Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.

Ever-expanding treatment options raise ethical issues and challenge nurses to be effective patient advocates. Evidence-based nursing interventions that promptly identify and address moral conflict will benefit patients, their families, and the entire healthcare team by mitigating potential moral distress and disengagement.

The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

This research project investigated the extent to which nurses engage in two important kinds of ethical behaviours: ethical activism (where they try to make hospitals more receptive to nurses' participation in ethics deliberations) and ethical assertiveness (where they participate in ethics deliberations even when not formally invited). This research probed not only the extent to which nurses engage in these ethical behaviours but also whether this is influenced by professional, training and organizational factors. A random sample of 165 nurses from three major hospitals in Los Angeles provided the data. Regression analyses indicate that both ethical activism and ethical assertiveness are strongly influenced by nurses' perceptions of the receptivity of hospitals to their inclusion in ethics deliberations. In addition, nurses' education in ethics is a significant predictor of ethical activism. The findings have important implications for the content of nurses' ethics training as well as for expanding the boundaries of nurses' participation in ethics deliberations. The authors define ethics deliberations as specific meetings of a number of people to discuss an ethical issue, such as one regarding the care of a patient.