal and informal medical, psychosocial, and spiritual
facts; opinions and impressions; problem solving; giving and receiving support;
relationship building; and conflict management. It is also a vehicle for sharing
values, beliefs, perceptions, and judgments. When nursing shift report is exe-
cuted in an ethically grounded manner, the quality and safety of patient care is
improved, relationships are strengthened, and team efficiency and functioning
are enhanced.
In contrast, nursing shift report can become a vehicle for gossip, disrespectful
communication, and blame, each with the potential for undermining relation-
ships and trust.3,4 Unconscious negativity, projections, unverified facts, opinions,
and assumptions become the basis for delivering care, thereby undermining rela-
tionships and ethical values.
Anecdotal observations during routine nursing shift report can be illuminat-
ing. Statements such as “Watch out! This is a problem patient or family” can
begin to create labels that, once established, may be difficult to overcome. Judg-
ments made about the patient/family understanding or comprehension may be
expressed in statements such as “They don’t get it—this family is in denial.”
Assumptions about the patient’s or family’s character, social or economic situation,
or relationships may be reflected in statements such as “This family NEVER
visits: they keep asking us to do things they won’t do themselves,” “They don’t
care,” or “Taxpayers, you and I, are paying for this patient’s futile treatment.”
Such statements about a patient or family member can quickly become a fact

Cynda Hylton Rushton is Associate Professor, School of Nursing Johns Hopkins University, 525 N Wolfe
St, Box 420, Baltimore, MD 21287 (crushton@son.jhmi.edu).
DOI:10.1097/NCI.0b013e3181ef8648

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VO L U M E 2 1 • N U M B E R 4 • O C TO B E R – D E C E M B E R 2 010
when shared as evidence to support a particu-
lar conclusion or viewpoint.
Projecting one’s own conclusions into the
patient’s or family’s story can create an envi-
ronment where innuendo and judgment can
add additional stress to the relationship, widen
the collaboration gap, and fuel conflicts and
misunderstandings. Consider, for example,
how information shared within the context of
a family meeting regarding resuscitation deci-
sions for a patient with metastatic cancer and
multisystem organ failure can lead to conclu-
sions that are biased or misrepresent the facts.
If clinicians have had prior negative experi-
ences with similar patients, for instance, they
may perceive that there is only one outcome of
the discussion that is acceptable, thereby creat-
ing the conditions for biased conclusions to be
communicated to other members of the team.
Questions such as “why are we doing this?”
may become a familiar refrain.
Similarly, frustrations in dealing with mem-
bers of the interdisciplinary team can be trans-
formed into conclusions that are repeatedly
communicated from shift to shift. Gossip about
other clinicians can break trust among the team
members and undermine their functioning.4
For example, consider the situation in which a
critical care physician writes an order to with-
draw life-sustaining therapies despite apparent
conflict between family members about the
plan of care. Nurses caring for the patient may
state, “We are killing the patient! These orders
will accelerate the patient’s death, and the fam-
ily is not ready!” The language conveys explicit
moral judgments about the permissibility of
the proposed action and is likely to ignite or
deepen conflicts and potentially scapegoat the
physician. The character of the clinician may
similarly be called into question with comments
such as “this surgeon rarely gives patients accu-
rate information about their operations—he
paints a more optimistic picture, no matter
how grim the outlook is.”
Without verification or clarification, inac-
curate, judgmental, or misleading opinions
can become a part of the story that is insidi-
ously propagated from one shift to the next.
The contents of these assumptions and conclu-
sions may also be reflected in the patient’s
record, the quality and content of communi-
cation, and the tenor of relationships. Negativ-
ity builds from one shift to the next as the
communication, collaboration, and teamwork
decline, relationships suffer, and trust is broken.
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Ethics in Critical Care
The purpose of this column is to explore this
aspect of nursing shift report, suggest an ethi-
cal framework for nursing shift report, and
propose recommendations for creating norms
for conducting report that reflect these under-
lying ethical values.
Ethical Framework for
Nursing Shift Report
Given the power of nursing shift report to con-
vey information, values, and facts, a conscious
awareness of the ethical underpinnings of nurs-
ing shift report can assist nurses to be more
aware of their responsibilities to uphold ethical
standards in all aspects of their work, including
nursing shift report.
Respect for Persons
The American Nurses Association code of ethics
for nurses5 offers important insight about the
values that ought to guide nursing shift report.
Notably, the first provision instructs nurses to
offer their knowledge and skills in a nonjudg-
mental, fair, and respectful manner.5 Respect for
persons invites nurses to honor the wholeness,
essence, and uniqueness of patients and their
families. Critically ill patients are particularly
vulnerable, often lacking the capacity to speak
for themselves, leaving surrogates to speak on
their behalf. Respect can be challenged when
we have insufficient understanding of our
patients, their goals, and their values; we mis-
represent our knowledge or feelings; or we dis-
agree with their decisions or behaviors. For
example, when patients make decisions that we
do not endorse, we show respect by accepting
their informed choices rather than engaging in
behaviors aimed at convincing them of our way
of thinking or discrediting their viewpoint.6
Respect for persons also encompasses ethical
values of veracity (telling the truth). Nurses have
an ethical obligation to demonstrate respect for
patients, families, and clinicians by sharing
honest, unbiased information without including
unverified assumptions or beliefs. Honest infor-
mation sharing is predicated on verifiable facts
and conclusions and a commitment to knowing
the wholeness of the person receiving care.
Systematic methods for discerning and doc-
umenting physical, psychosocial, spiritual, and
contextual information are essential to ensure
that honest, factual information is disclosed.
Similarly, the content of nursing shift report
should reflect a balance of medical, psychoso-
cial, spiritual, and contextual information.
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Ethics in Critical Care
Overemphasizing the medical or nursing aspects
of care has the potential to undermine holistic
patient care and may contribute to conflicts
or errors.
Another derivative principle of respect for
persons is fidelity (keeping promises). Clini-
cians make implicit promises that they will
work to serve the well-being of patients.5 Lack
of awareness about patient/family expecta-
tions for treatment or care can inadvertently
lead to disappointment or feelings of betrayal.7
Most patients assume that their clinicians will
speak about them in a respectful and profes-
sional manner. Clinicians expect similar
respect from their colleagues. When communi-
cation about patients, families, or colleagues
deviates from these norms, implicit promises
are broken. Consistency and reliability of indi-
viduals in honoring commitments of profes-
sionalism, collaboration, and respect are in
accordance with AACN’s standards for a
healthy work environment.2
Respect for persons also requires that pri-
vacy be protected. The implicit promise that
one’s privacy will be honored and protected,
to the extent possible, is foundational for build-
ing trustworthy relationships.8 Confidentiality
is the means for ensuring that the redisclosure
of information about patients, families, or col-
leagues that is discovered through one’s role as
a nurse carries with it a responsibility to do so
in a respectful manner. According to the code
of ethics, nurses’ primary commitment is to
the well-being of the patient.5,8 Upholding this
commitment to patient well-being involves
balancing the benefits and burdens of sharing
the information to which we have access with
others. As patient advocates and professional
colleagues, nurses must be clear about their
intentions for sharing facts and opinions and
for safeguarding the interests of themselves
and others. Determining what information is
relevant to the care of the patient involves
value judgments about what is relevant to their
care and what is authorized to share and under
what circumstances. Likewise, discerning what
information is relevant to disclose within the
context of collegial relationships and teamwork
is required.
An ethical framework for nursing shift report
also includes attention to contextual features,
relationships, and character and values such as
empathy, compassion, honesty, and generosity.
In the context of nursing shift report, being
able to imagine the situation of the other clini-
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A AC N
cian and respond with respect, compassion,
and generosity is essential in determining one’s
intentions, behaviors, and actions. Similarly,
attention to moral values and cultivating
moral sensitivity, moral competence, and
moral intelligence are foundational for ethical
nursing practice, yet easily challenged in the
fast-paced critical care setting.
Strategies for Ethically
Grounded Nursing
Shift Report
Monitor Language and Tone
Listening to the content and tone of the com-
munication may be a signal for deeper analysis
and reflection. Being mindful about the words
that are chosen, the tenor of comments and
observations, and the areas where speculation
or confusion is present is useful in discerning
alignment between intentions and actions. When
common phrases (such as those listed earlier)
that reflect judgmental or disparaging content,
criticisms, or negativity are communicated repeat-
edly, a process for pausing to verify the facts
and identify the source of various opinions
should be activated, and opportunities for adjust-
ments and reframing identified.
Challenge Assumptions
When unexamined or unreflective statements
such as those described earlier are expressed, a
pause is needed to discern whether they are
true or applicable.9 Making space for listening,
understanding, emotional attunement, and per-
spective taking can lead to greater awareness
and understanding. Questions such as those in
Table 1 may assist in distinguishing fact from
insights and opinion and help identify projec-
tions, inaccuracies, or misunderstandings. When
speaking from insight or opinion, such view-
points should be identified for others so that
they can interpret the meaning from the rele-
vant perspective.
Be Alert to the Presence of Gossip
Although group norms of communication can
include gossiping as a way to be included in a
group and for maintaining connections, it may
also reflect an unconscious or unmet need.
When people resort to gossiping, it may be a
reflection that attention is needed to address
their individual needs and what is happening
in the external environment. Monitoring the
extent of gossiping outside of nursing shift report
including breaks, off-duty time, and during work
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VO L U M E 2 1 • N U M B E R 4 • O C TO B E R – D E C E M B E R 2 010 Ethics in Critical Care

Table 1: Discernment Questions

What are my intentions in sharing this information in this way?

What may I be projecting into this situation that I am not aware of?

How might my past experiences be influencing my appraisal of this situation or my conclusions?

To what extent is my state of mind or sense of well-being impacting my ability to draw neutral or clear
conclusions?

Are my judgments or conclusions based on verifiable facts, or are they personal opinions?

Is this information relevant to the care of this patient or a curiosity or hearsay?

Is there potential for the patient, family, colleague, or interdisciplinary team member to be hurt or harmed
by what is being said?

What implicit or explicit promises related to the care of this patient have I made?

What implicit or explicit promises related to professional relationships have been made to colleagues?

Would I be willing to share my observations and perceptions with the patient, family, or colleague?

Am I willing to take responsibility for the consequences of my actions or inactions?

What would a respected colleague or mentor advise about what I am sharing?

Is there another way that the information can be stated with neutrality?

What additional information is needed to fairly represent the patient’s, family’s, or colleague’s viewpoint?

Whose perspective needs to be understood?

What additional resources are needed to support the patient, family, or health care team?

time and the impact of broken trust among team
members is useful in designing interventions to
address unmet needs and creating a healthier
work environment.
Develop Professional Norms
Professionalism demands that nurses and other
clinicians uphold standards of respect and civility
in their interactions with one another and with
their patients and families. Adhering to basic
standards of civility10 creates a basis for the
development of broader professional norms.
Developing explicit norms, such as codes of con-
duct, must be endorsed and adhered to by all
levels of leadership and staff, and these norms
must be widely communicated and integrated
into the fabric of the organization. Professional
norms must become a meaningful part of the
culture of a unit or organization and be fairly
applied to all team members.
Hold Yourself and One
Another Accountable
Accountability for professionalism in all com-
munications and interactions is central for cre-
ating a healthy work environment that is both
trustworthy and respectful. Each team member
has an obligation to speak up without reprisal,
persecution, or retaliation when professional
norms are violated. Transparent mechanisms
for addressing lapses in behavior are necessary
to support communication norms and organi-
zational practices designed to neutralize disre-
spectful communication.
Use a Standard Framework
Developing a standardized, evidence-based
format for nursing shift report that includes
attention to patients’ physical, psychosocial,
and spiritual needs can help to reduce sharing
extraneous, inappropriate, or inaccurate infor-
mation and enhance efficiency. Standardized
methods for structuring the content of hand-
offs between clinicians can help to focus infor-
mation that needs to be shared. Methods such
as the SBAR communication (Situation, Back-
ground, Assessment, Recommendation)11 have
been shown to reduce errors12 and can be adapted
to help reduce unnecessary or irrelevant infor-
mation sharing, bias, and assumptions.
Adopt a “Need-to-Know” Policy
Discerning what confidential information should
be shared with other members of the health

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Ethics in Critical Care
care team is vital to convey the patient’s plan
of care and enhance effective team functioning.
Similarly, determining what details need to be
shared and with whom helps to clarify the
scope and content of nursing shift report. For
example, do all members of the health care
team and support staff need to know the inti-
mate details of family finances to provide care?
A need-to-know policy formalizes the circum-
stances for appropriate access to and disclosure
of confidential information and defines the
accountability of each team member in respon-
sibly disclosing confidential patient informa-
tion with team members, consulting services,
and entities within the hospital, community,
and beyond. Similar policies governing the
disclosure of information about colleagues
offer guidance for interprofessional access and
disclosure.
Develop Policies and Safeguards
Standards for confidentiality have been made
explicit in laws such as the Health Insurance
Portability and Accountability Act13 and through
regulatory standards.14 Institutional policies
that define professional norms and the ethical
foundations of privacy and respect are neces-
sary to create an ethically grounded practice
environment and uphold commitments to
patients and families. Ongoing education using
case-based learning and interdisciplinary dia-
logue about the challenges of respect and privacy
can facilitate greater awareness and consistency
in interpretation of ethical norms.
Conclusion
Conscious attention to the ethical grounding of
nursing shift report offers unique opportunities
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A AC N
for nurses to uphold their ethical mandates to
patients, families, and colleagues. Intentional
and purposeful communication can support an
environment for healing and contribute to a
healthy work environment that uplifts the spir-
its of the entire team.
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