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Nursing Ethics
17(6) 769–776
Ethics in independent nurse ª The Author(s) 2010
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consulting: Strategies for 10.1177/0969733010379179
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avoiding ethical quicksand

Eileen L Creel
Southeastern Louisiana University, USA
Jennifer C Robinson
University of Mississippi, USA

Abstract
Changes in health care have created a variety of new roles and opportunities for nurses in advanced
practice. One of these changes is the increasing number of advanced practice nurses carrying out
independent consultation. Differences in goals between business and health care may create ethical
dilemmas for nurse consultants. The purpose of this article is to describe possible ethical pitfalls that
nurse consultants may encounter and strategies to prevent or solve these dilemmas. Three themes
related to nursing codes of ethics will be discussed: the duty to uphold human rights, the duty to fulfill
commitments, and the duty to practice the profession competently.

Keywords
advanced practice, consultant, ethical dilemma, ethics, nursing

Introduction
Over the last three decades, health care in the USA has shifted from being largely publicly owned or
not-for-profit institutions to managed care and a more investor-owned industry with aims that are
profit orientated as a means of containing rapidly escalating health care costs.1,2 Health care institutions
are seeking ways to maximize profits. The number of multi-hospital system organizations continues to
increase owing to participation in managed care contracting as a method to increase revenue and limit
costs by less duplication of needed resources.3 The changes in US health care over the last 20–30 years
have resulted in two very different sets of goals: those of business and those of health care. This shift in
health care goal orientation has often resulted in conflict from the discordance between two different
sets of ideological beliefs. The goals of business may predominately be concerned with the provision
of a service and maximizing profit for the shareholders,2 as opposed to traditional health care’s primary
responsibility to the social and individual good.4
Nursing has also changed, with the need for advanced practitioners to assume new positions and roles. The
need for efficient, cost-effective care has led increasing numbers of nurses with advanced degrees into the
role of independent, self-employed consultant. Consultation has traditionally been a role for clinical nurse

Corresponding author: Eileen L Creel, School of Nursing, Southeastern Louisiana University, SLU Box 10835, Hammond, LA
70402, USA
Email: ecreel@selu.edu
770 Nursing Ethics 17(6)

specialists working for health care facilities or nurses working for law firms. Advanced practice nurses are
now more frequently independently contracting their consulting services. These nurses may be hired to con-
sult on clinical practice, legal, ethics, or management issues. The role of independent nurse consultants has
not been well defined. They may find themselves in ethical ‘quicksand’ if unprepared for the potential moral
tensions frequently encountered in the business world of health care.
The purpose of this article is to describe possible ethical pitfalls that independent nurse consultants who
contract their services may encounter. These situations often conflict with core values of the nursing prof-
ession and can lead to ethical dilemmas. Many of these situations are relevant for independent nurse consul-
tants serving in any role. Finally, strategies to prevent or solve dilemmas are presented to help nurse
consultants to negotiate between clients’ (organizations) and agencies’ wants and needs. Standards for nur-
sing practice, relevant codes of ethics for nursing, and the principles of ethics that form the framework for
ethical care are also reviewed.

Background
From a duty or deontological ethical theoretical perspective, principles of intention and action help to guide
nurse consultants when faced with an ethical dilemma. Duty ethics, derived from Kant’s,5 and more recently
Ross’s,6 philosophies, emphasizes the principles of fidelity, autonomy, justice, beneficence, and non-
maleficence.
Ethics helps to answer moral questions such as: What should I do in this situation? or, What is my moral
duty? and is based on the principles of what is moral or right. Ethics helps us to understand how nurses should
‘make decisions, act, and behave’ as members of a professional group of caregivers (p.162).7 Ethics does not
tell us what to do; we must still make that decision on our own.8 However, the ethical principles of autonomy,
beneficence, justice, and fidelity that guide moral decisions in professional practice can serve as a reference
in ethical decision making. Briefly, autonomy refers to the independent uniqueness of persons and their right
to self-governance and decision making. Autonomy is rooted in respect for individuals. Beneficence in nur-
sing involves assisting persons in their effort to attain benefits and can be thought of as the other extreme of
non-maleficence, in which individual benefits may be at odds with the benefits or the risks of others and the
potential for causing harm or injury. Justice involves the duty to ensure the fair distribution of benefits and
costs, recognizing the worth of individuals. The last principle, fidelity, addresses adherence to the terms of an
oral or written agreement. Fidelity in nursing is the commitment to the obligation that nurses have in their
professional role. For nurse consultants, there may also be a commitment to the clients who contract for con-
sulting services in addition to the duty to individuals seeking health care through the societal obligation
inherent in the role of professional nurse8 and expressed in the American Nurses Association’s social policy
statement.9
The ethics of a group is based on the values and beliefs about the behavior of the group.7,10,11 The ethical
standards associated with nursing consultation include guidelines from nursing and non-nursing professions
such as the American Society for Bioethics and Humanities (Draft document: Core competencies for health
care ethics consultation, 2010. ASBH, Glenview, IL, USA), the American Nurses Association’s stan-
dards9,12,13 and their position statement on ethics and human rights,14 and legal nurse consultant guidelines,15
but no one specific code has been written for clinical nurse consultants’ use. Awareness of ethical issues in
the clinical arena may not readily prepare independent nurse consultants to act in an ethical manner; how-
ever, the established ethical standards of the nursing profession can be translated for use in consultation prac-
tice. The ethical principles can be organized into three recurring themes. Contained in the three themes that
provide the foundation for nurses’ codes of ethics, and also in Acts relating to nursing practice, are duties to
uphold human rights, fulfill commitments, and practice the profession competently. There are multiple areas
in nurse consulting that may result in ambiguous role issues and conflicts of interest. Ethical dilemmas can
Creel & Robinson 771

occur at any time when nurse consultants need to decide between competing values. Recognizing whether an
ethical challenge is involved includes the steps of: identifying that an ethical conflict may be present and
defining the issue; reflecting on the relevant facts, stakeholders, consequences, and resources available;
deciding on the right thing to do in the situation; and implementing, evaluating, and reassessing the path cho-
sen to deal with the ethical dilemma.16

Nurse consultant roles and potential conflicts


Newman17 states that nurse consultants’ relationships are triadic, including the consultants themselves, the
client or organization, and the client’s patients. Nurse consultants are not only responsible to their clients but
also to the patients of those clients for whom health care is provided. They may be hired to identify areas of
cost reduction in which services or employees can be reduced or eliminated. This could create ethical dilem-
mas for them if patient care would be adversely affected by their recommendations.11 Nurse consultants’
professional responsibility, like that of bedside nurses, is to patients. In a deontological framework, this
responsibility to patients is first, and is the actual duty. For example, if there is a conflict between the duties
of fidelity to the client and non-maleficence to a patient, the actual duty to the patient should be followed.6
Even when the patient is not in the forefront of the consultation, there is a fundamental ethical responsibility
for the impact the consultation services may have on outcomes.11,17 Nurse consultants should always keep
patients’ best interest in mind when recommendations are made to clients. They must always consider what
impact their advice will have on patients.
Some of the most common work-related relationships that can cause ethical dilemmas are supervisor/
consultant-, counselor/consultant-, or clinician/consultant-based.11 With any of these roles, conflicts of inter-
est may arise. Nurse supervisors who are also contracted as paid consultants for another area of a hospital or
by an outside client may have access to information in the consultant role about which they may not other-
wise have knowledge. This information could potentially be misused by consultants in a supervisory posi-
tion, even inadvertently. Which role will take priority? When trying to meet various role expectations, the
best interest of the client may not be considered first. It is consultants’ responsibility to establish and maintain
appropriate relationships.17

Power
Power is the ability of one person to influence another person’s behavior.18 It may be related to being an
expert, having more education than clients or informants, having authority given by an agency to make deci-
sions, or having information that others do not have.19 Ethical issues related to power stem from misuse of
that power. Nurse consultants may encounter an ethical quagmire in several ways related to the use of power.
In the consultation relationship, nurse consultants are in a position of power as experts sought by clients. Red-
wood and colleagues20 interviewed key nurse consultants and nurse consultant informants about role expec-
tations and found leadership and clinical expertise as an expectation of nurse consultants. They must be
cognizant of their role as leaders and aware of the power associated with leadership in order to prevent undue
influence.
Nurse consultants may be asked to consult on issues that are outside their area of expertise. Consulting in
this manner is a misuse of the expert power that they have by way of knowledge or training. They should be
careful to take only cases that they have the expertise to handle. If they take on cases when they do not posses
the necessary skills and knowledge, this could be detrimental to clients in the form of giving bad advice that
may jeopardize optimal patient care, as well as irreparably damaging their own reputation18 or the status of
the nursing profession. Additionally, faulty advice may jeopardize the trusting relationship between consul-
tants and clients that is fundamental to the principle of fidelity. For example, a nurse consultant with expertise
772 Nursing Ethics 17(6)

in the clinical aspects of patient care may be asked to give recommendations on staffing issues in that area,
but lack sufficient knowledge about administration. Advising in this manner may result in incorrect resource
allocation, suboptimal staffing in a specific unit, or even changes to staffing hospital wide, resulting in poor
patient outcomes as a consequence.
In addition, such ill-advised recommendations could result in the client’s unwillingness to re-hire the
nurse consultant for future projects and may even result in giving negative feedback to other potential clients.
Careful discussion about tasks and the expertise of nurse consultants should occur during contract negotia-
tions.21,22 All nurses are accountable for their practice and nursing decisions. Nurse consultants must be
aware of the limits of their competence and make these known to clients, with the goal of putting patients’
safety first.13
Another misuse of power may occur when nurse consultants seek to increase clients’ dependence on them.
One of the goals of consultation is to facilitate problem-solving skills for clients about work-related issues.
Ideally, nurse consultants should become increasingly unnecessary to clients as people within the organiza-
tion become more skilled in the decision-making process.11 Fostering dependence results in an increase in the
length of the consultation process and possibly increased charges. Wilson23 referred to this misuse of power
as not only a conflict of interest, but also as an exploitation of the consultant–client relationship. In this case,
nurse consultants can influence clients to act in ways that are in the best financial interest of the consultants
instead of the clients.
Finally, nurse consultants may misuse referent power (power obtained through respect of one person for
another) by fostering relationships that seem reciprocal, but in truth have been fostered for the sole advance-
ment of the consultants.24 For example, a legal nurse consultant may develop what seems to be a friendship
with a particular nurse, when in truth the relationship was formed by the nurse consultant to obtain informa-
tion on potential cases. Nurse consultants who misuse professional venues to promote their business may be
viewed as engaging in inappropriate use of referent power. Adams25 interviewed nurse consultants about
their roles and found that they thought it was an inappropriate use of the situation for them to place their con-
sulting logo on each slide when giving a visual presentation at a professional conference. Nurse consultants,
as professionals, must consciously examine their use of dependent and referent power.

Autonomy and confidentiality


Nurse consultants have the duty to uphold human rights, of which informed consent and confidentiality are
components.11,17 Informed consent is one of the best ways to protect clients’ rights. It is possible that nurse
consultants could be placed in the position of working with employees who are coerced into working with
them by the use of threats, often in the form of negative consequences for their job. Identifying informants in
the consultation process, as well as the possible ramifications of that participation, should be addressed up
front between consultants and clients. For example, nurse consultants may very well be in a position to solicit
information pertaining to management issues from employees who report to that level. Careful thought about
what information is required, to whom the information will be transferred, and how it will ultimately be used,
even after the consultation is over, should be considered by consultants. Employees should be informed about
the possible risks and benefits of participating and given the option not to take part without jeopardy or neg-
ative consequences for their job.17 Asking informants’ permission to use the information given, but keeping
their identity anonymous, is a possible way to address this ethical hazard.11
Confidentiality can present as an ethical trap in several ways. During the assessment phase of the consul-
tation, nurse consultants may become privy to more information than is really needed. For example, during
data collection they may have access to medical records, but need only limited information from these.
Although additional data are available, the nurse consultant must be careful to use only the data specifically
required for the task. Any records reviewed should be considered as confidential, whether they are medical
Creel & Robinson 773

records or other hospital information. Nurse consultants must protect against the misuse of assessment data.17
In addition, they may obtain information that could help the consultation process but is unusable owing to an
informant’s need for confidentiality.
Confidentiality can be violated either internally or externally. Nurse consultants may share data inappro-
priately with a unit or peer within the organization, or violate confidentiality externally by talking with a per-
son in the community about information obtained during consultation. Additionally, and possibly most
disturbing, are consultants who are asked by administrators for confidential details obtained during consulta-
tion and which may then be used in a punitive way against the informants. Nurse consultants must clarify who
will have access to the information obtained and how it is to be used.17
In addition to information related to individual patients, nurse consultants often have access to informa-
tion about the organization. Confidentiality of proprietary data must also be safeguarded. An ethical dilemma
described by a nurse consultant occurred when one client organization asked for pricing information from
another competitor for whom the consultant was working. The nurse consultant noted that there could be
times when a request seems innocent but, on further reflection, involves confidential information, which,
if given, could harm not only the client organization but also the nurse consultant’s reputation and the pro-
fession as a whole.25

Conflicting goals and multiple relationships


Dual relationships between nurse consultants and either clients or other employees threaten consultants’
objectivity.17 Dual relationships could come in the form of social friendships or work-related relation-
ships. Nurses who provide internal consultation (for a facility where they work in another capacity, such
as clinical nurse specialists) are more likely to experience this ethical dilemma. Nurse consultants may
feel torn over recommendations that would be detrimental to a friend or even use their consultant position
to benefit someone with whom a dual relationship exists. The principle of fidelity is important in this sit-
uation. Nurse consultants must ask, ‘Who is my client?’ and, ‘What did I contract to do for my client?’ in
order to make decisions and recommendations that maintain fidelity and uphold their commitment to the
client. Awareness and internal assessment of personal motives will help nurse consultants to remain
objective. If objectivity cannot be maintained, they may need to withdraw from making recommendations
in such cases.
Opposing goals may additionally play a role in the misuse of information. Employees may readily volun-
teer information about a process or problem with a specific goal in mind, but that is not the goal of the orga-
nization (i.e. client). Consultants should be aware of possible differences in outcome goals between
informants and clients in order to determine where possible ethical dilemmas may arise. Additionally, pre-
viously completed work, as in research or data collection by others that will later be used by nurse consul-
tants, could be an area that presents as an ethical dilemma. To whom do the data belong and how will any
possible ‘glory’ be shared in the use or presentation of the work? Nurse consultants must be sensitive to infor-
mation that is shared with them and contributions of others’ work.20

Potential consequences of unresolved ethical dilemmas


Nurse consultants’ lack of awareness and consideration of ethical dilemmas could have serious conse-
quences, which could include loss of personal reputation, loss of business and income, damage to the status
and esteem of the profession, and loss of trust. These consequences could result from nurse consultants pro-
posing to give advice in an area where they lack expertise or failing to complete assignments at all or in a
timely manner. More serious consequences could result when they fail to keep patients in the forefront of
the consultation process and do not always consider the impact of consultation decisions on patient
774 Nursing Ethics 17(6)

outcomes. Other consequences, such as breach of contract, breach of confidentiality, or negligence should
not be discounted.

Strategies for recognizing and managing ethical decisions


How can nurse consultants deal with ethical dilemmas? Although there is no one set of rules that can be used
in every situation, several positive ideas could be helpful. As advanced practice nurses, nurse consultants
should be well educated in all aspects of nursing consultation and their practice should be theory based.23
Another suggestion includes the development of a personal framework to use to guide their practice. Using
a grounded theory approach, Laabs26 developed a process for managing moral problems. The four aspects of
her theory included: encountering the conflict with an awareness of the moral dilemma, drawing the line
between right and wrong for the individual nurse consultant, finding a way to complete the task without
crossing the line, and then evaluating the actions taken in light of outcomes and in accordance with personal
moral principles. Additionally, the American Association’s Code of ethics for nurses,13 their statement on
ethics and human rights,14 together with guidelines from the American Society for Bioethics and Humanities
(Draft document: Core competencies for health care ethics consultation, 2010. ASBH, Glenview, IL, USA),
can be helpful. These guidelines include respect for human dignity, the right to privacy, accountability, com-
petence and informed consent. Always relating consultation activities back to these guidelines would provide
grounding for nurse consultants’ business practices.
Prior to beginning the consultation process, nurse consultants should carefully consider clarifying values
and roles. A personal self-assessment may be carried out.23 This may be in a self-reflective manner and also
as an a priori discussion with clients before final contracts are negotiated. Redwood and colleagues20 iden-
tified role confusion as a problem present in nurse consultation. Clarification about expectations of the pro-
cess among all stakeholders before accepting a job is important. Careful discussion up front can help nurse
consultants to identify potential problems, explore and examine possible outcomes, and avoid ethical
conflict.
Informed consent obtained from both clients and informants concerning the consultation process includes
explanation of procedures, goals, costs, consultant qualifications, length of consultation and limits of confi-
dentiality, and disclosure of any dual relationships. Additional recommendations include consulting with a
colleague whenever a dilemma arises. However, using peer review or engaging in a personal reflective
evaluation about the process, even when no ethical problem is apparent, may uncover hidden issues.11,23
As commonsense as it sounds, consultants should not enter into contracts with clients whose values oppose
their own.17 Nurse consultants should be proactive in the identification of the possible value conflicts they
may encounter. Personal awareness beforehand and reflection after each encounter may be used as a
cornerstone of their practice.

Summary
Changes in the health care market have led to expanded roles for advanced practice in nursing. One oppor-
tunity has been an increasing need for nurse consultants. However, with the broader scope of practice and
responsibilities that vary based on clients’ needs, situations may arise when it is not clear where consultants’
duties lie or what the possible consequences of decisions may be. Not fully understanding the situation and
the possible negative outcomes may lead independent nurse consultants into ethical trouble before they
realize what is happening. Some of the ethical dilemmas involve the use of power, the use and misuse of
information, recognizing and working with the needs of patients, informants, clients, and self, and managing
opposing goals and multiple relationships. Because of their expanded role and multiple relationships, nurse
consultants frequently encounter ethical dilemmas.
Creel & Robinson 775

Guidelines for ethical decision making involve reflective practice using the American Nurses Associa-
tion’s code of ethics,13 nurse practice Acts, ethical principles, seeking advice from colleagues, understanding
and negotiating contracts that delineate responsibilities, and taking contracts where nurse consultants have
the time and expertise to provide fully for clients’ needs. By adhering to the guidelines, nurse consultants
may be able to avoid an ethical quicksand.

Conflict of interest statement


The authors declare that there is no conflict of interest.

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