Dr Wueste's framework offers nurses a tool for use in examining some of the complex questions that arise in our practice. Many nurses are troubled by some aspect of a patient's care but are so busy that worries are pushed to the background. These worries surface in after-hour awakenings and dreams or as old baggage in a new patient situation. I think we are often unaware of what it is that is troubling us until we are invited to think it through. I see fine nurses, clinical experts, who discount their right to express concern about the way a patient or family is treated or who feel frustrated by the lack of attention to their concerns. There is a need to encourage nurses to articulate their concerns, and to provide avenues for addressing them, whether in professional dialogue or a formal ethics consult. A structure within which exploring thoughts and feelings contributes to acquiring skill in problem solving may lead to increased confidence in negotiating complicated situations.

This article provides such a structure and could be used in a number of ways: as a means of staff support, legitimizing concerns, as a discussion tool in an ethics education course, and in preparing nurses to serve on ethics consult services. In this hospital system, during orientation, newly employed nurses attend a session on ethics before they begin clinical practice. Utilizing this framework would serve as a discussion starter and give them one method for reviewing the challenging situations they will encounter in practice. New graduates receive additional support in weekly sessions for a 6-week period. During this time, they are encouraged to process some of their early practice dilemmas. Dr Wueste's framework could be used during the session titled "Caring for Self and Others" because it presents a step-by-step method for exploring how one achieves confidence in working through an ethics question to a satisfactory conclusion. His guide is a self-explanatory tool for understanding how one justifies a professional opinion regarding ethics and might be seen as one means of preparing to participate in an interdisciplinary discussion of an ethics problem.

The framework in Figure 1 is particularly helpful in working through an ethics question. For clarification, it may be useful to add the ethics principles in the analysis section alongside the options and the clinician virtues in the decision/action section. In this way, a novice may visualize the links between principles and virtues and choices. Process is a powerful anchor for content in learning new skills.

Many years ago, I was asked to accompany a physician as he went in to tell his patient that he had reached the point in care where further aggressive treatment would yield no more benefit. He began the conversation by saying, "Remember when I first talked to you about your diagnosis and I told you that there may come a point where I would have to tell you that we had tried all the options for cure but that the disease was getting the upper hand?" With great compassion, he went on to tell the patient that he would continue with his care and that what was changing was the expectation of cure, that now the goal would be maximizing comfort and quality of life. This story demonstrates the ethical principles of beneficence, truth telling, and respect for autonomy and the clinician virtues of integrity and courage. All too often I see that patients are not fully informed of their prognosis or their right to participate in care decisions. Nurses at the bedside confront this challenging reality daily. Dr Wueste's framework provides one resource that allows nurses to give a name to their frustration and a means of addressing a concern in a professional way.

Reviewing the case of Justin-the hypothetical but reality-based case-casts light on missteps in his care along the way and demonstrates how the nurse is often entangled in a dilemma that begins long before he or she enters the picture. It is common for a patient to ask a nurse questions that family members are reluctant to answer. Using the article for practice in thinking through how one would respond to patient questions allows nurses to plan their responses before they are on the spot. Role-playing conversations with Justin, his parents, and physicians may increase comfort levels when a real-life situation presents itself. To follow through with Dr Wueste's sports metaphor, the nurse, as advocate on the patient's team, is often placed in the role of relief pitcher, stepping in too late to save the day. At the very least, he or she needs the tools that will help in meeting the challenge successfully.

I cannot read a case such as Justin's without asking how we in nursing are working to prevent such situations from unfolding. Asking the hard questions and having the courage to challenge the status quo and the willingness to push past our own comfort levels are all hallmarks of professional nurses. Certainly, a discourse on social activism is outside the scope of this commentary. However, bringing professional nurses into the discussion of ethics problems, preparing them to serve on ethics committees, and providing them with the skills necessary for success in these activities will benefit patients, families, and the profession of nursing.

Coming in the May/June 2005 Issue

* Guide to Nursing Organizations

* The Graduation

* The Role of BNP in Systolic Heart Failure

* Self-annihilation: A Cell's Story of Suicide

* Holism in Critical Care

* Research Abstracts

* Hiring and Mentoring Graduate Nurses in the Intensive Care Unit

* Anxiety in Acute Myocardial Infarction Patients