A 126-Year Legacy of Nursing Ethics

When Cynda H. Rushton, PhD, RN, FAAN, started her nursing career in a pediatric intensive care unit, she found herself in what she now calls moral distress. A young patient had been admitted with a serious injury that had cut off oxygen to the brain, leading to severe neurological damage. The patient’s parents wanted to limit life-sustaining therapies and let their child die naturally, but the clinicians in charge opted for more aggressive treatment. As Rushton cared for this patient for almost a year, she felt distressed by the gap between the care she was required to give and what she thought she should be doing. 

Situations like these motivated Rushton to continue her education in the field of bioethics. She became a pediatric clinical nurse specialist to help parents make these difficult medical decisions and earned her doctorate in nursing with specialization in bioethics. In 1991, she joined the Johns Hopkins Children’s Center as a clinical nurse specialist in ethics, and she became the chair of the Johns Hopkins Hospital ethics committee in 1999. Rushton is now the Anne and George L. Bunting Professor of Clinical Ethics and Nursing at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing.  

“Nurses play a critical role in healthcare decision-making,” Rushton says. “Having this professorship really highlights how important nurses’ voices are in that conversation and how important it is to have leadership by nursing in the field of bioethics.” 

Rushton isn’t the first nurse at Hopkins to advance the field of bioethics. Isabel Hampton Robb served as the first superintendent of the nurses at Johns Hopkins Hospital and the principal of its training school for nurses from 1889 to 1894. In 1900, she wrote Nursing Ethics, the first textbook in the United States to cover the qualities that should make up a nurse’s moral formation, which are integrity, honesty, and transparency, according to Robb. 

“At the time, these kinds of ethical conversations were largely unheard of, especially from a woman,” Rushton says. “She was really a true pioneer in bringing these considerations into nursing practice. And her book is the foundation for what became our profession’s code of ethics.” 

While nurses today grapple with novel questions about technology, end-of-life care, access to healthcare, and the fair allocation of scarce resources, some ethical areas overlap between the two eras. 

In the late 1800s, Robb had identified the importance of nurses taking care of their own well-being, especially in an emotionally taxing job that was part of a system that did not value their contributions. This topic still resonates with Rushton today. 

“Those are similar themes that have motivated my work. We need to remind nurses that their well-being and integrity are scarce resources, and we have to invest in it so they’re able to be a whole person, but also so they can serve,” Rushton says. “Having healthy workplaces to support nurses is a vital necessity.” 

Rushton’s current focus is on moral resilience or the ability to preserve or restore integrity in response to adversity. She’s implemented a variety of strategies to support clinicians, including the Mindful Ethical Practice and Resilience Academy, a training program that started at Johns Hopkins Hospital aimed at helping clinicians handle ethically difficult situations through mindfulness, ethical confidence, and resilience. More than 350 nurses have gone through the program.  

“We found really significant increases in nurses’ ethical confidence and competence, mindfulness, resilience, and work engagement,” Rushton says. “And we also saw decreases in depression, anger, emotional exhaustion, and intent to leave the profession.” 

Rushton took this success and implemented it in the statewide R3: Resilient Nurses Initiative, which has educated thousands of nurses, educators, and nursing students in how to confront ethical challenges and support their well-being while advocating for healthy workplaces. She credits the resources from the Bunting Professorship with giving her the freedom to pursue this work at the scale it has reached. 

“It’s just invaluable to have space to think, innovate, research, and collaborate with others to achieve these outcomes,” Rushton says. “I can’t imagine having gotten to this place in my career without that support.” 

As Rushton looks toward continuing to expand clinicians’ moral resilience in the face of ethical challenges, she says she keeps Robb’s legacy in mind as a reminder that a change in method or perspective may be necessary in her quest to improve healthcare and bioethics. 

“For me, the legacy of Isabel Hampton Robb is really her leadership and her willingness to take risks, push boundaries, and challenge the way things have always been,” Rushton says. “I think it’s an important reminder that, even at the turn of the century, there were still people who pushed the limits and helped us to make progress. I find that tenacity to be something we need right now, both in our profession and in healthcare.”