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This lesson breaks down something that every nurse and nursing student will encounter. Whether you’re in the classroom, in clinical, or practicing at the bedside, you are bound to encounter situations that involve ethics. Yes, “nursing ethics” might sound like a super dry textbook chapter, but trust me, these principles come up all the time. For example:

  • When a patient refuses treatment.
  • When your personal beliefs clash with a patient’s choices.
  • When you’re stretched thin and trying to give everyone equal care.

These are ethical dilemmas, and you must know how to navigate them if you want to be a compassionate, safe, and effective nurse.

So in this lesson we’ll review the five core ethical principles in nursing: autonomy, beneficence, nonmaleficence, justice, and fidelity.

Ready?

The principle of autonomy in nursing

Autonomy is essentially the patient’s right to make their own decisions about their care. Even if you, as the nurse, don’t agree with their choices, your job is to respect and support their decisions. Think of autonomy as the foundation of informed consent, which is obtained prior to undergoing a surgical or invasive procedure. The patient has the right to hear their options, weigh the risks and benefits, ask questions, and make the final call.

How might this look in the real world of nursing? Let’s look at an example. You are caring for a patient with advanced cancer. Their oncologist recommends another round of chemotherapy, but the patient declines stating they suffered greatly with the side effects during prior treatments. They’ve decided to focus on palliative measures instead. As the nurse, you might think things like “They’re giving up” or “What if this round works?”. And while it’s normal to feel those things, your job is to respect and honor the patient’s autonomy. This might look like supporting their decision, listening to their concerns, helping coordinate with the palliative care team, educating the patient and family on what to expect, and providing information about other resources such as support groups or respite care. 

Here’s another example. You’re caring for an unstable patient with an active GI bleed who refuses a blood transfusion due to his religious beliefs. As the nurse you are likely worried about their low hemoglobin level and may even feel frustrated because you know the transfusion could help stabilize him. However, autonomy comes first. As long as patients are cognitively competent to make their own decisions, we must honor their decisions. 

Not all cases where autonomy comes into play are big and dramatic. In fact, autonomy shows up every single shift. For example: 

  • A patient declines their medication because they don’t like the way it makes them feel
  • A new mom chooses not to breastfeed
  • An immobile patient declines being repositioned and says they’re more comfortable on their back
  • A patient declines performing oral care or allowing anyone else to do it

All of these are situations showing autonomy in action, though it’s important to note that patient education is a key component. Many times a patient will accept the intervention once they’ve received education. But not always. 

For instance, if the patient who refuses to brush their teeth has received education about pneumonia prevention and still refuses…that’s their right. If the immobile patient has been informed that they are at high risk for developing pressure ulcers, they may still continue to refuse repositioning. If that’s the case, you can’t force them. You can continue to educate, inform and advocate. But at the end of the day, patients have autonomy and it’s a key component of nursing ethics and patient-centered care.

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The principle of beneficence in nursing

Next up is beneficence, which is a fancy way of saying you are taking positive actions to help your patients and that their best interests are the priority. In other words, you’re doing good things in service to others.

As nurses, beneficence is baked into everything we do such as relieving suffering, promoting healing, and helping improve outcomes however we can. Here’s an example:

You’re caring for a patient who is scheduled for surgery and they’re very anxious. You could simply give a dose of lorazepam and move on about your day, but instead you take the time to sit and talk with the patient even though you are already feeling stressed by the demands of your shift. In this case, you put the patient’s needs above your own and took a moment to reduce the patient’s suffering. That’s beneficence. 

But it’s also the everyday things such as warming a blanket, noticing a change in condition and speaking up, catching the wrong dose on a medication before it’s given, or providing a patient with extra pillows so they can find a position of comfort. 

One way to think about beneficence as you go throughout your shift is to ask yourself, “What can I do to help this person feel better, heal faster, or avoid harm?” Then, you take steps to make it happen.

The principle of nonmaleficence in nursing

Nonmaleficence simply means “do no harm” and it’s one of the oldest ethical principles in healthcare. And while this may seem obvious, it can feel a bit more nuanced or subtle in the real world. Here’s an example:

You’re a new grad nurse in a busy ER and you’re excited to place an IV on your 86-year old patient. The problem is, your patient has very small and tricky veins. After two misses, the patient is clearly anxious and in pain. You’re getting flustered, but you also really want to obtain this IV access to prove you’re a valued member of the team. Do you keep trying or do you make a conscious decision to avoid causing the patient more harm? If you are aware of  nonmaleficence, then you ask a more experienced nurse or even the IV therapy nurse to step in. By doing so, the patient avoids unnecessary pain, you put their well-being above your own pride or learning opportunity, and you did what was best for the patient.

Here’s another example. You’re caring for a patient who is NPO for surgery, but they are really, really thirsty. You’re tempted to sneak them a sip of water because you want to be kind and alleviate their suffering. But that kindness could put them at risk of aspiration under anesthesia. In this case, saying “no” is the best action since you’re protecting the patient from future harm by doing so.

Nonmaleficence can also show up when we advocate against treatments that could be more harmful than helpful. For example, if a frail patient with a history of recurrent UTI is being considered for an indwelling catheter, you might raise concerns about whether this intervention is truly in their best interest since it could cause more harm than benefits.

So when it comes to keeping nonmaleficence at the forefront of your practice, it’s simple. Just always be thinking about ways you can minimize harm to your patients.

The principle of justice in nursing

In a word, justice is all about fairness. It means we treat all patients equitably, regardless of their background, income, ethnicity, race, appearance, insurance status, behavior, or even their attitude toward us. In short, justice means we deliver care without bias. 

Here’s an example. You’re working on a busy surgical unit and you have three patients.

  • One is charming, funny, polite, and his family is delightful.
  • Another is confused and argumentative while his daughter is rude and demanding.
  • The third patient is withdrawn and quiet, rarely asking for anything or using the call light.

Justice means all three patients get your best nursing care. It may feel easier to subconsciously prioritize the pleasant and quiet patients, but the challenging patient needs you, too. 

Here’s another example. You’re working triage in the emergency department during a snow storm and a scruffy looking young man without insurance comes in complaining of vague abdominal pain. While it may be tempting to assume it’s not serious or that the patient just wants to get out of the cold, justice reminds us to assess everyone the same way. 

Justice also shows up when we allocate limited resources, such as during a medication shortage. At the time of this writing, there is a nationwide shortage of levothyroxine. In order to provide this medication to everyone who needs it, prescribers are limiting it to a 30-day supply. 

And here’s something you might not have considered about justice: it requires self-awareness.
The truth is, we all have implicit biases. The key is recognizing them, checking them, and committing to showing up equally for every patient you care for. Things to think about as you incorporate justice into your practice: 

  • “Am I giving this patient the same attention and compassion I’d give someone else?”
  • “Would I advocate this hard if they were a different race, age, gender, or social status? Or if they were rude to me?”
  • “Am I treating people based on need, or based on how they make me feel?”

In short, justice means leveling the playing field because everyone deserves safe, respectful, compassionate, and high-quality care.

The principle of fidelity in nursing

In the context of nursing ethics, fidelity means being faithful to your professional responsibilities, keeping your promises, and staying true to the trust your patients place in you. In other words, it’s about loyalty, honesty, and follow-through.

This one might seem simple, but it’s incredibly powerful. This is where nurses either build strong therapeutic relationships, or unintentionally break them. Here’s an example.

You’re caring for a patient after knee surgery and they tell you they’re experiencing 5 out of 10 pain. You tell her “I’ll be back in 15 minutes with your pain medication.” But, the universe has other plans and you get distracted by another patient. You finally remember an hour later and by the time you administer the medication, the pain level is 9 out of 10 and the patient is rightfully upset. 

Yes, things like this happen because nursing is a dynamic activity where things often change. But, to your patient, all they see is that you made a promise and failed to follow through. This erodes their trust in you. 

If you notice this happening and you realize you’re not going to be able to keep your promise, you have a few options:

  • Let them know: “It might be closer to 30 minutes, but I will come back with your meds.”
  • Delegate by asking another RN to administer the medication.
  • If you forget (because you’re human), avoid making excuses. Instead, own it and apologize.

Here’s another example. You’ve made a meaningful connection with a patient you’ve been caring for the past three weeks. During a difficult night of insomnia, she confides something deeply personal to you regarding her past. Unless it’s something directly related to her care or affecting her safety, fidelity means protecting that confidentiality. You don’t share that story with your coworkers, the patient’s family members, or blast it on social media. You hold that trust like it matters. Because it absolutely does. 

Guess what? Fidelity also applies to your coworkers, your scope of practice, and the policies of your workplace. For example, fidelity means…

  • You don’t make up vital signs when you’re in a rush.
  • You don’t document that you did a dressing change when you didn’t.
  • You don’t ignore unsafe practice on your unit just because it’s uncomfortable to speak up.

In summary, fidelity is doing the right thing, even when no one is watching and even when doing the right thing is a lot more work. 

TL;DR

Here’s a quick recap of the five core ethical principles in nursing:

  • Autonomy – Respect your patient’s right to make their own choices, even when you don’t agree. It’s their body, their life, their decision. As long as they have the information and are competent to make decisions, they have full autonomy.
  • Beneficence – Always be looking for ways to do good for your patients. This can include advocating, educating, anticipating needs, and taking that extra step.
  • Nonmaleficence – Do no harm. Speak up when something doesn’t feel right. Protect your patient at all times, even from seemingly beneficial actions that could cause more harm than good.
  • Justice – Everyone gets equal care. It doesn’t matter who they are, how they behave, or what kind of insurance they have. Bias definitely doesn’t belong at the bedside.
  • Fidelity – Be someone your patients and team can count on. Keep your promises and stay true to your professional standards and facility policies (even when it’s hard).

Nursing Ethics Practice Questions:

A patient with chronic kidney disease decides to stop dialysis, stating they are tired of the treatments and want to let nature take its course. The patient is alert, oriented, and manages all his affairs independently.  What is the nurse’s most appropriate response?

A. Notify the provider and continue to support the patient’s decision.
B. Tell the patient that stopping dialysis is a form of giving up and they should reconsider.
C. Involve the patient’s family to persuade them to continue treatment.
D. Delay documentation until the provider confirms the patient’s capacity.

While administering a routine IM injection, the nurse realizes the ordered dose seems unusually high for the patient’s age and condition. What action best demonstrates the principle of nonmaleficence?
A. Administer the injection to avoid delaying treatment.
B. Ask the charge nurse to give the medication instead.
C. Hold the medication and verify the order with the prescribing provider.
D. Document the dose and monitor the patient closely for side effects.

A hospital has one ICU bed available. Two patients need admission: a 34-year-old marathon runner with community-acquired pneumonia and a 79-year-old patient with multiple comorbidities recovering from major surgery. According to the principle of justice, how should the nurse advocate during the care team’s discussion?

A. Recommend the younger patient receive the bed due to greater likelihood of recovery.
B. Advocate for whichever patient the attending physician prefers.
C. Suggest using objective clinical criteria to determine who has the greatest need.
D. Assign the bed to the patient with more family support to help with recovery.

A nurse is caring for a patient who recently had surgery. The patient is anxious about developing a blood clot after hearing about a family member’s experience. The nurse takes time to explain how ambulation, SCDs, and medication help prevent clots, and offers to walk with the patient around the unit.

What ethical principle is the nurse demonstrating?

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Fidelity
E. Justice

A patient recovering from a traumatic brain injury becomes confused and agitated. Although they are trying to leave the bed on their own, they don’t understand the risk of falling. The nurse applies a temporary restraint per hospital policy and immediately contacts the provider for a formal order.
Which ethical principle justifies the nurse’s action?
A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Fidelity
E. Justice

A nurse tells a pediatric patient they’ll return after lunch with a new coloring book. Despite getting pulled into an emergency situation, the nurse remembers the promise and brings the book to the child before the end of the shift.
Which ethical principle is demonstrated here?
A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Fidelity
E. Justice

A nurse is caring for a newly diagnosed diabetic patient. The patient is refusing to attend the hospital’s diabetes education class, saying they want to manage their condition in their own way. The nurse listens without judgment, provides education about diabetes, information about resources, and documents the patient’s decision.
Which ethical principle is the nurse demonstrating?
A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Fidelity
E. Justice

A nurse is triaging four patients in the emergency department. Instead of seeing patients in the order they arrived, the nurse assesses each one’s condition and ensures the patient with signs of severe sepsis is prioritized for immediate care.
Which ethical principle is demonstrated in this situation?
A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Fidelity
E. Justice

Great job! Understanding how to apply the five core principles of nursing ethics helps to set you up for success on exams, NCLEX and on the job! For more fundamental nursing concepts, explore here!

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The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

REFERENCES:

Potter, P. A., & Perry, A. G. (2017). Fundamentals of Nursing (Ninth). Elsevier.