Professional ethical challenges and suggested strategies in nursing: a qualitative study

Abstract

Professional ethics are essential for supporting nurses in making ethical decisions and responding to current challenges. This study aimed to explore professional ethical challenges and the strategies nurses use to address them in Iran. An exploratory descriptive qualitative approach was employed, with data collected through two focus groups involving 16 nurses and semi-structured individual interviews with six nursing faculty members. Data were analyzed using thematic analysis following Braun and Clarke’s method. Participants shared their experiences and perceptions of professional ethical challenges and proposed strategies to address them. Nine categories and 51 subcategories were identified, including:

1) Deficiencies in patient-centered care; 2) Communicating bad news to patients and families; 3) Decisions on withholding or withdrawing life-sustaining treatments; 4) Lack of cultural consideration in nursing care; 5) Challenges of incorporating new technology; 6) Ethical concerns in managing and using large patient datasets; 7) Upholding ethical principles in disaster or crisis nursing; 8) Gaps in providing palliative care; and 9) Fear of causing moral distress. The findings underscore the ethical challenges faced by nurses in clinical practice and suggest strategies for addressing each challenge in Iran.

Introduction

Ethics refers to the values and principles related to human morality, professional ethics, and ethical norms that are essential for a particular occupational group when facing ambiguous ethical situations and preventing moral hazards. Professional ethics is described as an intra-professional approach to care ethics, to which professionals voluntarily commit (1). It is a critical aspect of nursing, encompassing the standards and practices that guide nurses in performing their duties (2). In daily patient care, nurses encounter many ethical dilemmas, requiring ethical decisions based on professional values and a strong sense of responsibility (3).

Ethics has been internationally recognized as a fundamental aspect of nursing care. However, due to the constant evolution of internal factors (such as the interpretation of values, responsibilities, duties, and their integration with professional rights) and external factors (such as organizational characteristics) that impact the profession, ethics in nursing practice requires ongoing review (1,4). Given that nurses confront these ethical questions daily, professional ethics remains a challenging aspect of nursing. As the largest group providing healthcare services, nurses have a significant impact on the quality of care, making adherence to ethical standards in nursing practice essential (5).

A study by Yang et al. identified the core of nursing ethics as adherence to professional ethics, encompassing the following subcategories: causal conditions (code of professional ethics, morals), intervention conditions (personal growth, social support systems, predicting adverse consequences), and action strategies (adherence to professional values, self-regulation, flexible response, and post-event recovery) (6). In addition to theoretical learning, nurses need models to help them develop practical nursing strategies for use in clinical environments (7,8). Therefore, professional ethics are essential for supporting nurses' ethical decision-making and must address the current and evolving challenges in healthcare and communities. Due to constant changes driven by internal and external factors, professional ethics should be regularly evaluated to adapt to shifts in nursing practice (1). Additionally, the nature of professional ethics is influenced by societal and cultural factors, meaning that professional ethics must consider not only ethical theories but also contemporary issues related to culture and the professional environment (1,9). However, few studies have been conducted globally on professional ethics in nursing (1), and greater knowledge in this area is needed to understand and support nurses' ethical decision-making in response to the challenges posed by current changes in healthcare and society (2). Some studies conducted on ethical challenges in Iranian nursing focus on specific patient groups (10,11) or particular conditions (12–14). No studies have evaluated the professional ethical challenges in nursing practice in general or the strategies that nurses use to respond to these challenges. Understanding the ethical challenges specific to this geographic area can provide valuable guidance to nurses. Therefore, this study aimed to explore professional ethical challenges and the strategies that nurses employ to address them.

Methods

Qualitative Approach and Research Paradigm

This qualitative study employed an exploratory descriptive approach and adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ checklist) (15). Two focus groups were conducted with 16 nurses, along with semi-structured individual interviews with six nursing faculty members. Data were analyzed using thematic analysis based on Braun and Clarke’s method (16).

Researcher Characteristics and Reflexivity

A total of 22 nurses participated in the study, including 16 nurses enrolled in a master's degree program and 6 nurse faculty members from the University of Medical Sciences in Iran. Although recruitment took place at a single nursing school, participants represented five capital cities and had work experience in various hospitals across different provinces of Iran. This diverse geographic sampling was designed to provide insight into ethical challenges and suggested strategies from nurses of different regions and cultures. The inclusion of master's nursing students was based on their coursework in professional ethics, alongside their clinical experiences as nurses. Among the participants, some served as head nurses while others worked as bedside nurses.

Context and Sampling Strategy

Using purposeful sampling, we recruited nurses with rich, informed experiences. Participants possessed both a high level of education and substantial nursing work experience. Recruitment was facilitated by the dean of the school of nursing, who identified nurses in the master's degree program and faculty members meeting the inclusion criteria for this study. The inclusion criteria for nurses required enrollment in the master’s in nursing program and a minimum of two years of nursing work experience across various wards. For faculty members, inclusion criteria specified that they be teachers and/or researchers with a focus on nursing ethics. Faculty were invited to participate to further examine and validate the strategies identified by master's degree students for addressing ethical challenges in clinical practice

Ethical Issues Pertaining to Human Subjects

This study was approved by the Ethics Committee of Islamic Azad University (IR.AZMED.REC.1401.1080). The objectives and procedures of the study were explained to all participants, along with measures to protect their confidentiality. Participants’ personal information was kept confidential, and their experiences and perceptions were included in this study without names or identifying details. Written informed consent was obtained from all participants, and the focus groups and interviews were audio-recorded with their permission.

Data collection

Data collection involved focus groups with nurses holding a master’s degree and individual interviews with faculty members. All participants completed both focus group sessions, which were held in a meeting hall at the nursing school and lasted three hours each. An interview guide was utilized to elicit participants’ experiences and perceptions of professional ethical challenges in nursing care, as well as the strategies used or that could be employed to address these challenges. While there were preset interview questions, probing questions were also asked to encourage clarification and further exploration of participants’ responses.

Individual interviews were conducted with the faculty members, each lasting between 60 to 70 minutes. A separate interview guide was utilized during these interviews to gather information about their experiences with professional ethical challenges in nursing care based on their teaching and research backgrounds. The guide also aimed to explore the strategies they employed to address these ethical challenges, as well as their perceptions of effective strategies that nurses can use.

Data Collection Instruments

An interview guide was used during both the focus groups and individual interviews. Examples of questions included: 'What professional ethical challenges in nursing care have you experienced during your working, teaching, and research experiences?' 'How did you manage these ethical challenges?' and 'What strategies would be beneficial in helping nurses address professional ethical challenges?' Probing questions were asked to clarify and further explore responses. Additionally, at the end of the interviews with faculty participants, they were invited to review and comment on the ethical challenges and strategies that emerged from the focus groups with master's degree nursing students.

Data collection continued until data saturation was achieved (17), meaning that no new information or codes were identified at the conclusion of the second focus group and in the last four individual interviews.

Units of Study

In this study, 16 nurses enrolled in a master's degree program participated in the two focus group sessions. The nurse participants were aged 26 to 44 years, with an average of 8.6 years of nursing experience across six different areas of practice. Additionally, six faculty members from various departments of the nursing school participated in individual interviews. All faculty members had extensive nursing experiences and were currently teaching nursing ethics courses. Demographic details of the participants are provided in Table 1.

Table 1.

Sociodemographic and professional details of participants in the study.

Variable	Nurses with a master's degree (n= 16)		Faculty members (n = 6)
	N	%	n	%
Field of practice or academic
Medical-surgical	7	43.75	3	50.00
Emergency	2	12.50
Intensive Care Unit (ICU)	3	18.75
Neonatal Intensive Care Unit (NICU)	1	6.25	2	33.33
Pediatric	2	12.50
Mental health	1	6.25	1	16.67
Gender
Female	11	68.75	3	50.00
Male	5	31.25	3	50.00
Work experience
< 10	13	81.25	1	16.67
≥ 10	3	18.75	5	83.33
Marital status
Married	9	56.25	6	100.00
Single	7	43.75	0	00.00

Data Processing

The first and second authors conducted two focus group sessions with the master's degree students. The first author held individual interviews in each faculty member’s office at the nursing school. The recorded focus group and individual interviews were transcribed verbatim, and thematic analysis was performed by two researchers following Braun and Clarke’s method (2006) (16).

Data Analysis

First, the transcript of each interview was read multiple times. The content was then broken down into meaningful units and coded both manually and using MAXQDA 2020 software. A list of codes related to all transcribed texts was compiled, with each code linked to its corresponding domain. The codes were categorized based on their similarities and differences. Researchers reviewed the themes in relation to the coded extracts and the entire dataset. Ongoing analysis was conducted to refine the specifics of each theme and to generate clear definitions and names for each theme. All authors confirmed the data collection and analysis process.

Techniques to Enhance Trustworthiness

To enhance trustworthiness, the data analysis process was conducted by two researchers who independently extracted and categorized the codes from each interview, subsequently collating them into preliminary themes. The extracted themes were then discussed, confirmed, and agreed upon by both researchers, and presented for validation by the other authors. Participant quotes were selected to enrich the understanding of the themes.

To promote rigor, credibility, transferability, dependability, and confirmability were emphasized (18–20). For credibility, strategies included continuous engagement with participants, such as a second focus group session to ensure data saturation; allocating ample time for both focus groups and interviews; allowing participants to review and confirm the extracted codes (i.e., member checking) and correct them as needed; and providing examples of participants' quotes. For transferability, we examined the experiences and perceptions of nurses working in various hospitals and wards, as well as those of faculty members who were experts in nursing ethics. Dependability was addressed using the peer-checking method, which also helped assure confirmability. For confirmability, two nurses who did not participate in the study compared the results, codes, and categories with their own nursing experiences.

Results

The participants shared their experiences and perceptions of professional ethical challenges and proposed strategies to address these challenges in nursing care. A total of nine categories and 51 subcategories were identified. Figure 1 presents a concept map illustrating the categories and subcategories related to professional ethical challenges and the suggested strategies for addressing them in nursing.

Figure 1.

Concept map illustrating categories and subcategories related to professional ethical challenges and suggested strategies for addressing these challenges in nursing.

1. Defects in patient-centered care

The experiences and perceptions of participants indicated that patient care should be delivered with a patient-centered approach. However, due to a lack of nursing staff and high workloads in hospitals, nurses often find it challenging to provide comprehensive patient care. One nurse shared: “Because of the heavy workload and responsibilities, we cannot participate in patient visits; head nurses or shift managers usually visit patients alongside doctors. The nurse assigned to a patient cannot provide the physician with information about that patient, which may lead to certain aspects of care being overlooked.” [Participant No. 7]

A nursing ethics teacher stated, “There is no patient-oriented care in hospitals; it is, in fact, a treatment-oriented practice. Physicians and nurses perform their respective roles but cooperate less and focus more on the physical treatment of patients rather than on other dimensions of care.” [Participant No. 3]

2. Giving bad news to the patient and family

Delivering bad news to patients and their families emerged as a significant challenge for nurses. According to the participants' experiences, there were no specific guidelines for conveying bad news, and each nurse approached the situation based on their own subjective understanding. One nurse shared their experience, “I did not tell my patient that he had cancer when he asked me about his condition. I honestly did not know how to communicate that or what to say...'” [Participant No. 1]

3. No treatment / no life-supporting treatments

Most participants shared experiences and perceptions regarding the need to make decisions about ceasing aggressive care. They discussed the challenge of not making decisions to discontinue treatment for patients with a poor prognosis for survival. This raised ethical concerns, as the resources and equipment used for these patients could have been allocated to others with a better prognosis. Additionally, legal barriers prevented nurses from making decisions regarding no mechanical ventilation and no resuscitation for patients.

One nurse explained, “We had a newborn with a single [heart] ventricle, for which there was no specific treatment available. The prognosis for this neonate was poor. On the other hand, we had another newborn with simple esophageal atresia, but the bed was occupied, so we could not admit the second neonate.” [Participant No. 13]

Another nurse added, “There was a patient for whom nothing could be done. The doctor gave a verbal order for do not resuscitate, but we could not act on this verbal order because the physician did not fulfill their responsibility of writing it down. As a result, the patient was resuscitated and remained alive for months. In addition to occupying the bed, he received expensive medications, but ultimately died.” [Participant No. 11]

4. Failure to consider patient’s culture in nursing care

Some participants discussed their colleagues' disregard for patients' cultural backgrounds as an ethical concern. A teacher of nursing ethics shared their experience, “My wife was hospitalized, and the doctors indicated there was no hope for her recovery. One of my friends gave me a small amount of soil from Karbala (a holy place). I placed it on my wife’s bed. A nurse who recognized me as a professor at the university said to me, "You are a person of science; it is not right for you to believe in superstitions." I felt disheartened because I had tried to educate and nurture nurses to respect patients’ beliefs, values, and cultures.” [Participant No. 6]

5. Challenges of using new technologies

Based on the participants' experiences and perceptions, there is a tendency to accept and use, and even overuse, new technological methods, even when there is no evidence to support their use. This can lead to increased costs for the patient without their awareness of alternatives. In this regard, one participant stated, “The cast plaster and fiberglass splints yield similar outcomes, but fiberglass imposes a higher cost on the patient. However, system policy and economic benefits for the organization create obstacles to informing patients about this issue.” [Participant No. 9]

6. Health information as an ethical challenge for managing and using large patient datasets

The participants' experiences and perceptions revealed that electronic patient clinical information is beneficial for developing evidence-based practice standards and improving the quality of care. However, there are also risks and challenges associated with it. Easy access to patient information creates a moral and social problem of particular importance. A nurse explained, “If I enter the patient's name or the disease code in the hospital information system (HIS), all patient information registered in the system becomes available. This easy access is tempting, yet I lack the official authority to use this information.'” [Participant No. 8]

7. Nursing in disasters or crises and challenges associated with respecting ethical principles

Based on the experiences and perceptions of nurses who participated in this study, nursing in disaster or crisis situations can challenge nurses' ability to uphold the code and principles of nursing ethics. A nurse explained, “During a bus accident, a large number of patients were brought to the emergency department. I was providing medical treatment to patients with more urgent conditions, but I was forced to leave one patient to attend to another due to the mental stress caused by the second patient’s family.” [Participant No. 8]

8. Defects in palliative care for patients

Whether or not to use sedation and pain medications for patients created ethical challenges for the participants. Some nurses reported instances of over-injecting these medications based on the patient’s request. One nurse shared their experience, “My patient was a 7-year-old child with malignant cancer in the end stage. The entire treatment team knew that she would die. The physician had prescribed Morphine according to her weight and age, but the child's pain was not relieved by the dose. Due to legal requirements, the doctor could not prescribe a higher dosage. I was torn between whether to administer more or a larger dose of medication to the child. On one hand, I didn't want her to suffer, but on the other hand, I was afraid that she might experience apnea.” [Participant No.15]

9. Fear of creating moral distress

Most of the nurses participating in this study, particularly those working in critical care units and novice nurses, faced ethical issues and struggled to make decisions due to fear or a lack of moral courage. Often, they were compelled to take actions beyond their responsibilities, leading to conflicting decision-making. If they failed to complete a necessary task, it could harm the patient; however, if they proceeded, they risked reprimand for acting outside their scope of responsibility. This created moral distress among the nurses. One nurse recounted, “A patient was intubated, but her SpO2 dropped. When the graph was taken, it showed that the endotracheal tube (ETT) was inserted too far. The physician instructed me to pull it out one inch without documenting this in the patient’s file. It was not my responsibility, and there was a risk of the tube exiting. This was the physician's responsibility, and I felt unable to make a decision.” [Participant No.10]

The strategies proposed to address the challenges, based on the participants' experiences and perceptions, were discussed, confirmed, and agreed upon by all participants. Table 2 outlines the suggested strategies for each ethical challenge.

Table 2.

Categories and subcategories of professional ethical challenges and suggested strategies in nursing.

Categories Ethical challenge	Subcategories Suggested strategies
1. Defects in patient-centered care	- Implementing a fundamental change in the health system; - Developing a framework for patient-centered tasks that aligns with ethical considerations; - Revising payment structures for nursing performance to reflect quality of care, rather than just work shifts and hours; - Increasing the nursing workforce and ensuring manageable patient-to-nurse ratios; - Fostering motivation for patient-centered care rather than relying on coercion;
2. Giving bad news to the patient and family	- Establishing a protocol for delivering bad news; - Taking into account individual and social characteristics (e.g., whether the patient is a child or an elderly individual, their family role, and any relevant medical history) - Identifying a family member to inform about the patient's status; - Selecting staff members who can effectively communicate and interact with the patient and their family, particularly those with relevant experience; - Providing context and background before delivering bad news, starting with strengths before discussing negative aspects; - Demonstrating empathy when conveying bad news, ensuring that both appearance and tone align with the message; - Allowing family presence during the treatment process and keeping them informed about the patient's condition to facilitate acceptance of bad news; - Acknowledging and highlighting the efforts of the healthcare team before delivering bad news; - Recognizing that patients may find it more acceptable to receive bad news from the physician, especially in time-sensitive situations when the nurse has limited time for communication; - Confirming the accuracy of the bad news before delivering it; - Tailoring the delivery of bad news to the patient's cultural and religious beliefs.
3. No treatment / no life-supporting treatments	- Advocating for discussions about treatment cessation with the hospital’s ethics committee, which should include doctors from various specialties, nurses, clerics, and lawyers to facilitate appropriate decision-making; - Allowing patients in the end stages of life to make their own decisions while they are still alert, provided it is legally feasible; - Designating a family member or legal guardian to make decisions on behalf of the patient in certain circumstances; - Enabling discussions between the doctor and the family when a patient can survive without hospital equipment but there is no longer hope for recovery, allowing for patient discharge with family consent; - Ensuring the availability of a dedicated space for end-of-life care (e.g., hospice);
4. Failure to consider patient’s culture in nursing care	- Extracting the principles of professional ethics and develop protocols informed by cultural research, such as ethnography; - Establishing a common language between nurses and patients, which should guide the selection and recruitment of nurses who are knowledgeable about the language and culture of the patients they serve; - Recognizing that nursing is an art, allowing for various methods of communication between nurses and patients; - Encouraging nurses to familiarize themselves with different cultures and, when necessary, seek cultural information through communication with cultural informants;
5- Challenges of using new technologies	- Each new technology and treatment present initial challenges; therefore, new methods should be evaluated regarding cost, physical consequences, and prognosis. - Staff providing clinical services should be involved in decision-making regarding the implementation of new technologies. - The use of new technologies must adhere to principles such as the protection of human rights, utility, justice, and financial effectiveness. - Traditional methods that effectively contribute to treatment goals should also be considered.
6. Health information as an ethical challenge for managing and using large patient datasets	- Access to health information should be restricted to ensure that patient information is no longer easily accessible once the patient is discharged. - Each individual should have a health card, similar to a bank card or another secure method, allowing patients to share their information only with those who need it.
7. Nursing in disasters or crises and the challenge associated with respecting ethical principles	- Healthcare systems must be equipped to manage crises, providing education to staff to prepare them for various emergency situations. - Educational curricula focused on disaster nursing should be developed. - Triage should be conducted fairly, ensuring that justice guides healthcare provision; factors that hinder nurses' ability to prioritize during crises, such as security measures and stress reduction, should be addressed. - A designated area for patients' companions should be available in the emergency department to create a safe and suitable environment for nurses. - Spiritual support from the treatment team is essential during disasters and accidents.
8. Defects in palliative care for patients	- Protocols for measuring pain should be established based on the patient's age across different wards. - Each hospital should have a pain specialist, whether a nurse or physician, who can make decisions regarding non-pharmacological and pharmacological treatments. - Nurses should participate in palliative care courses to receive specialized education.
9. F ear of creating moral distress	- Creating a safe environment for expressing ethical challenges and providing education is essential for learning from errors and preventing future issues. - Interdisciplinary meetings between doctors and nurses can help ensure adherence to specific principles and facilitate necessary decisions in ethically challenging situations. - Nurses must have the ability to assertively decline responsibilities that do not fall within their scope. - Access to medical doctors should be ensured for nurses to facilitate collaboration and decision-making. - Personal relationships, such as friendships, in the workplace should not interfere with the performance of professional duties. - Adequate knowledge, confidence, and familiarity with responsibilities are crucial to preventing moral dilemmas. - Promoting peer teaching and sharing experiences related to ethical challenges is important for professional development. - Utilizing scenario-based role play in education for nurses and students can enhance ethical decision-making skills. - Efforts should focus on strengthening the ethical reasoning of staff. - An ethics committee should be established in each hospital to address ethical concerns effectively. - Clear identification of legal accountability for nurses versus physicians is necessary to delineate responsibilities. - Ensuring nurses stay informed about current rules and information through inter-group and intra-group communication is vital for effective practice.

Discussion

The present study aimed to investigate the nurses’ experiences and perceptions of professional ethical challenges in nursing care, as well as strategies to address these challenges. To our knowledge, this is the first study exploring Iranian nurses’ experiences and perceptions of ethical challenges.

The results of this study revealed that the inability to adopt a patient-centered care approach constituted an ethical challenge. This finding is consistent with results from other studies that indicate nurses are under pressure and face daily challenges due to time constraints and inadequate staffing levels, leading to the neglect of a patient-centered care approach (8, 21–23). Doukas et al. suggested that nurses should be aware of how to effectively respond to the detrimental characteristics of the healthcare system in order to provide professional, effective, and supportive care to patients. Nursing education should promote an ethically critical perspective on the current organization of healthcare, aiming to enhance patient-centered care (24). Therefore, improving healthcare system conditions can enable nurses to provide comprehensive patient care, thereby reducing the ethical challenges they encounter.

The obligation to deliver bad news, or the inability to do so, created ethical challenges for the participants. Research has shown that conveying bad news to patients and their families is a significant challenge for healthcare professionals (25, 26). In a study by Griffiths et al. even nurses with years of experience reported difficulties and struggles when tasked with delivering bad news to patients (25), highlighting the need for targeted education in this area (25, 27). While some studies propose structured models for delivering bad news, such as the SPIKES¹ model (25,28) , the findings of this study indicate that nurses often lacked a formal protocol and instead relied on their individual preferences when faced with this situation. Hoseini also found that no specific strategy or protocol was utilized for delivering bad news. It was suggested that incorporating the SPIKES protocol while considering the concept of 'transcendence' when conveying bad news would align better with the cultural and societal contexts of Muslims. In Islam, encountering unpleasant life events is viewed as an opportunity for human transcendence and growth. Muslims believe that during challenging times, they are under the watchful eye of God and that such experiences can lead to spiritual development (29). Therefore, nurses can benefit from being aware of, paying attention to, and respecting the distinct religious beliefs of patients, applying this understanding in their approach to delivering bad news.

The absence of treatment orders in place for patients with a poor prognosis presented an ethical challenge for nurses in this study. This aligns with findings from other studies indicating that most nurses are unable to participate in decisions regarding the resuscitation of premature infants and individuals at the end of life (30,31), and that there is a lack of clear guidance to assist nurses confronting this dilemma (30–32). The findings of this study suggest that establishing a hospital ethics committee, comprising doctors from various specialties, nurses, clerics, and lawyers, is essential to address the ethical challenges associated with patients who are not candidates for treatment. Such a committee would facilitate ethical decision-making regarding no mechanical ventilation and do-not-resuscitate orders. Other studies have also highlighted the importance of discussion sessions, effective communication, role clarity, education, intra-professional collaboration, and consultation with legal authorities, with parents often serving as decision-makers for children (30,31,33). Additionally, considering the legal implications is crucial, as cultural issues and laws vary across nations (30,34). For instance, a review study indicated that euthanasia has been legal in several countries for many years and is currently being considered for legalization in others (35). Caring involves supporting the patient throughout their life until death; therefore, taking a life is fundamentally incompatible with professional commitment (36). In a study conducted in Jordan, a predominantly Muslim country, most participants disagreed with euthanasia, citing the influence of religious and cultural beliefs as their main reasons (37). This finding is consistent with the results of the current study, where euthanasia is seen as contradictory to Islamic laws and the beliefs of the participants.

Failure to consider the patient’s culture in the provision of nursing care was an ethical concern raised by the participants. Consistent with this study, challenges include a lack of education to make nurses familiar with caring for individuals from various cultures (38), as well as differences in values between the nurse and patient, which can lead to distress and difficulty coping (39). Milliken and Grace stated that effective nurse-patient communication is essential for providing optimal care (7). According to Foronda et al. integrating concepts of cultural humility throughout the nursing curriculum can help educators shape learners’ perspectives to better appreciate and value diversity (40). Familiarity with and respect for the spirituality, culture, and religion of patients should be taught in nursing schools and emphasized as a core value throughout nurses' careers.

Participants felt that new technology and challenges related to its overuse represented an ethical concern. Other studies have emphasized that while modern technologies advance medical science, their use should proceed with caution unless comparative studies, such as those comparing them with standard therapies, are conducted (41,42). Additionally, participants in this study indicated that new methods should be evaluated in terms of cost, safety, and prognosis. They expressed the view that if the new technology is of comparable quality to existing practices, the cost benefits must be taken into account.

The emergence and expansion of electronic medical records, along with open access to these records, has raised concerns about patients’ privacy, which was identified as an ethical challenge. Other studies have found that easy access to patient information poses a threat to the identities of the social groups to which patients belong (43) and undermines patient autonomy and informed consent (44). Participants suggested that an e-health card be developed for each patient, allowing access to their information to be based on their will and decision. This approach would help uphold the principles of confidentiality and autonomy for patients.

Many ethical challenges arise during catastrophic events and pandemics (45,46), a concern that participants highlighted. Aliakbari et al. examined the experiences and perceptions of nurses during such events and identified the capabilities needed by nurses. Their study found that familiarity with existing legal requirements, guidelines, protocols, and adherence to rules are essential for effective disaster planning. In this regard, exploring ethical principles related to disasters by analyzing post-accident events and nurses' experiences can be beneficial, as integrating this knowledge into curricula is vital (46). These findings align with this study, where participants emphasized the importance of educating and preparing nurses for ethical challenges during disasters or crises.

Alleviating pain and suffering through the use of medications presented an ethical challenge for nurses in this study. The decision of whether and how to use these medications posed significant ethical dilemmas. In a study by Schildmann and Schildmann it was found that sedation can lead to challenges such as reduced consciousness for the patient, which presents a moral quandary (47). Hold explored the experiences of nurses caring for patients in the end stages of life and found that patients often desired control over their pain, with the fear of suffering prompting some to request death (48). To address ethical dilemmas, nurses can collaborate with colleagues, other healthcare professionals, and ethics committee members, while also considering organizational policies (47,48). Similarly, participants emphasized the importance of establishing pain protocols and educating staff on palliative care to mitigate patients' pain and suffering, thus alleviating this ethical challenge.

In relation to the challenge of fearing moral distress, participants faced duality in decision-making about whether to say no when they were not responsible for a task or to alert others to a problem, such as an error they had made. Other studies have supported these findings, indicating that moral courage is closely linked to patient safety and quality of care, and can enhance decision-making and effective functioning (49,50). Nurses often experience moral distress, which can lead to burnout, as they feel unable to act in accordance with their values, potentially compromising the quality of care (8,51). Strategies for addressing ethical challenges related to weaknesses in moral courage include educating peers, sharing experiences, learning from colleagues’ errors, and collaborative decision-making (51–53). On an organizational level, implementing policies, promoting interdisciplinary collaboration, and holding various meetings can also be effective strategies (7,22,33,51,54,55). These strategies align with the results of this study.

Strengths and limitations

In this study, nurses from various wards shared their experiences and suggestions for addressing ethical challenges, which were further validated by faculty members expert in nursing ethics to gain a more comprehensive understanding and identify practical strategies for nurses. The qualitative approach employed in this research allowed for a deeper exploration of the phenomenon of interest. Additionally, cultural considerations surfaced when examining the experiences and perceptions of nurses, which may vary in different geographic locations.

This study, like other qualitative studies, suffers from some limitations. One limitation is selection bias, as those with strong views about professional ethics in nursing may have been more likely to participate. Additionally, the generalizability and transferability of the findings pose challenges typical of qualitative research. Despite these limitations, the study's findings are significant in encouraging further research aimed at developing policies and protocols. The insights gained also serve to guide nurses in their decision-making when confronted with ethical challenges.

¹- S-setting up the interview, P- assessing the patient’s perception, I- obtaining the patient’ invitation, K- giving knowledge and information to the patient, E- addressing the patient’s emotions with empathic responses and S- strategy

Conclusion

The study findings highlight the ethical challenges that nurses encounter in clinical practice, which include the inability to provide patient-centered care, delivering bad news, making decisions regarding no treatment, insufficient attention to patients’ cultural backgrounds, overreliance on new technology, privacy concerns regarding health information, nursing during disasters, issues in palliative care, and the fear of creating moral distress. Drawing on the experiences and perceptions of the participants, strategies to help address these ethical challenges were proposed. These insights, gathered from nurse participants in Iran, emphasize the cultural, social, and religious factors that contribute to professional ethical challenges in clinical nursing care. Nurses can implement the suggested strategies to navigate ethical dilemmas and mitigate moral distress. Furthermore, the results of this study can provide a framework for healthcare organizations to develop protocols through collaborative efforts and consultations with ethics committees. Future research is essential to further explore the ethical challenges and related strategies

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article

Notes:

Citation to this article: Ghavi A, Valizadeh L, Powers K, Zamanzadeh V. Professional ethical challenges and suggested strategies in nursing: a qualitative study. J Med Ethics Hist Med. 2024; 17: 10.

Conflict of Interests

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Authors’ contributions

AG: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Writing – review & editing. LV: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Supervision. KP: Methodology, Formal analysis, Writing – review & editing, Supervision. VZ: Methodology, Writing – review & editing, Supervision.