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Situational awareness and the Nursing Code of Ethics

By: Teresa M. Stephens, PhD, MSN, RN, CNE

Solving ethical dilemmas requires a thoughtful process.


  • Ethical dilemmas are a common occurrence in nursing, often resulting in moral distress.
  • Situational awareness is as a useful method to guide nurses in exploring ethical dilemmas to better identify appropriate actions and responses.

By Teresa M. Stephens, PhD, MSN, RN, CNE

In 2015, the American Nurses Association (ANA) revised the Code of Ethics for Nurses (The Code) to better reflect “the complexities of modern nursing, to simplify and more clearly articulate the content, to anticipate advances in health care, and to incorporate aids that would make it richer, more accessible, and easier to use.” To emphasize the importance of ethical practice in patient safety and care, ANA designated 2015 as the Year of Ethics, providing an opportunity to explore our ethical code within various contexts.

ANA’s focus on ethics in 2015 prompted my use of situational awareness (SA) to teach students to objectively assess ethical dilemmas. SA is most simply defined as understanding what’s going on around you. However, understanding, according to the Institute of Medicine (IOM), is more than information gathering. It involves gathering the right information, correctly analyzing it, and making decisions based on the analysis. Ideally, the result will be choosing the right decision for immediate action as well as identifying future actions. The SA method lends itself to solving ethical dilemmas by creating a framework for assessment, application, and reflection for nurses at all levels within any organizations.

In this article, I’ll describe SA and demonstrate its use as a tool to enhance and improve nurses’ ethical decision-making.


SA is well-known within high-reliability organizations (HROs), such as aviation, air-traffic control, nuclear facilities, and the military. These organizations operate within a world of high risk and complexity, but they’ve demonstrated performance levels with fewer-than-expected accidents and the ability to avoid catastrophic events. The IOM and The Joint Commission have recommended that healthcare organizations model HRO strategies.

A loss or decrease in SA has been noted as the most frequent cause of real-time error and has been linked to poor performance and poor outcomes. SA strategies are of obvious benefit for nurses engaged in critical decision- making, but they’re also useful in non urgent situations, as well as those not dictated by law or policy, such as ethical dilemmas. A nurse’s decision-making process is strongly driven by individual morals and values. When we’re faced with a decision that causes us to compromise our personal values, we can experience moral distress. Ethical dilemmas, which occur on a regular basis for nurses, are a root cause of this distress.

Contrary to decisions guided by legalities or policies, ethical dilemmas are open to interpretation, which can lead to disagreements and conflicts within an organization. When a nurse faces an ethical dilemma, he or she will rely heavily on personal values to guide decisions. Using SA can help reduce conflict that may occur when individuals react emotionally because of moral distress and don’t pause to critically analyze the situation.

SA competence

SA involves understanding the meaning of a given situation as well as the ability to predict its effects on future events. It affects patient care and patient outcomes based on organizational or system factors and individual and team levels of SA. System factors include the organization’s safety culture, teamwork behaviors, available resources (human, information, equipment), automated processes, and provider demographics. Ultimately, clinical decision-making is optimized through SA by maximizing cognitive resources, both individually and collectively.

SA can be threatened by several factors, including mental load, task load, time pressures, distractions, fatigue, and automation. (See Automation requires diligence.)

Automation requires diligence

Automation includes the use of control systems and technologies to reduce cost and eliminate waste. While beneficial to process improvement, automation can place the provider in the role of monitor instead of operator. Relying on automation can lead to complacency, reduced vigilance, and changes in the quality of feedback provided to the human operator.

Consider a car’s global positioning system (GPS). The driver no longer relies on cognitive function to navigate, but instead allows the automated system to guide the journey. Many drivers have noted an inability to describe the details of a car trip after using GPS for navigation.

We can relate this to the nursing profession with our dependence on alarms, notifications, and decision-support alerts. This automation can improve patient care quality and safety, but we must be diligent to maintain a high level of personal and team situational awareness.

SA and The Code

When you’re faced with ethical dilemmas, the SA process, combined with The Code, can guide you. The SA process can be described in three phases:

1. Stop—Much like the nursing process, the first phase of the SA process includes pausing, focusing on the issue, and eliminating distractions.

2. Think—During this phase, pause and reflect on the information obtained in the first phase.

3. Act—This final phase includes identifying priorities that must be addressed immediately and those that can be explored later. (See SA process—Stop, think, act.)

You can view The Code with interpretive statements for free at the ANA website (goo.gl/MVZ1uJ), but you might also want to purchase a copy.

Applying SA to ethical dilemmas

Just as we practice clinical skills to gain competence, we also must practice desired behaviors. I often tell my students that we wrongly assume that skills like communication and teamwork will come naturally. These skills must be learned and practiced for competence, just like I.V. insertion and physical assessment. We must incorporate SA into our daily routine and reflect on ways to enhance and improve our performance.

One way to do this is with case studies. You can use them on your own and in group settings, such as staff meetings, nursing courses, or professional organization meetings, to practice applying SA to ethical dilemmas. (See SA in action.) Case studies can be especially useful when adapted to populations or contexts of particular interest to you or your team. For instance, altering a case study set in an academic setting to a clinical setting relevant to you can enhance your understanding of SA.

ANA’s website offers case studies to demonstrate the use of The Code in decision-making. These practical clinical applications, Part I (available at goo.gl/tcaAR5) and Part II (available at goo.gl/Kc7L8p), are provided free of charge. As you work through the case studies, use the three phases of the SA process (stop, think, act) to guide you. Also, refer to The Code to help you identify the relevant provisional statements.

Enhancing decision-making

SA can enhance nurses’ ethical decision-making process and improve team performance. It’s a simple and effective way to identify specific provisions related to ethical dilemmas and evaluate the interpretive statements provided within The Code to develop an appropriate response.

Teresa M. Stephens is an associate professor at the Medical University of South Carolina in Charleston.

Selected references

American Nurses Association. Code of Ethics for Nurses with interpretive statements. 2016.

Epstein B, Turner M. The nursing code of ethics: Its value, its history. Online J Issues Nurs. 2015;20(2):4.

Fore AM, Sculli GL. A concept analysis of situational awareness in nursing. J Adv Nurs. 2013;69(12):2613-21.

Lachman VD, Swanson EO, Winland-Brown J. The new ‘Code of Ethics for Nurses with Interpretive Statements’ (2015): Practical clinical application, part II. MedSurg Nurs. 2015;24(5):363-6, 368.

Winland-Brown J, Lachman VD, Swanson, EO. The new ‘Code of Ethics for Nurses with Interpretive Statements’ (2015): Practical clinical application, part I. MedSurg Nurs. 2015;24(4):268-71.

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