Abstract
An urgent need exists to elevate the agenda of family ethics, rooted in family nursing’s moral commitment to the well-being of families and society. This paper highlights the practice, research, and educational implications for this agenda. Grounded in relational ethics, this vision calls for a curriculum and practice landscape that reflects the lived realities of diverse families and communities. Clinically, it recommends the creation of interdisciplinary care protocols that embed structured family ethics conversations, drawing on an understanding of family systems. In research, it advocates for expanding studies that examine how familial and cultural values shape moral distress and care outcomes, and for broadening traditional bioethical inquiries to include family-centered perspectives. Educationally, it urges the integration of real-world scenarios, cultural analysis, and emotional intelligence training into classrooms and skills labs. Together, these strategies aim to cultivate ethically grounded, socially responsive nurses equipped to lead transformative changes in family health care.
Introduction
Family nursing and family ethics occupy a nexus where relational practice, bioethical complexity, and the lived realities of families intersect. Family nursing centers on understanding families within their ecological context considering how social determinants of health (SDOH) influence and are influenced by families (Deatrick, 2017). It takes a relational, holistic view, treating families as active partners in health and illness to identify those issues of importance to its members. Rooted in a moral commitment to family and societal well-being, it upholds respect, partnership, and empowerment as core clinical responsibilities (Freshwater & Stickley, 2024; International Family Nursing Association, 2025). Recognition and development of the family nursing practice, research, and education regarding family ethics will not only enhance the preparation of nurses and their research regarding families but also the outcomes of their care (Oh et al., in press).
Consistent with family nursing, family ethics centers on family-defined concerns about their experiences, emphasizing the relational and contextual moral dimensions of illness (Verkerk et al., 2015). It recognizes the family’s role in both care of the patient and the well-being and identity of its members (Cho et al., 2020), however family is defined.
Family ethics expands beyond individually oriented ethical perspectives like autonomy to a relational perspective. Autonomy treats the individual as the primary moral unit, emphasizing the protection of personal choice and self-determination. A relational ethics perspective treats relationships as the primary moral unit, emphasizing how to foster mutual responsibility, trust, and the interdependence of family members in meeting family obligations and moral responsibilities (Gauthier, 1993; Seidlein & Salloch, 2020; Weaver & Hinds, 2022). The importance of such a perspective is illustrated by the results of a study of 196 hospitalized patients and their families, in which family members identified family tensions and strained provider relationships, including racial discrimination, as the nexus of ethical problems (Cho et al., 2020). Fewer participants cited issues like end-of-life care, access, or clinical trials, which are the usual focus of ethics consultations, which underscores the importance of attending to family-identified issues (Fiester, 2020).
Family moral distress arises when individuals—or the family collectively—experience distress rooted in unresolved value conflicts. When a family member is ill the family’s usual responsibility is to support that person’s health, safety, and daily functioning in a way that is acceptable to the family culture while adapting family life in ways that preserve stability, shared roles, and a sense of normalcy for everyone. Moral distress can emerge when they contemplate or enact decisions that violate these core values, often because internal pressures or external constraints have limited their ability to act in accordance with those values (Campbell et al., 2016; Mooney-Doyle & Ulrich, 2020). Given their moral commitment to families and societal well-being, and their fundamentally relational perspectives, nurses also experience moral distress when providing family-centered care (Oh et al., in press; Ulrich et al., 2010).
A critical need exists to advance the agenda of family ethics, based on family nursing’s moral commitment to the health of the family and society. The purposes of this paper are to describe a forward-thinking agenda about family ethics for family nurses.
Resetting The Agenda About Family Ethics
Resetting the agenda for family ethics requires a shift toward a relational perspective—one that centers the lived experiences of families, acknowledges moral distress, and integrates SDOH. Ethical action is rooted not in isolated principles but in relationships themselves, where decisions emerge through mutual respect, engagement, embodied knowledge, environmental context, and certainty (Seidlein & Salloch, 2020; Weaver & Hinds, 2022). To move forward, we must radically reimagine clinical practice, research, and education by beginning with the perspectives of patients and families and those who care for them.
Clinical Implications: Ethical Communication and Cultural Assessment
Aligned with the principles of family ethics, nurses can prioritize open, respectful communication to uncover the values, beliefs, and traditions that shape ethical concerns (Cho et al., 2020; Ulrich et al., 2010). This begins with asking open-ended questions that elicit cultural and ethical dimensions like religion, gender roles, and intergenerational decision-making. Such dialogue not only clarifies patient and family perspectives but also models how these conversations can strengthen intra-family communication. They can be incorporated into interdisciplinary care protocols that provide equitable opportunities for all patients, families, and staff to have conversations that are both meaningful and productive.
When collecting demographic information, those not physically present should be considered, ensuring inclusive and equitable care planning. Moreover, contextualizing surface-level findings—such as caregiving capacity—with deeper insights into prior caregiving experiences can significantly reduce suffering and positively influence outcomes for both the ill family member and their caregivers (Bell & Wright, 2015). In addition, clinical team members with decision-making authority in ethical matters must remain attuned to the social positioning, vulnerabilities, and conflicts within those families.
Research Implications: Empirical Research About the Ethical Dilemmas of Families
Commitment to rigorous, transparent, and ethical research with families using continual self-reflection, member checking, and effective implementation strategies are key to advancing both scientific understanding and clinical effectiveness. Next-generation research in family nursing ethics must intentionally pursue inclusive research designs that reflect the diversity of contemporary families and their lived experiences. This means using research designs tools such as community-based participatory research (CBPR) and participatory action research (PAR) to democratize the research process and ensure that the voices of marginalized families are heard and respected. Mixed-methods and qualitative research can further strengthen study designs, so they capture the complexity of family systems, cultural contexts, and ethical tensions. Reflexivity and positionality statements, along with adherence to inclusive reporting standards for race, ethnicity, gender, and intersectionality, are essential. Equally important are efforts to recruit diverse samples and to include variables/data collection strategies that illuminate the lived experiences of underrepresented and marginalized families (Gray et al., 2023). Finally, new valid and reliable measures and evaluation tools are needed to assess the effectiveness of family-engaged interventions, SDOH-targeted policies, and ethics education programs.
Research Agenda and Training Priorities
A forward-looking bioethics research agenda must prioritize the inclusion of families in studies addressing core ethical issues, such as decision-making in care. To meaningfully advance the field, research teams should integrate scholars with expertise in family systems and family ethics. Their perspectives are essential for capturing the relational dynamics that shape ethical deliberation and care experiences.
Equally critical is sustained inquiry into moral distress as it intersects with family processes. Research should illuminate the lived experiences of suffering and the pathways through which moral distress emerges—both among health care professionals and within families, particularly during moments of decisional conflict and under conditions of systemic constraint.
Further investigation is also needed to assess the relationship between family processes and SDOH. An investigation is warranted to explore how family processes intersect with SDOH. At the most fundamental level, it is essential to recognize that structural and intermediary determinants extend beyond mere demographic descriptors. These factors must be captured conceptually to reflect their complexity and relevance, enabling meaningful identification of the issues most salient to specific family populations.
Finally, in the realm of ethics education, it is imperative to examine the long-term impacts of ethics training, anti-racist interventions, and participatory care models on both provider and patient outcomes. These insights will inform the development of future educational approaches that engage not only professionals but also the broader community.
Educational Implications: Ethics Education as a Tool for Reducing Moral Distress
Innovative programs are both available locally, regionally, and nationally that provide immersive, multi-modal training to deepen ethical knowledge and strengthen professional identity.
Integrating relational and structural ethics into nursing education requires a transformative shift in pedagogy—one that moves beyond traditional ethical dilemmas to embrace the relational, contextual, and systemic dimensions of care. Crucially, ethics education must be explicitly linked to SDOH, equipping students to critically examine how poverty, racism, structural oppression, and policy decisions shape both health outcomes and ethical challenges. Foundational ethics curricula must cultivate moral sensitivity, agency, and reflective competence; cultural humility, social justice, and critical race praxis; and promote empathy, open listening, and values clarification. By integrating problem-based learning, community engagement, and scenario-based discussion, nursing pedagogy can simulate the complexity of real-world practice and empower nurses to serve as both compassionate clinicians and advocates for systemic change. Practical examples of teaching strategies include the following:
Integrating questions related to family ethics into discussions, like, “What relational obligations are shaping this decision by the family?”
Mapping the members of the family system to analyze ethical issues and ask questions like, “Who is carrying the moral burden?”
Plan an unfolding case study about a family-nurse situation that involves a potential conflict between the nurses’ perceived ethical obligation and the families’ perceived ethical obligation. Ask students to write about the nurse’s ethical view, that of the family, and that of the team.
Simulations that reflect potential ethical challenges to providing family-centered care with an interdisciplinary team. For example, when a nurse is advocating for a family and meets resistance from members of the health care team. Ask them to role-play what they would say or do as the nurse. Afterwards, ask them why they took that approach.
A forward-looking family nursing curriculum must reflect the lived realities of today’s families and their ethical dilemmas—diverse in structure, shaped by complex social contexts, and navigating evolving ethical landscapes. Central to this redesign is a robust emphasis on relational, contextual, and systems-informed ethics, grounded in contemporary research and attuned to emerging family forms and cultural nuances. Through integrating emotional intelligence training, students’ self-awareness, self-management, and social awareness, relationship-building skills can be fostered (Freshwater & Stickley, 2024). Programs should weave SDOH and health equity throughout the curriculum, offering hands-on opportunities to apply ethical principles in interprofessional, community-engaged, and real-world settings. A commitment to inclusive language, gender representation, and continuous curricular evaluation is essential to identify gaps, challenge bias, and uphold best practices. Interprofessional collaboration and shared decision-making must be embedded throughout, reflecting the collaborative environments in which family nurses operate. To prepare nurses as leaders and change agents, curricula should cultivate policy literacy, advocacy skills, and the capacity to engage in systemic reform. Sustained curriculum renewal requires iterative evaluation, stakeholder collaboration, and a readiness to adapt pedagogy and content in response to emerging evidence, shifting demographics, and the evolving needs of families and learners.
Conclusion and Directions for Family Nursing
The convergence of family nursing and family ethics defines a vibrant, continually evolving field—one that demands innovative paradigms, persistent advocacy, and a steadfast commitment to justice. Today’s nurses must be not only socially attuned but also ethically literate, equipped to navigate the nuanced dynamics of family life across diverse contexts. Grounded in the SDOH and the realities of moral distress, and enriched by relational ethics, the future of family nursing must reflect the lived experiences of families and communities in all their complexity. Advancing this domain—through practice, research, and education—requires more than clinical expertise; it calls for moral courage, deep humility, and a collective resolve to co-create resilient, equitable systems of care. As nurses, educators, and policymakers embrace these imperatives, the promise of family-centered, ethically robust, and socially just health care comes ever closer to fulfillment.
Recommendations for practice, education, and research:
Ethical awareness is crucial to the future of nursing education, research, and clinical practice.
In practice, develop interdisciplinary care protocols that include structured family ethics conversations that build upon use of open-ended questions and knowledge about the family system.
In research, expand upon studies about how families and cultural values influence moral distress and care outcomes as well as studies that focus on typical bioethical issues to include family perspectives.
In education, incorporate real-world scenarios, cultural analysis, and emotional intelligence development into classroom and skills laboratory to develop student’s self-awareness, self-management, social awareness, and relationship management.
Footnotes
Acknowledgements
The author thanks those at the University of San Paulo and in the International Family Nursing Association who organized the conference that is directly related to this work; ‘Determinantes Sociais de Saúde no Cuidado da Família’, no “II Encontro Internacional do NIPPEL: Considerações Globais em Ética Familiar–Avanços no Cuidado da Família e nas Pesquisas em Cuidados Paliativos para o Desenvolvimento Sustentável.” San Paulo, Brazil, 06/03/2023. Thank you to the many students, colleagues, and families who contributed to this including Dr. Lamia Barakat, Dr. Anne Kazak, Dr. Kim Mooney-Doyle, Dr. Connie Ulrich, and Dr. Kathleen Knafl and Shannon Hammer for daily inspiration. In addition, the author thanks Dr. Maiara Rodrigues Dos Santos and Dr. Regina Bousso, who provided guidance and support in Brazil and who directly inspired me to write about this topic.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding provided by Minnesota State University, Mankato Glen Taylor Institute for Family and Society Interunidades EE-EERP/USP; 50 anos PPGE (Programa de Pos-Graduacao em Enfermagem).
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.