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Nurs Outlook 65 (2017) S92eS99

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Making the hard decisions: Ethical care decisions in

wartime nursing practice
Janice Agazio, PhD, CRNP, RN, FAANP, FAAN*, Petra Goodman, PhD, RN, WHNP-BC
School of Nursing, The Catholic University of America, Washington, DC

article info abstract

Article history: Background: Codes of ethics set forth standards of ethical conduct for nurses. How-
Received 30 March 2017 ever, nurses involved in wartime operations, or disasters, may often have their
Revised 21 June 2017 moral compass challenged by the patient care decisions necessary under adverse
Accepted 23 June 2017 conditions. Reverse triage, resource allocation, and promotion of patient autonomy
Available online June 30, 2017. present multiple challenges to meeting commonly applied ethical principles.
Purpose: The purpose of this study was to use the International Council of Nursing
code of ethics as a framework to organize the ethical issues emerging from
Keywords: wartime nursing.
Military nursing Methods: This article represents a secondary analysis of two studies using thematic
Ethics analysis to identify ethical issues encountered by military nurses during the recent
Wartime conflicts in Iraq and Afghanistan. Data were collected from nurses deployed from
2002 to 2015 and from 111 military nurses during focused interviews.
Discussion: Across both studies, issues such as resource allocation, patient triage,
cultural differences, and equitable treatment for all emerged as challenges within
the wartime environment. Nurses were at a loss at times as to how best to manage
the situations and recommended that more education is needed in ethical decision
making before, during, and after deployment as a debriefing strategy. Similar issues
have been documented in military and disaster literature indicating that such
challenges are not limited to the recent conflicts but cross time and location.
Conclusion: By better understanding how nurses define, assess, and manage the ethical
situations they encounter in wartime nursing practice, military nurses can better
prepare for future conflicts, provide mentorship and targeted education to hopefully
reducing any feelings of moral distress, and promote ethical decision making that will
best promote outcomes in accordance with nursings ethical codes.
Cite this article: Agazio, J., & Goodman, P. (2017, OCTOBER). Making the hard decisions: Ethical care de-
cisions in wartime nursing practice. Nursing Outlook, 65(5S), S92-S99. http://dx.doi.org/10.1016/
j.outlook.2017.06.010.

Introduction not only legislated behavior such as found in Board of

Codes of ethics, according to Johnstone (1999), have
several purposes. First, the codes set the standards for
professional conduct. Codes go beyond what might be
Nursing practice acts but also include moral positions
such as voluntarily engaging in behavior that demon-
strates caring and concern for patients and quality care.
Codes of ethics also set up standards of professional
conduct for nurses that send a message to the public of

* Corresponding author: Janice Agazio, School of Nursing, The Catholic University of America, 620 Michigan Avenue Northeast, Wash-
ington, DC 20064.
E-mail address: agazio@cua.edu (J. Agazio).
0029-6554/$ - see front matter 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.outlook.2017.06.010
 Nurs Outlook 65 (2017) S92eS99
what to expect of nurses behavior. In codification of
ethical conduct, codes elucidate the values, duties, and
virtues of nursing within a scope of moral guidelines.
For example, nurses are obligated to provide care to all
without discrimination based on gender, sexual orien-
tation, race, religion, ethnic background, and socioeco-
nomic status. This is a standard that holds true across
national borders and is articulated eloquently in codes
such as the International Council of Nursing (ICN) Code
of Ethics for Nurses (2012). Within the ICN Code of
Nurses, four fundamental responsibilities are identified
for nursing practice: to promote health, prevent illness,
restore health, and alleviate suffering. The code expects
nurses to have respect for human rights, including
cultural rights, the right to life and choice, to dignity,
and to be treated with respect (ICN Code, 2012, p. 1). In
addition, care should be respectful of and unrestricted
by considerations of age, color, creed, culture, disability
or illness, gender, sexual orientation, nationality,
politics, race, or social status (ICN Code, 2012, p. 1). The
code proposes four elements in which nurses care for
individuals, families, and communities: nurses and
people; nurses and practice; nurses and the profession;
and nurses and coworkers. Each of these elements in
turn set forth the standards for conducting nursing
practice and will be used in this article to illuminate
ethical situations that occur in a wartime environment.
The ICN code holds true within areas of conflict such
as that experienced by nurses serving in the military
and assigned to support troops within Iraq and
Afghanistan. Governed not only by the ICN Code of
Ethics, the Geneva Conventions of 1949 also dictate
that these military nurses additionally had an obliga-
tion to care for those who may be injured and must be
cared for whether that person is from the nurses
country or is a detainee, enemy, or, as in the current
conflicts, insurgents who may have caused the injury
and death of friendly forces. Situations such as
wartime nursing can, in some instances, be compared
with those ethical issues that could be encountered
within a natural disaster, taking what in this study
were military wartime experiences, and bringing them
into a more widespread nonmilitary occurrences.
Many anecdotal accounts have been recently pub-
lished by military nurses who have served in the recent
conflicts in Iraq and Afghanistan (De La Rosa & Goke,
2007; Haynes-Smith, 2010; Kondro, 2007; Kraemer,
2008; Middleton, 2009). Reading these accounts, it is
evident that military nurses are bothered by the diffi-
cult decisions that they faced during their service
regarding what, in essence, were ethical situations and
dilemmas. For example, nurses reported struggling
with questions such as the following: Who makes de-
cisions regarding distribution of scarce resources for
wounded patients? Does it make a difference if that
patient is a military member, civilian casualty, or
enemy prisoner? How does a military nurse deal with
the triage decisions that may place patients in an
expectant (terminal) category in a deployed setting, but
who might be able to be saved if the injuries had
S93
perhaps occurred stateside? Military members are
returning from deployment suffering from symptoms
related possibly to compassion fatigue, burnout, and
post-traumatic stress disorder (Kelly, 2010; Middleton,
2009) Yet, perhaps those conditions are as a result of,
or compounded by, the lingering uncertainty or
distress related to how one, multiple, or recurring sit-
uations were resolved or handled? Consequently, this
study represents an exploration of the types of situa-
tions that were faced by nurses during these conflicts
and the context in which they would be viewed from
the perspective of the actions prescribed by nursings
code of ethics.
To date, few studies have considered the ethical sit-
uations faced by military nurses during the recent
conflicts or explored the application of the codes of
ethics in directing the conduct of these nurses when
encountering ethical situations. Most often, this infor-
mation has emerged in anecdotal personal accounts or
incidental to related studies of military nurses.
Alamonte (2009) identified ethical issues and subse-
quent moral distress in Navy nurses who were deployed
on the U.S. Comfort in response to the 2004 tsunami in
the Indian Ocean using grounded theory methods. She
encouraged further examination of the situations these
nurses encountered providing care of the indigenous
people in the region and the ramifications for education
and intervention for nurses experiencing distress as
they realized the limitations in providing definitive and
sustainable treatment. Specific to a wartime environ-
ment and studying nurses from the United Kingdom,
Griffiths and Jasper (2007) identified some ethical con-
cerns in their grounded theory study conducted from
1999 to 2002 overlapping the start of the war in
Afghanistan to explore the effects of war on the nursing
role. They noted that respect for humanity and the
value become lost amid the blatant hatred displayed by
hostile parties (p. 95) that led to moral discomfort in the
operational environment. Thompson et al. (2014) pro-
vided a descriptive account of deployment culled from
multiple first-person accounts in the literature for the
purpose of defining caring within the wartime setting.
As with the previous article, they found that working
with injured insurgents challenged the ethical mandate
to build a caring nurseepatient relationship (p. 24).
Emotional responses, such as anger, fear, resentment,
hatred, and prejudice, conflicted with the ethical
mandates of nursing. Many were able to move past the
detainees actions and view them as fellow human be-
ings; however, many felt conflicting loyalties viewing
those individuals as the enemy and perhaps the cause
for harm to friendly forces (Germain & Lounsbury, 2007).
Haynes-Smith (2010) described the moral and ethical
challenges she encountered while caring for Iraqi de-
tainees during a deployment to Iraq in 2005. She related
her struggles in maintaining compassionate care to
those viewed as the enemy that added to the stress and
strain of life in the combat zone. Kraemer (2008) also
reported similar issues in her account of experiences in
Iraq. Furthermore, she found it was difficult to reconcile
S94 Nurs Outlook 65 (2017) S92eS99
Table 1 e Participants in the Studies
Demographics Army Nursing Practice Study
Number of participants n 77
Age 38.7 (25e57 years)
Gender Males: 42%
Females: 58%
Length of time in nursing 13 years (1e33)
Number of years in military 5.9 years (2e24)
Military service Army: 100%
Component Active duty: 92%
Reserve: 8%
Deployment locations Iraq: 72%
Afghanistan: 2%
the loss of life and what she perceived as the futility of
treatment in many cases where every effort had been
made to save life, limb, or eyesight.
Mark et al. (2009) identified resource allocation and
continuity of care to civilian casualties to be particularly
challenging to the participants in their focus group
exploration of deployment experiences. Similarly, Ross
et al. (2008) also identified ethical issues as part of
their mixed-method qualitative study in which partici-
pants commented on the risky nature of caring for
enemy prisoners of war; the difficulties they experi-
enced while caring for foreign national civilian casu-
alties; resupply problems; and scope of practice role and
expectations as posing ethical conflicts. Goodman,
Edge, Agazio, and Prue-Owens (2013), Scannell-Desch
and Doherty (2010), and Wilson (2011) conducted qual-
itative studies describing many cultural factors that had
an impact on military nursing care for Iraqi and Afghani
patients. Findings revealed that the nurses expressed
difficulty encountering cultural norms, such as gender,
dietary, and religious belief differences, which
conflicted with the provision of care.
To date, none of these studies have grounded the
findings from these conflicts into the framework of a
code of ethics to compare the behaviors of the nurses
with the expected conduct encountered in these chal-
lenging situations.
Methods
This article represents a secondary analysis of data
collected in two previous studies. The first, Army
nursing practice challenges in wartime and peace-
keeping operations (Agazio, 2010), focused primarily
on the competencies needed to practice in austere
environments. As a consequence of relating episodes
of care situations, nurses additionally related ethical
situations that occurred in patient care and within the
Ethical Issues Study
n 34
44.3 (26e67 years)
Males: 27%
Females: 73%
17 years (4e30)
Army: 50%
Air force: 26%
Navy: 24%
Active duty: 79%
Reserve: 12%
Retired: 9%
Iraq: 59%
Afghanistan: 53%
Both: 15%
deployed environment. These data were collected
early in the wars in Iraq and Afghanistan from 2002 to
2005. The second study referenced in this article spe-
cifically focused on identifying the types and man-
agement of ethical situations occurring in a wartime
environment. These data were collected from 2011 to
2015. Both studies used qualitative methods. The first
used a descriptive qualitative design, and the second
used grounded theory methods. This project repre-
sents a secondary comparative thematic analysis be-
tween the two studies to distill the ethical issues
encountered across the trajectory of Operation
Enduring Freedom (Afghanistan) and Operation Iraqi
Freedom missions.
The demographics for both studies are found in
Table 1. Because the first study focused on both hu-
manitarian and wartime missions, those individuals
who had only served in operations other than war were
extracted from the combined sample, and their data
were not used in this analysis.
Both studies used a focused interview guide. The
Army nursing practice study was organized around the
readiness framework proposed by Reineck (1999) so
that the interview queried the nurses regarding their
military, operational, clinical, and personal readiness
as they practiced in the deployed environment. The
questions also included leadership and coworker as-
pects of the deployment. In contrast, the interview
guide used in the ethical issues study focused primarily
on those situations that had overtones or aspects of
ethical decision making. Nurses were asked to relay
the circumstances of the situation, identify the ethical
dimensions, and discuss how the situation was
managed, describe the resources available to them in
ethical situations, and their evaluation of the resolu-
tion. Thematic analysis was applied to the data
extracted for this study from the two existing data sets.
For the presentation in this article, the elements of the
ICN Code of Ethics (2012) were used to organize the
themes identified in the two studies.
 Nurs Outlook 65 (2017) S92eS99
Findings
Nurses and People
For the element nurses and people, the standards list
expectations for nurses primary responsibilities in
respecting the culture and environment in which pa-
tients receive care with expectations for nurses pro-
fessional conduct and equitable allocation of resources
to provide care to those requiring nursing care (ICN
Code, 2012, p. 2). Some of the themes emerging from
the data sets illustrated the standards set forth in this
element. Nurses reiterated the primary directive of
nursing, as noted in the code, the primary re-
sponsibility is to people requiring nursing care. Com-
ments made by nurses illustrating this standard
included the observation that their care was directed
by always doing good for the patients, or doing no
harm was always our mainstay, regardless of status,
that is, being enemy combatant, coalition force, local
national, whatever the case may be .. The nurses
spoke to the directive to demonstrate professional
values as one, giving advice to another nurse who was
deploying, related, I would remind them why they are
in the medical field and basically emphasize what our
professional . responsibilities and ethics and values
and all those things are.. Within the austere envi-
ronment of the deployed setting in either Iraq or
Afghanistan, nurses found challenges in respecting the
culture and cultural beliefs of the civilian population or
insurgents/detainees to whom they were called on to
provide care. These standards included those noting
that nurses should promote an environment in which
human rights, values, customs, and spiritual beliefs ..
are respected and culturally appropriate care is
rendered. Some of the participants noted:
Nurses have saved more lives than can be imagined.
Over there, I could speak to that happening on
several occasions where nurses had to keep going to
different physicians to advocate for the patient.
Regarding post-mortem care in Muslim tradition:
They were human beings and they deserved that
respect and care.as Muslims, they have a timeline
where they need to be buried, that sort of thing.
Everyone is a human being and they all deserve the
best.
The code also notes that nurses should be advo-
cates for equity and social justice in resource alloca-
tion, access to health care, and other social and
economic services (p. 2). Nurses often faced the
dilemma of deciding how to balance resource use in
providing care. When the situation was potentially
volatile, casualties could be arriving on a moments
notice. Depending on the ability to resupply, the units
S95
needed to maintain safe supply levels to address
potential mass casualty situations. The nurses also had
to be mindful that their primary mission was to care for
the war fighters. Providing humanitarian care to
civilian casualties had to be balanced with these other
care challenges and professional responsibilities as
nurses. Some of the participants offered these com-
ments in terms of how they approached equitable use
of their available resources.
Our role is [that] we are advocates to the patient
always.
What if there is a mass casualty and we dont have
the supplies to care for our troops if we use too many
for this patient?
The Iraqis, we gave them good care, Im not saying
that we didnt give them good care; its just that
more corners were probably cut with the supplies
because supplies were a bigger issue.
Nurses and Practice
Nurses and practice represented the second element
according to the ICN code. Under this element, the
standards address accountability, maintaining
competence and standards of personal health, using
professional judgment in accepting and delegating
responsibility, protecting the safety and dignity of
people, and practice culture promoting ethical
behavior. The nurses in these studies served in lead-
ership positions in their units and were challenged at
times with personnel assignments that perhaps were
not as appropriate. Some mentioned new nurses being
assigned to units right out of their basic officer course
and not being ready for the level of trauma care pre-
sented by the casualties. Early in the war, policies were
changed to avoid these early assignments for new
nurses and officers. However, nurses did note that they
did receive personnel who were clearly not trained or
ready for the care needed in the field. For example, one
nurse commented, we had a couple who should not
have been deployed in the first place . their mental
capacity wasnt there whether it be from a knowledge
or anxiety standpoint . having to worry about if were
going to have the people there to actually do the job.
Some nurses pondered their own competence in
meeting some of the care challenges. Many noted the
need to provide pediatric care because of civilian ca-
sualties who would present with injuries, Just taking
care of the pediatric patients was important for the
population over there. Not only was the infrastructure
lacking to provide care to these inadvertent casualties,
as noted in this comment, caring for the children rep-
resented an important humanitarian outreach to the
populace as well. Other nurses noted that the level of
care required for those with polytrauma challenged the
S96 Nurs Outlook 65 (2017) S92eS99
competence of even seasoned trauma nurses as noted
in this nurses comment, You know you always want
[to know] even though I felt secure in my skills and my
ability to do what the Army pays me to do, I always
wonder if its going to be good enough. Is it going to be
enough? Am I making a difference? You always have
those self-concerns. And for delegation concerns, this
nurse noted, for herself, Im not going to pretend to be
something Im not. Im well aware of my limitations.
Im well aware of what is expected of me.
This element also sets the standard for nurses to
maintain personal standards of conduct. Interestingly
in the demographics, most nurses noted receiving
ethics education through the military modules
completed as part of the deployment orientation pro-
cess. Few referenced back to formal education ethics
courses or the American Nurses Association or ICN
codes of ethics as directing their ethical or professional
conduct. Many referenced a faith-based origin for how
they decided to conduct themselves and direct their
behavior in ethical situations. Some indicated that they
had witnessed less than ethical behavior from guards
and coworkers in perhaps treating an insurgent or
detainee roughly or aggressively. Many commented on
how they would intercede in those situations to redirect
the behavior and hold the individuals to respectful care.
Setting a personal ethical code of behavior was
described by these two nurses:
I think what is important honestly is to acknowledge
that you do have biases. To acknowledge, hand to
God, that if an EPW [enemy prisoner of war] and a
soldier roll up in here at the same time, Im going to
want to shove a needle in that guys neck, but you
dont. You dont because [as] the healthcare pro-
fessional, you have to live by a different standard
that everyone is a human being and they all deserve
your best
I think there is an opportunity to say Where can I
grow as a person from this?
Nurses and the Profession
Nurses and the profession is the third element in the
ICN code. This element dictates that the nurse should
provide an environment of professional values; set and
implement acceptable standards of practice; and
maintain safe working conditions. Nurses working
with insurgents and detainees in particular found it
difficult to move between those patients and injured
American service members. Early in the war, leader-
ship found that it worked better to separate these types
of patients if possible. Then nurses could be assigned
to one group or the other for their shift with some
alternating of staff between these units to avoid
burnout. Care was especially stressful when working
with the detainees as many needed to be restrained
and were under constant guard to prevent self or staff
injury. As noted by this nurse:
As far as psychologically, I just, again, I had to think
of what am I going to do to remove myself from a
bad situation. If you take care of an EPW, is it better
to take care of an EPW because you dont work on
ten GIs or is it better to work on a GI because you are
not wasting your time and money and effort on an
EPW? Well, you just cant think that way. You are
here to do a job. You do your job. Do it well.
Commenting on the stress in these patient care
situations, another nurse reflected:
There was a lot of stress, a lot of call for mass cal
[mass causalities], and I know that some of the
leaders over there, they got pretty stressed out.
When you start acting up as, you know, barking
orders and telling people what to do left and right,
and treat them like they are morons, like they dont
know what they are doing, people get very resentful.
Leadership needed to be sensitive to the reactions of
the staff and to intercede when noting anyone acting
inappropriately toward patients. Nurses noted that
leadership set the tone within the unit as to how pa-
tients were to be treated and how staff were supported
in their decisions and care. Leaders who practiced
topedown and bottomeup communications were
especially appreciated by the staff in that transparency
was critical in maintaining unit morale. Those who
were out in the units and constantly monitored the
environment were effective in interceding in those
patient care situations that stressed staff and re-
sources. These situations were best illustrated by these
comments:
.that woman truly supported her people 100%. And
she truly lived by that. It wasnt just somebody who
said it. It was by somebody who did it. And in her
absence, if you made a decision, she supported you
on it
It really falls on leadership to bring a soldiers moral
compass to the situation.
Nurses and Coworkers
Nurses and coworkers represent the final element in the
ICN code. This element incorporates standards of colle-
giality and collaboration and directing others in
advancing ethical conduct and safeguarding the health
of patients endangered from others. Nurses noted the
critical aspects of being able to rely on their colleagues
not just for support in clinical care but also in debriefing
and providing support in ethically challenging situations.
During and after deployments, nurses commented on
 Nurs Outlook 65 (2017) S92eS99
how difficult it was to share with family members or
nondeployed colleagues as they did not have the view-
point or experiences to connect with what they had
encountered in the deployment. Many spoke of the
closeness with their colleagues in the deployed unit.
Each counted on the other to work at or above their
stateside skill level. For example, these quotes illustrate
their relationships:
everyday we did a team huddle .. I would take
people that were coming on .. and say, okay, give
me your thoughts ..
For me, my practice advanced more there than here
because all of the doctors do the majority of the
things here. Over there they are relying on you at the
bedside to make decisions and notify them as soon
as possible.
For many, these relationships were built on mutual
respect after determining the expertise of each other
and building a level of trust that each would meet the
demands of the care required for those patients in the
unit.
A lot of what I was doing was having to keep
empowering my staff and keep building up my staff
and keep trying to tell them that youre doing the right
thing and you are caring for all the patients here just
as you would care for anybody and they really did
When we were actually providing care, everybody was
cohesive, all specialists in our particular areas, and we
all had a high level of knowledge of nursing. None of
us were fresh, none of us were green; we all had at
least 6 years of nursing experience under us. We
meshed well together, and we provided great care
We were going to make the best of it, were going to
stick tight, and were going to do well. Thats exactly
what we did.
At the same time, for this element, nurses are
required to also safeguard patients from untoward ef-
fects from the care of others. Describing these actions,
nurses made these comments:
I understand the leadership was concerned about
the safety of the unit but at the same time, they were
more detrimental, I felt, to the US/Iraqi relationships
You have to prepare yourself mentally because
other people justdyou see these people that you
know are gung ho, Rambo type, but when they came
there, they just broke. They did everything they
could do to go home.
Some just couldnt handle it and did everything they
candthey used drugs and they confessed to it.
S97
Discussion and Recommendations
Emerging from both studies was a clear indication that
more education is needed in ethical decision making
before, during, and after deployment as a debriefing
strategy. Participants, although noting that any prep-
aration would not completely prepare nurses for what
to expect, felt that using some of the patient care and
situational experiences that they related could be used
to initiate discussion with deploying nurses before
encountering the issue for the first time in the field.
Participants asked for more complete cultural prepa-
ration as they stumbled quite a bit initially in providing
what they would believe was culturally appropriate,
but later found that it was not. Supporting this finding,
Johnstone and Turale (2014) conducted a systematic
review of nurses preparedness for disasters and public
health emergencies. Primarily pulling qualitative
research, the team extracted 12 articles meeting the
inclusion criteria of using only the direct experiences
of nurses in the research who had responded to a va-
riety of disasters. Of note, all the articles identified the
need for better preparation of nurses before encoun-
tering the devastation and decisions within the
disaster environment. Although the authors advocated
for advanced preventive ethics training, they also
acknowledged the difficulties in ethical preparedness
because each situation is necessarily unique so that is
not a one-size-fits-all plan that will apply to all situa-
tions. However, three of the studies specifically singled
out a common thread for most that included resource
allocation and reverse triage procedures as the hot
button ethical issues in the disaster situation. Grimaldi
(2007) similarly confirms that most disaster situations
have three primary challenges: rationing, restrictions,
and responsibilities (p. 164).
Resource utilization, or rationing, is a theme that
arises in both wartime and disaster nursing literature.
Bahrami, Aliakbari, and Aein (2014) conducted a quali-
tative study related to disaster relief in Iran. They found
that nurses need to include proper management of
available resources for maximum use of them locally
and to identify external sources of support (p. 8) as they
care for victims of man-made or natural disasters. Like
the military nurses, decisions needed to be made
regarding patients requiring high volumes of resources
in making triage decisions when the next casualties
could be arriving at any time. In a similar vein, this
study also noted the nurses acknowledgement of their
moral obligation to care for all who needed care. As one
of their participants observed, the patients right
should be observed, and you should respect his/her
characteristic and personality (p. 5). Supporting this
nurses comment, Wagner and Dahnke (2015) insight-
fully remarked on the difficulties in triage in their
analysis of ethical theory as applied in disaster situa-
tions: making a life or death decision that a patient will
consume too many resources and must go into the dead
S98 Nurs Outlook 65 (2017) S92eS99
or dying category runs counter to the moral intuition of
most people and most nurses, as well as counter to the
typical ethical principles that normally inform daily
nursing practice (p. 300). Triage in wartime scenarios,
and disasters, must necessarily apply a more utilitarian
approach in doing the greatest good for the greatest
number. For the military, this means treating those with
lesser injuries to more quickly return them to their duty;
in disasters, this means spreading finite resources to
treat as many as possible to do the maximum good for
the most casualties through the most efficient use of
resources (p. 303). This focus may be perceived by
nurses to be in opposition to their code of ethics and as
such may cause some moral distress as they apply
disaster triage priorities. As noted by Wagner and
Dahnke (2015) and as identified by the military nurses
in this study, it is difficult to provide adequate prepa-
ration for the conflict emotionally and morally that
nurses may experience in these situations.
Restrictions, as defined by Grimaldi (2007), refer to
the boundaries that may be placed on freedom of
movement in a disaster situation. Sometimes this is
related to prevention of infection or limiting spread of
biologic or chemical exposure. In other situations, such
as a wartime scenario, restrictions may refer to
detainment of insurgents or enemy prisoners of war. In
these situations, nurses may be morally challenged by
the denial of autonomy of those affected by the re-
strictions as this may be in conflict with the principles
of respect for persons.
Grimaldi (2007) also includes responsibilities as an
ethical challenge, because, as she notes, it is hard to
predict what people will do during times of crisis
(p. 164). She cites the situation in New Orleans during
Katrina where four patients were euthanized after a
week of heroic efforts by medical and nursing staff to
care for patients under increasingly adverse conditions.
She presents the dilemma they faced in determining at
what point continued care was futile vs. perhaps putt-
ing their own life at risk by staying in the deteriorating
environment. She raises the question as to how far re-
sponsibility for patients extends because there are no
clear guidelines in disaster situations as to what obli-
gations providers have to patients when there also
exists a duty to take care of oneself (p. 164). Military
nurses as well may face danger to self in wartime con-
ditions and have, in the recent war and others, sacri-
ficed their lives caring for others.
The leaders participating in the two studies often
commented on the active role they assumed in
addressing ethical situations especially when they
knew staff was having a hard time after a death or other
challenging care decision. Even seeming to be the an-
tithesis of a military environment, staff were very
appreciative of two-way communication with leader-
ship. Being able to express their concerns without
retribution opened a dialog for understanding different
sides of an issue. All staff need education in how to
provide care that supports and respects human rights
and is especially sensitive to cultural values and
customs. Dialog and training should be interprofes-
sional in nature as it was clear that all unit personnel
need to bond and work together closely in deployed
units. Wagner and Dahnke (2015) also noted that leaders
have a responsibility to stay on the alert to the distress
caused by ethical situations in disasters as well. They
suggest the use of debriefing as a tool to process the
experience and promote group cohesion that can act as
a buffer for the repeated stressors in the disaster situ-
ation. An additional benefit they identify for debriefing
is that the leader can also use these sessions to identify
individuals who may need more extensive intervention
or counseling to help process the experience. Incorpo-
rating training in how to debrief and recognize signs of
distress would be important in preparing leaders for
their roles in wartime or disaster environments.
Conclusions
By better understanding how nurses define, assess, and
manage the ethical situations they encounter in
wartime nursing practice, military nurses can better
prepare for future conflicts; provide mentorship and
targeted education to hopefully reducing any feelings of
moral distress; and promote ethical decision making
that will best promote outcomes in accordance with
nursings ethical codes. To date, most research on
ethical issues experienced by nurses in wartime have
emerged from qualitative studies or incidental to
studies of military nursing practice or reactions to
working in the wartime environment. More research is
needed in this area particularly related to helping
nurses understand how to identify and approach ethical
situations and to apply codes of ethics such as that
published by the ICN. The better we equip nurses to
negotiate these care challenges, the more we can insure
the quality and compassionate care for all patients.
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