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Ethical nursing practice demands that we provide quality care to our patients. The role of advocate is a heavy responsibility fraught with financial limitations, organizational restrictions and physician directives. Making do with what is available is encouraged in an attempt to defray overhead. However, daily activities demand that we evaluate our moral obligations. We continually attempt to balance the enormous demands placed on us by increasing patient:nurse ratios, staff shortages and mandatory overtime. Often our endeavors only succeed in producing exhaustion and overwhelming feelings of guilt. Must we be forced to choose between spending time teaching a family member about the progression of the loved one's disease process and completing the numerous complicated procedures our increased workload and patient acuity demand?

The American Nurses Act (ANA 1995) allows nursing staff to refuse to accept or to reject an assignment, yet I rarely observe this used. The mere thought of speaking up in an attempt to change the situation evokes fear of reprimand. Yet, the responsibility to the patient resides with the nurse to provide competent care and ensure that the patient is not at risk. The nurse is accountable for the care of each and all of the patients in their assignment, and may be held legally responsible for nursing actions. Threat of losing licensure should be compelling enough to speak out, but it is rarely done: it is viewed as an act of futility that controls and limits the voice of the collectively shared rut that staff nursing faces on a day to day basis.

Nursing education is necessary to encourage and enable nursing staff to participate actively and assertively in ethical decision-making. Dodd et al. (2004) encourage nursing staff not to avoid ethical decisions, but to actively approach deliberations even when their input is not solicited. The ANA Code of Ethics for Nurses (ANA 2001) addresses these conflicts and is the guideline to be used in these situations. Unfortunately, nursing has traditionally been seen as a subservient role and this has tied our hands with threads of doubt and insecurity in our ability to effect change. We acquiesce instead of assert, and bow our heads in defeat instead of raising our fists in defiance. What possible course of action could have led to this demeaning, frustrating acceptance of fate? Wurzbach (1999) attempted to answer this when she defined the historical metaphor of nursing. She described early nursing ethics as a matter of doing one's duty, in which loyalty to the physician was placed above all else. Progression of the role of nursing in society has demanded a change in the metaphor.

The advocacy metaphor defines current nursing practice as an autonomous decision-maker in a patient advocated society (Wurzbach 1999). Yet our decisions are restricted to what we have to get done in this shift. We are continually forced to consider if something ‘bad’ is going to happen if that does not get done, even if the patient would benefit from it? Are we not large enough in number to compel those who supervise to look at the faces of nursing staff as they shake heads while giving report and hear our cries – our feelings of guilt for only accomplishing enough? I cannot tolerate hearing another nurse tell me ‘at least no one died’ while giving report. Is that how we measure competent, effective, ethical nursing practice?

Varcoe et al. (2004) accurately described the dilemma of nursing ethics as a subcomponent of biomedical ethics, and its limitations. Development and utilization of an ethical construct specifically to guide the practice of nursing in the future is necessary to provide competent patient advocated care. As Varcoe et al. (2004) stated, even the data set in their study was limited by nurse leader involvement, which may have skewed the information provided. The overwhelming limitation placed on all aspects of nursing has touched research in this manner and only stands to perpetuate the ineffectiveness of our voice. Varcoe et al. (2004) identified nursing ethics as a practice. The ability to identify the ethical or ‘right thing’ to do was cited as the catalyst to ethical practice. Speaking up is quite often the right thing to do. Yet, we hold our tongues and discuss our fate within our own ranks. One voice may not effect change, but the collective group must stand up and demand better working conditions, less overtime, necessary specialty equipment, and most importantly the time we need to care for our patients.

Only through utilization of numbers are we going to effect change. Yet, membership in nursing organizations such as the ANA remains at approximately 150,000 of the 2.7 million nurses it represents. Only 5.5% of Registered Nurses participate or contribute to an organization for all. Groups such as this, when supported by larger numbers, would be more effective in lobbying to get initiatives such as the Patient Safety Act passed. The Patient Safety Act (1997) would require healthcare institutions to make public specified information on staffing levels, mix and patient outcomes. Providing this information to the public would strengthen our collective voice. We need to teach our student nurses, and recruit those who are not currently members, to participate in organizations whose purpose is to protect us. If ethics, as Merriam Webster's (2004) defines, is ‘dealing with what is good and bad and with moral duty and obligation’, then ethics in today's nursing practice is still just out of reach.

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