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Leadership Challenges and Dilemmas in the Nursing Profession

Each day, nurses are faced with different situations that test their choices. There are moral or ethical dilemmas that they have to reconcile with their values, judgments while still fulfilling the requirements of their professional duties. In today’s complex hospital environments, nursing leadership often compels the nurse to take hard decisions that can often conflict with ethical and moral values, leading to remorse or moral distress. This paper seeks to study and present different leadership styles and how one’s personality and leadership traits affect the choices they have to make each day in the nursing profession, using examples from a specific scenario, where I as a nurse, was faced with making an ethical, moral or legal choice, keeping organizational constraints in mind.

To take a moral decision requires moral courage, not opting for the moral choice leads to moral distress. Moral leadership strategies offer ways to promote moral courage in decision making. Researchers have noted that that moral dilemmas or issues are not defined through scientific know-how’s, but by questions of what ought to be done, explaining that being able to, for example, know or identify how to take care of a patient is unlike choosing what kind of care to deliver and how to prioritize between patients requiring greater care (Edmonson, 2010). The conduct of a moral leader is based on the way he or she takes a decision, in which positive social norms and values, and those that have long terms benefits to the society, are taken into consideration. Leaders are expected to be able to portray societal and intuitional beliefs, aspirations and principles (L.S Leach, 2014). Because nurses principally act as moral representatives in a hospital or a healthcare organization, therefore their moral acts and decisions help maintain not only nurse retention and work satisfaction, but raises the patient’s comfort, relieves his/her distress, and promotes the reputation of the hospital (Corley, 2002). The main treatise for nurses is learning to make the moral choice, remain moral and apply morality to every aspect of life, in individual, social as well as their professional/organizational capacity.  Morality by its nature is not dependent one ‘s geographic nature, neither is it time-oriented or time-determined. A moral leader maintains morality in every time, location, and circumstance (Toulassi, 2013). When faced with a moral choice, moral distress in nurses can arise when confronted with personal value conflicts that can lead to anxiety, anger or frustration, because of his/her’s inability to act as one sees fit due to organizational constraints. These feelings can lead to low self-esteem, emotional exhaustion, job dissatisfaction or self-hate that subsequently leads to absenteeism, lack of morale, and hence poor work efficiency for the organization (Coles, 2010).

The ethical form of leadership is slightly different from moral leadership. Morality is ultimately a private compass of good and evil, right and wrong. Ethics, on the other hand, are dependent on others for definition, It is conduct recognized for particular class of human actions provided by an external source, and can vary between contexts. A professional example of ethics inconsistent with morals is the work of a lawyer. A lawyer’s individual morality, for example, tells him that murderers to be punished, but as a professional lawyer, he is ethically required to defend his client in the court using his skills, despite knowing that the client is blameworthy. For the nursing profession, ethical dilemmas occur quite frequently in their careers. Ethical decisions regarding caregiving and patient advocacy and prioritizing duties and patients are faced on a routine basis. Nursing ethical codes code are written to define ethical standards in the profession across all roles and levels. A common ethical situation is providing care in a custody environment. They should balance demonstrating an approach to care and empathy and make sure that inmates’ health needs are addressed and respected, and be appropriately responded to. Other ethical values associated with nursing practices include nurse advocacy, eliminating barriers to care and regard for humans. The nurse often finds himself in a unique leadership position where he is given to evaluate the effectiveness and quality of care required by the patient. (Mary V. Muse, 2011)

Legal principles involved in the nursing role range from issues such as anti-discrimination, acceptable staffing, and compliance with labor and healthcare laws. The legal associations of the nursing profession are linked with state and federal licensing and laws, the scope of practice and public expectations regarding their performance. The legal standards and framework are provided by the nurse’s license, training materials, education and nursing-standards that provide the framework for professionally expected nursing practices. Performing below acceptable standards of care and competency exposes the nurse to litigation, as a violation of the patient’s civil rights. When the patient has requested care, the nurse is legally and ethically mandated to respond. Based on standard practices and codes, the nurse has to evaluate the patients’ healthcare needs to determine the type or level of intervention needed and implemented. The nurse also has to take a legal decision whether to refer the patient to another facility or a physician if the work falls beyond his/her scope (Mary V. Muse, 2011).

As a nurse leader, it is important to realize that a single person alone cannot achieve substantial results. Behind all successful leaders are a team of individuals with different personalities who provide that necessary support to their leader and achieve success through collective efforts. A nurse leader who does not regard his team members’ experience, knowledge or ideas may be seen as the dictatorial type. This type of leadership may display his or her strengths, but it is also has a lot of drawbacks that could be minimized in a proper team atmosphere. It is possible that during duties, the nursing staff may be headed in different directions, or they could work together as a team with defined objectives and focused targets. Team-based success is highly dependent on the strength or weakness of the nurse leader and his or her capability to remain consistent and inspire others by taking courageous moral, ethical stands. (Frandsen, 2014)

In my career as a Nurse, I have faced multiple instances where I have had to make a timely decision. One of the first ethical dilemmas I remember facing was during the early part of my career placed as a Licensed Vocational Nurse in a general hospital. The hospital was funded by a charity frequented by people from low-income backgrounds. There was an elderly patient once who visited the hospital and stood in line to be examined for his condition. The senior man had visited a few hospitals before and had his conditions tested, but they kept referring him to the other hospital for specialized help. As I came to know of his situation, that he had a critical chest disease that was diagnosed through laboratory tests by the medical specialists he had consulted before. Taking a decision, I referred his case to a doctor who took in the elderly patient to perform some further screenings and tests on him. The doctor explained his conditions to me and tasked me to break down the details of the disease to the patient, in a suitable manner. The patient was suffering from non-small cell lung cancer that had advanced to such a stage that he only had a few more months to live. I was handed the responsibility for delivering the news of his condition by establishing a mechanism to ensure that he is psychologically ready to face the news. It was not just a legal obligation, but I also morally felt that the patient must be told about the truth of his condition. In my understanding, it was only through telling him the truth that I was able to help him in the management of his condition. As a nurse, I was ethically bound to help the patient manage his condition according to the best of my knowledge. The previous hospitals the patient had visited had not disclosed to him his full condition. Therefore I opted to consult my fellow nurses from the group. From a legal perspective, nurses are restricted by law to share the patient’s information with third parties, especially sensitive medical details of his ailment, unless they are associates with a proper medical background from where once could seek consultation to best address the situation.

Based on the Keirsey temperament sorter II test, my personality type was concluded to be an ISFJ protector-guardian. According to the assessment, a guardian is a vital participant of the society who is devoted to helping others (Keirsey, 1998). As a nurse, with the temperament of a guardian, my professional duties are aligned with my own personal beliefs and values that led me to adopt the nursing profession. Alleviating the agony and suffering of the patients and serving humanity is a key trademark of leaders with the ISFJ temperament. I have always believed in democratic-consultation as an instrument for simplifying decision-making in my profession. My decision in the wake of this dilemma was to initially prescribe painkillers to the patient for the next few days before he will be called again. This provided me time for further consultations with my peers, whose opinion I decided to seek before making a decision. I discussed with them details and issues with regards to the manner, I was to reveal the update to the elderly man. Some of my colleagues were more experienced and had practice of disclosing such news to the patients in a professional and calm way. I was advised by some of my colleagues to again refer him to another hospital, as had been done by the hospitals he visited before. Then, I was advised by some other team members to not disclose the actual situation to him but falsify the nature of his disease and reassure him that continuing his medication but ease his ailment in a few months. Some experienced members were of the opinion that I should bring the patient to one of the offices, locked from outside, where I will take the full time to explain the nature of his ailment and situation to him properly, in a way that would be psychologically reassuring. As a leader, the different views of my group were important to me. I weighed them against my own values and judgment and after an analyses decided to follow the majority opinion, that I should disclose the news to the elderly patient in a moral manner and advise him on the available options for him appropriately. Taking the decision, I called the patient to my office, locking it temporarily. After a prolonged conversation, he understood and accepted his situation and agreed to adhere to the medication plan suggested in this case for the last few months of his life, left. In this case, responding to the ethical dilemma, I had relied on the democratic style of leadership and used moral courage to break news of the reality to him. If I had given a false sense of hope to the patient, that would have created an internal moral conflict in me, possibly leading to lower morale. In the democratic style of moral leadership, one listen to the opinion of others and weighs the available options, then opts for the best option considering the majority opinion as an important factor that leads to the decision. The nurse leader has the last say, after the voting process, in the “democratic leadership framework” (Somecha, 2014)  In my case, I carefully considered the views of my colleagues and came to the realization that the majority opinion was also in line with my personal sense of moral values. Therefore it helped make a decision and to be sincere to my patient. In the end I was able to convince him how to cope with his situation in a way that would minimize psychological stress on him, and fulfilled my ethical obligation to help him manage the last few months of his life in comfort.

As a nurse leader, It may often be necessary to embrace features from a multiple other leadership styles depending upon the situation and its requirement but regardless of the nature of leadership traits, what remains consistent between them is to act with integrity, fix realistic targets, efficiently communicate in a way to encourage other people and to appreciate the strengths of your team members. Inspiring others with your strong vision and enabling them to see the bigger picture.


Coles, D. (2010). Because we can: Leadership responsibility and the moral distress dilemma. Nursing Management, 41 (3), 26-30.

Corley, M. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics , 9 (6), 636-650.

Edmonson, C. (2010). Moral Courage and the Nurse Leader. OJIN: The Online Journal of Issues in Nursing , 15 (3), 5.

Frandsen, B. (2014). Nursing Leadership: Management and Leadership Styles. American Association of Nurse Assessment Coordination .

Keirsey, D. D. (1998). Please Understand Me II: Temperament, Character, Intelligence. United States: Prometheus Nemesis Book Co.

L.S Leach, P. M. (2014). Assessing the Professional development needs of experienced burse executie leaders. Jounral of nursing administration , 4 (1), 51-62.

Mary V. Muse, L. S. (2011). Correctional Nursing Practice: What you need to know. CorrectCare , 25 (1), pp. 16-17.

Somecha, P. B. (2014). The health and performance effects of participative leaders: Exploring the moderating role of the Big Five personality dimensions. European Journal of Work and Organizational Psychology , 23 (2), 277-294.

Toulassi, B. (2013). Moral Leadership: The Morality of Leadership. Virginia Beach: Regent University.



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