A social–ecological framework: A model for addressing ethical practice in nursing

AIMS AND OBJECTIVES: To develop a framework to enable discussion, debate and the formulation of interventions to address ethical issues in nursing practice. BACKGROUND: Social, cultural, political and economic drivers are rapidly changing the landscape of health care in our local environments but also in a global context. Increasingly, nurses are faced with a range of ethical dilemmas in their work. This requires investigation into the culture of healthcare systems and organisations to identify the root causes and address the barriers and enablers of ethical practice. The increased medicalisation of health care; pressures for systemisation; efficiency and cost reduction; and an ageing population contribute to this complexity. Often, ethical issues in nursing are considered within the abstract and philosophical realm until a dilemma is encountered. Such an approach limits the capacity to tangibly embrace ethical values and frameworks as pathways to equitable, accessible, safe and quality health care and as a foundation for strengthening a supportive and enabling workplace for nurses and other healthcare workers. DESIGN: Conceptual framework development. METHODS: A comprehensive literature review was undertaken using the social-ecological framework as an organising construct. RESULTS: This framework views ethical practice as the outcome of interaction among a range of factors at eight levels: individual factors (patients and families); individual factors (nurses); relationships between healthcare professionals; relationships between patients and nurses; organisational healthcare context; professional and education regulation and standards; community; and social, political and economic. CONCLUSIONS: Considering these elements as discrete, yet interactive and intertwined forces can be useful in developing interventions to promote ethical practice. We consider this framework to have utility in policy, practice, education and research. RELEVANCE TO CLINICAL PRACTICE: Nurses face ethical challenges on a daily basis, considering these within a social-ecological framework can assist in developing strategies and resolutions.