Primary care presents distressful moral problems for nurse practitioners (NPs) who report frustration, powerlessness, changing jobs and leaving advanced practice. The purpose of this grounded theory study was to describe the process NPs use to manage moral problems common to primary care. Twenty-three NPs were interviewed, commenting on hypothetical situations depicting ethical issues common to primary care. Coding was conducted using a constant comparative method. A theory of maintaining moral integrity emerged consisting of the phases of encountering conflict, drawing a line, finding a way without crossing the line, and evaluating actions. The NPs varied in their awareness and the discord encountered in conflict, and in clarity, flexibility and justification of the line drawn. A critical juncture occurred when NPs evaluated how well integrity had been maintained. Some experienced no distress while others experienced self-doubt, regret, outrage and frustration at external constraints, and attempted to reconcile through avoiding, convincing themselves, and compensating.

More research is needed to clearly understand ethical issues and moral problems for NPs in primary care, how NPs identify and manage problems, and the effects on NPs and patients.

The incidence of moral distress, compromised moral integrity, and leaving nursing is highest among nurses new to the profession. Understanding perceptions of moral integrity may assist in developing strategies to reduce distress and promote workforce retention. The purpose of this study was to determine how newly graduated baccalaureate prepared nurses perceive moral integrity and how prepared they feel to manage challenges to it. The design was qualitative descriptive using a confidential short answer online survey. Data were analyzed using conventional content analysis. Moral integrity was perceived as acting like, becoming, and being a certain kind of person who was honest, trustworthy, consistently doing and standing up for what is right, despite the consequences but also expected to set aside their values and beliefs and do what others ask, even if this would mean acting contrary to their conscience. The contradiction within this perception needs explanation.

The purpose of this study was to begin to develop a consensus as to the essential content and methods of ethics education for advanced practice nurses. An online Delphi technique was used to survey ethics experts to determine whether items were essential, desirable, or unnecessary to ethics education for students in doctor of nursing practice programs. Only the American Nurses Association Code of Ethics and ethics terminology were deemed essential foundational knowledge.

As the scope of advanced practice nursing expands and the educational requirements increase, so do the ethical responsibilities. How prepared are advanced practice nurses (APNs) to manage the ethical challenges in advanced practice? The purpose of this study was to determine APNs' ethics knowledge and perceived level of confidence in their ability to manage ethical problems in advanced practice. Assuming ethics knowledge and abilities of APNs are similar to those of medical residents, a survey instrument for medical residents was modified for use with APNs. Responses to the modified survey indicated a fairly high level of confidence but a fairly low level of knowledge. Studies show that ethics education can be effective in improving knowledge, confidence, and ethical behavior. Given the expanding role of APNs as doctors of nursing practice, research is needed to determine the ethics knowledge needs and teaching strategies to better prepare nurses for the challenges of advanced practice.