Emerging Digital Technologies in Virtual Care in Clinical Nursing Practice: An Integrative Review of Ethical Considerations and Strategies


Background. Leveraging the potential practical benefits of emerging digital technologies (EDTs) like robots, artificial intelligence, virtual reality, and 3D printing to provide and improve nursing care outcomes in ethical, sustainable ways requires an understanding of the ethical considerations regarding EDTs in clinical practice to inform research, practice, and policy.

Objectives. To map and discuss the nature and scope of ethical considerations regarding EDTs in clinical nursing practice from published literature, and identify ethical approaches and strategies deemed effective to address such challenges.

Results. Three main categories of ethical considerations that comprised 12 key emerging themes of ethical concerns were identified: Ethical Concerns related to Meaningful Understandings in the local Moral Horizon of Significance in Nursing Practice; the Organizational Imaginary; and Societal Imaginary. The twelve identified emerging key themes of ethical concerns regarding EDTs in clinical nursing practice comprised: (i) the nurse-patient relationship and inauthentic care interaction; (ii) patient dignity, autonomy and [self]deception; (iii) privacy, confidentiality, trust and integrity; (iv) patient safety; and (v) [social] justice, bias, discrimination, and stigmatization; (vi) Informed Consent, Transparency, and Data management; (vii) [Dis]Trust in the Healthcare System; (viii) Job displacement, Losses, and Fading in Professional Competencies; (ix) Liability, Accountability, Interpretability (Explainability); (x) Social isolation and Depersonalization of Human-beings and Care; (xi) Surveillance: Disciplining, Exploitation, and Manipulation of Human-beings and Society; and (xii) Vulnerability and Moral Fading: Human, Moral Authority and Agency and Future.

Key messages. Emerging digital technologies offering promising benefits to help address disparities in care and improve the effectiveness of services. However, this requires a keen understanding of the nature and scope of ethical considerations with using emerging digital technologies such as robots, artificial intelligence, virtual reality, and three-dimensional (3D)-printing in clinical nursing practice. Understanding the identified ethical concerns and best-practice ethical strategies regarding EDT may help guide robust research, practice, and policy initiatives to generate, validate, and translate evidence on EDTs before use in virtual care. Moreover, evidence might be helpful to ensure the ethical design, applications, implementation, and evaluation of emerging digital tools and techniques for use in virtual nursing care in clinical practice to benefit and improve the health of vulnerable clients, nurses, and health systems in ethical and sustainable ways. Additionally, key ethical considerations regarding EDTs might be also help inform curriculum innovations to build capacity, cultivate ethical competency and responsiveness among nurses and other health professionals transitioning to a workplace amid digital ethics and technological disruptions to sustain good care and practice.

Methodology. We conducted an integrative review using a comprehensive three-step sequential search strategy to search and retrieve published English language, peer-reviewed articles and grey literature documents from databases like CINAHL, PubMed, Web of Science, and Philosopher’s Index and relevant, reputable platforms. For this review, our team used COVIDENCE (Extraction 2.0 version) as a gold standard process and workflow platform to streamline our title and abstract screening, conduct a full-text review, data extraction, quality appraisal, data abstraction, evidence synthesis and interpretation to create high-quality systematic reviews. Following the removal of duplicate articles, the remaining articles were screened for eligibility using a two-step process: (i) title and abstract screening and (ii) full-text review against a set of inclusion and exclusion criteria. All included articles were read thoroughly to gain an understanding of the material. Following the title and abstract screening and full-text review process, a final sample of (n = 64) documents were selected that met all our inclusion criteria. We used an electronic data extraction form and a combination of quality appraisal tools from the Johanna Briggs Institute and the Centre for Children’s Health Ethics and Law (CCHEL) to extract essential methodological information and appraise the evidence from sampled documents. We used a five-stage Framework Analysis approach to abstract and synthesized evidence. This analysis provided a schematic diagram of ethical considerations related to using EDTs in virtual care, thus guiding the final interpretation of the data set while remaining mindful of the objectives of this review. The results of the review are presented both narratively and in a tabular format. A detailed discussion of ethical concerns and best-practice strategies, along with implications for health policy, education, clinical practice, and future research, is presented.

Ethical considerations, Emerging Digital technologies, Integrative Review, Virtual care