Nurses’ adherence to ethical principles – A qualitative study

Abstract

Background

Nursing is regulated by a set of professional standards. Whilst many forms of ethics apply to nursing, the biomedical ethical framework is common, involving autonomy, beneficence, non-maleficence and justice. In healthcare, nurses often encounter ethical dilemmas that require them to navigate conflicting ethical principles. However, how nurses adhere to these principles in such situations is unclear.

Research Aim

To explore how registered nurses adhere to ethical principles when dealing with ethical dilemmas at work.

Research Design

A qualitative descriptive study design.

Participants and Research Context

Between August and December 2023, 21 registered nurses were recruited from a teaching hospital through purposive sampling. Data were collected through semi-structured in-person interviews or online video conferencing. Braun and Clarke’s thematic analysis approach was employed to analyse the data.

Ethical Considerations

Interview participation was voluntary. Written consent was obtained before participation. Participants’ real identities were replaced with pseudonyms. This study was approved by the SingHealth Centralised Institutional Review Board.

Findings

The data analysis developed four major themes and 15 subthemes. The four major themes are “Addressing the dilemma,” “Contemplating the principles and consequences,” “Coordinating for well-informed, ethical decision,” and “Self-reflecting and finding consolation.”

Conclusion

This study explains how nurses navigate and uphold ethical principles when caring for patients to the best of their ability. Fully adhering to ethical principles can be challenging for caring for actively dying patients. Further research can expound on nurses’ experiences and adherence to ethical principles in complex clinical cases.

Introduction

Nurses frequently encounter ethical dilemmas, requiring them to navigate difficult choices between conflicting principles. Whilst the epistemological position on ethics is curated in the academic field, the translation of the nurses' ethical knowing into clinical practice as they become registered nurses becomes less distinct and even as they become experienced nurses. An institution-based health care ethics workshop was curated for registered nurses to revisit their ethical knowledge. This would close their knowledge translation gap in their practice. This study aimed to explore how the registered nurses apply their ethics knowledge and adhere to biomedical ethics principles after attending the workshop.

Background

Nursing, an indispensable pillar in the healthcare domain, constitutes approximately half of the worldwide healthcare workforce. ¹ Nurses have the reputation for their unparalleled dedication to patient care, investing more time in direct patient interaction than other healthcare professionals. ² Their role extends across the entire lifespan, offering holistic care to individuals from birth to end-of-life. A range of guidelines and ethical standards have been instituted to regulate nursing practice. Examples include the American Nurses Association Code of Ethics for Nurses and the International Council of Nurses Code of Ethics for Nurses.^3,4 These ethical codes establish expectations for professional conduct, ethical values, and practice standards, providing a universal ethical framework for nurses. ⁵ Additionally, they serve as guides for nurses to regulate practice.^3,4 In Singapore, nurses adhere to the Singapore Nursing Board Code of Ethics for Nurses and Midwives. ⁶ Embedded within the code of ethics for nurses are the four fundamental ethical principles of the biomedical ethics framework in healthcare practice. ⁷ These principles include respecting patients’ rights to self-determination and decision-making (autonomy), acting in patients’ best interests (beneficence), avoiding or minimising harm (non-maleficence), and ensuring fair and equitable allocation of healthcare resources and benefits (justice).^8,9

In keeping with the biomedical ethics framework, nurses work within its parameters to deliver ethical care that requires critical deliberation. This lends them to ethical dilemmas, requiring them to navigate difficult choices between conflicting principles. These dilemmas arise from the delicate balance between patient autonomy and beneficence, decisions related to life-sustaining treatments, or conflicts of interest among patients, their families, and healthcare providers.^10–12 Other dilemmas include justifying medical resource allocation during the COVID-19 pandemic and preserving beneficence.^13–15 In the pressing need to deliver prompt care, adherence to ethical principles becomes challenging.

Some studies have reported utilising nurses’ ethical codes to develop questionnaires to assess nurses’ adherence to these ethical standards.^16–18 Although nurses’ adherence to ethical codes was optimal in all three studies, there was a significant difference in the nurses’ adherence level when compared with the viewpoints of the patient, caregiver or manager, which inferred that the perceived adherence of nurses to ethical codes is lower than how the nurses themselves evaluate their performance.^16,18 Another study highlighted that healthcare professionals have a strong awareness of the significance of patient rights, but adherence was low in practice. ¹⁹

Several studies suggest that despite facing many challenges in their decision making and interactions with colleagues and patients, nurses remain devoted to their professional responsibility, ensuring that nursing care prioritises patient well-being and prevents harm.^20–22 This accentuates the unwavering commitment of nurses to apply ethical principles and standards while providing holistic care consistently. ²³ Additionally, they steadfastly upheld patient dignity by respecting privacy, providing appropriate treatment and support, and honouring patients’ autonomy in decision-making.^23,24 Apart from engaging patients and their families in nursing care,^25,26 nurses emphasise the significance of teamwork among healthcare professionals. They highlight how teamwork supports ethical care and the effective resolution of challenges by incorporating diverse perspectives and collaborative efforts, ultimately enhancing ethical decision making and ensuring well-coordinated patient-centred care.^13,20,26

Notably, there is a scarcity of similar studies conducted in Singapore. Researching within the local context is essential to understand how nurses navigate unique ethical challenges and adhere to ethical principles when dealing with workplace ethical dilemmas. In one teaching hospital, efforts were made to curate a healthcare ethics workshop to bridge the knowledge translation gap for nurses by covering the foundational knowledge of the biomedical ethical framework, recognising ethical dilemmas, and drawing an ethical decision in clinical cases. As part of the learning evaluation, there was an interest in exploring their knowledge translation to practice, particularly in keeping within the biomedical ethical framework. Using a naturalistic inquiry, the study aimed to explore how registered nurses (RNs) attempted to adhere to ethical principles when dealing with ethical dilemmas at work.

Methods

Study design

A qualitative descriptive study design was used to describe the rich, in-depth understanding of the nurses’ experiences adhering to ethical principles. ²⁷

Participants and settings

The study was conducted in a teaching hospital in Singapore, where over 2500 nurses work across various departments. Purposive sampling was used to select participants from different job positions and work settings to ensure a greater representativeness and diversity of nurses. ²⁸ Inclusion criteria were RNs who had attended the hospital’s healthcare ethics workshop and were agreeable to be audio recorded during the interview. The exclusion criteria were RNs who had not attended the full duration of the workshop or had left the organisation.

Data collection

Data was collected using semi-structured interviews from August to December 2023. The interview guide was created by the Principal Investigator (PI), a certified ethics educator, and a member of the hospital’s clinical ethics committee. Semi-structured interview questions help steer the research within the topic while offering flexibility to delve deeper and adapt based on participants’ responses. ²⁹ Potential participants were invited through a secured communication platform for a one-time audio-recorded interview. Nurses were given a week to respond, and upon expressing interest, arrangements were made for face-to-face meetings. Participants were provided with an information sheet to understand the study objectives and expectations and the opportunity to address their concerns and seek clarification. Written consent, demographic data, and verbal consent to audio-record the interviews were obtained if participants agreed to participate. Interviews were conducted in private meeting rooms, with participants reminded of their voluntary participation rights and assured anonymity using pseudonyms. Sixteen interviews were conducted face-to-face, while five were conducted through an online video conferencing platform as requested by the participants. The average duration of interviews was 27 minutes. The 18th participant reached data saturation. Three additional interviews were conducted to ensure no new insights emerged. ³⁰ In total, 21 participants completed the interview.

Ethical considerations

This study was granted exemption from full review by the SingHealth Centralised Institutional Review Board (CIRB) (CIRB Reference No.: 2022/2503). Participants were recruited voluntarily, explaining their rights to participate and withdraw at any time without negative consequences. All verbal and written informed consent was obtained before commencing the interview. Privacy and confidentiality were prioritised using pseudonyms and secure data storage methods. Any participants experiencing research-related injuries, such as emotional distress, were assured of appropriate psychological support through the hospital peer support service.

Rigour of the study

Lincoln and Guba’s ³¹ approach was employed to examine the trustworthiness of this study, focusing on credibility, dependability, transferability and confirmability. To enhance the accuracy and truth value of data (credibility), the researchers continued the engagement with participants. They performed member checks to ensure that the identified themes and subthemes resonated with them. Additionally, incorporating paraphrasing throughout the interview allowed the researcher and participants to confirm their statements and clarify any subtle meanings that might have gone unnoticed. ³² The researchers maintained an audit trail that detailed the entire research process, ensuring data stability over time and conditions (dependability). Participants were purposively sampled from different departments to ensure representativeness, and their demographic data and study context were also provided to support potential extrapolation (transferability). Objectivity and neutrality of data (confirmability) were addressed by incorporating the collective opinions of all study team members in the data analysis process and verbatim quotes from participants were integrated into the study findings.

Data analysis

Braun and Clarke’s ³³ six-step thematic analysis was employed to identify and elicit common patterns from nurses’ experiences in attempting to adhere to ethical principles amid workplace ethical dilemmas. ³⁴ As data analysis may affect the data saturation, it was conducted concurrently with data collection. The PI and one Co-Investigator (Co-I) transcribed all audio recordings verbatim. Pseudonyms were consistently used throughout data analysis to preserve participants’ anonymity. The Co-I mainly conducted data coding with inputs from the PI with qualitative research experience. The process began with the Co-I becoming immersed in the collected data through transcription, iterative reading, and the creation of initial notes. Initial codes were generated by identifying significant segments and concepts within the transcripts. They subsequently organised them into potential themes, and all relevant data extracts were compiled within these identified themes. The themes underwent multiple reviews by the research team to ensure an accurate representation of the coded extracts and the entire dataset. Subsequently, the themes were refined and adjusted accordingly, with clear definitions and names assigned to each theme and subthemes. Finally, discussions were held with all research team members to validate the identified themes and subthemes. Concurrently, participants were consulted to affirm those themes.

Findings

Twenty-one RNs were interviewed. Their positions varied from staff nurse to nurse clinician (supervisor), and their collective nursing experience spanned 3 to 37 years. The participants were from different departments, with ten from inpatient wards, five from outpatient clinics, three from specialty nursing, two from intensive care units, and one from the emergency department. Participants’ demographics are presented in Table 1.

Table 1.

Participants’ demographics.

No.	Pseudonym	Sex	Current designation	Department	Total nursing experience (Years)	Highest educational level
1	Adam	M	SN	Inpatient Ward	1-5	Bachelor’s Degree
2	Annie	F	ANC	Inpatient Ward	11-15	Bachelor’s Degree
3	Chloe	F	SSN	Inpatient Ward	6-10	Bachelor’s Degree
4	Crystal	F	SSN	Specialty Nursing	6-10	Bachelor’s Degree
5	Dahlia	F	SSN	Inpatient Ward	16 and more	Bachelor’s Degree
6	Gin	F	ANC	Outpatient Clinic	16 and more	Bachelor’s Degree
7	Jane	F	SSN	Outpatient Clinic	6-10	Bachelor’s Degree
8	Jessie	F	SN	Inpatient Ward	1-5	Bachelor’s Degree
9	Joan	F	SSN	Intensive Care Unit	6-10	Master’s Degree
10	KC	F	SSN	Outpatient Clinic	16 and more	Bachelor’s Degree
11	Lisa	F	SSN	Outpatient Clinic	16 and more	Bachelor’s Degree
12	Mel	F	ANC	Specialty Nursing	16 and more	Bachelor’s Degree
13	Missy M	F	SSN	Specialty Nursing	6-10	Bachelor’s Degree
14	Nancy	F	ANC	Inpatient Ward	11-15	Bachelor’s Degree
15	Penny	F	NC	Inpatient Ward	6-10	Bachelor’s Degree
16	Phoebe	F	ANC	Intensive Care Unit	16 and more	Master’s Degree
17	Rose	F	ANC	Outpatient Clinic	16 and more	Bachelor’s Degree
18	Sally	F	NC	Inpatient Ward	16 and more	Bachelor’s Degree
19	Shela	F	SSN	Inpatient Ward	6-10	Bachelor’s Degree
20	Sue	F	SN	Inpatient Ward	1-5	Bachelor’s Degree
21	Tom	F	SSN	Emergency Department	6-10	Bachelor’s Degree

Note. ANC, Assistant Nurse Clinician; F, Female; M, Male; NC, Nurse Clinician; SSN, Senior Staff Nurse; SN, Staff Nurse.

The analysis identified four main themes and 15 subthemes, outlined in Table 2. Each finding is supported by relevant verbatim quotations from participants, identified by pseudonyms.

Table 2.

Overview of the themes and subthemes.

Themes	Subthemes
Theme 1	Recognising patient’s safety is at risk
Addressing the dilemma	Sensing patient’s interest is at stake
Theme 2	Weighing in all the ethical principles
Contemplating the principles and consequences	Seeing things in patient’s perspectives
	Foreseeing consequences if ethical principles were to be violated
	Having an impetus for the next course of action
Theme 3	Obtaining more information from patients
Coordinating for well-informed, ethical decision	Providing information for patient to make an informed decision
	Seeking opinion and information
	Seeking interventions from other healthcare professionals
Theme 4	Reappraising own actions
Self-reflecting and finding consolation	Self-regulating to deliver safe care
	Seeking knowledge
	Learning the morals from past ethical cases
	Making patients’ last days meaningful

Theme 1: Addressing the dilemma

As the interviews revealed, the initial and fundamental step in participants’ adherence to ethical principles amidst workplace ethical dilemmas involved their ability to identify the root causes of these challenges. This pivotal phase necessitated their recognition of situations where patients’ safety was at risk and their interests were compromised.

Recognising patient’s safety is at risk

Participants demonstrated their commitment to ethical principles by keenly identifying situations where patient safety was in danger. This awareness prompted decisive actions, placing the utmost importance on the safety of their patients. A participant recounted an experience where her patient disclosed suicidal thoughts and requested confidentiality. Despite the patient’s insistence on secrecy, driven by genuine concern, she expressed fear of potential harm and was apprehensive about the patient’s safety. Hence, it led her to escalate the matter to the primary doctors for necessary interventions.

“It’s a mixed feeling. Yeah, I'm concerned for the patient’s welfare, whether he would do anything that, you know, may harm himself.” (Missy M)

Sensing patient’s interest is at stake

The participants’ adherence to autonomy was also driven by their ability to recognise situations where a patient’s interest is compromised, leading them to take action to safeguard these interests. In Sally’s case, she experienced discomfort when family members requested non-disclosure of a diagnosis to a mentally competent patient. Similarly, Joan faced a dilemma between providing intravenous hydration and acceding to a patient’s son’s request to cease nutritional support. These instances highlighted the participants’ determination to intervene actively to defend patients’ interests.

“He's not confused and everything...But the wife and daughter spoke to us, asking us not to disclose (diagnosis)...I felt very bad.” (Sally)

“We don’t feel good when we nurse the patient and we see that he has this need, but we’re unable to meet that need.” (Joan)

Theme 2: Contemplating the principles and consequences

Given the above, several nurses demonstrated their commitment to ethical principles through a deliberate phase of contemplation characterised by thoughtful considerations before taking action to address ethical challenges. This introspective process enabled them to delve into the complexities of ethical principles governing their practices and align their decisions with the biomedical ethics framework. During this phase, some participants were inspired by their colleagues to take action to uphold ethical principles.

Weighing in all the ethical principles

Participants acknowledged that every decision had its potential benefits and harms. They carefully assessed the potential impact of each ethical principle on the decision at hand, trying their best to serve ethical care to patients. This was evident in Crystal’s encounter, in which the terminally ill patient she was assisting perceived that receiving fewer blood transfusions was harming her, even though she had received 15 pints of blood over 2 weeks without significant improvement.

“I would say between the four, the autonomy, the beneficence, doing no harm and justice, I would say beneficence will be the utmost (priority). Then, autonomy will be last.” (Crystal)

Seeing things in patient’s perspective

Nurses considered the principle of non-maleficence by adopting patient perspectives, which facilitated ethical decision-making. They empathised with and comprehended situations from the patients’ viewpoints. This approach not only cultivated compassionate care that prioritised patients’ needs and well-being but ensured that ethical considerations guided their practice, fostering a comprehensive standard of patient-centred care.

“If you put yourself in the patient's shoes and somebody else nurses you (and) does that (harmful) thing to you, you will be concerned.” (Shela)

“If you put yourself having a sore on (your) back (from) sitting (too) long, it's not very comfortable...So it's got to do with (a) righteous (act) and conscience… to have that courage...to put the patient on the bed first.” (Gin)

Foreseeing consequences if ethical principles were to be violated

Participants shared that engaging in a thoughtful process guided their ethical decision-making by foreseeing the repercussions of their actions. This allowed them to anticipate and weigh potential outcomes. Adam described his way:

“I think about the consequences and (how) I can explain my decision. I have to make sure that whatever I do, I can justify.” (Adam)

Having an impetus for the next course of action

Several participants were fortunate to have colleagues who played a pivotal role in shaping their ethical behaviours. Their input stimulated their thinking and allowed them to model ethical conduct. In Mel’s experience as an enrolled nurse, she found herself undertaking tasks beyond her job scope, but a colleague intervened, making her realised the impropriety of her actions. Similarly, Lisa was inspired by a plastic surgeon who prioritised patients’ needs over financial gain, influencing her to emulate his ethical behaviours.

“So my friend (asked) ‘How do you see yourself in five years? (Continue) working in this clinic?’... ‘Do you think you're allowed to do the same thing?’…Then, I was like ‘Err, err I don’t think so.’” (Mel)

“I'm very thankful that I met my first boss who’s a very ethical person. I’ve learned to practise the ethics that he had taught me.” (Lisa)

Theme 3: Coordinating for well-informed, ethical decisions

This theme emerged as participants recognised the necessity of collaborative decision-making. They acknowledged that well-informed ethical decisions could not be made in isolation; instead, the active involvement of patients and other healthcare professionals was crucial.

Obtaining more information from patients

During ethical dilemmas, participants articulated their proactive approach of acquiring additional information from patients to enhance ethical decision-making. This involved fostering open communication to gain insights into patients’ values, preferences, and concerns. Crystal’s experience exemplified this, as she communicated with her patient by discussing the goals of care in case the blood transfusion proved ineffective.

“We communicate with her. Then we do anticipatory planning (in the event) blood transfusion does not work.” (Crystal)

Providing information for patient to make an informed decision

Participants shared about respecting patients’ autonomy. This entailed providing comprehensive information and engaging patients in the decision-making process. Several participants demonstrated this commitment by discussing treatment options with patients, including the associated risks and benefits. By empowering patients to make informed decisions, these nurses underscored the fundamental role of patient autonomy in healthcare decision-making.

“We respect her (and) her decision because it's an informed decision. We tell the advantage(s) and the side effect(s) of the dialysis. She knew everything.” (Rose)

Seeking opinion and information

When participants encountered ethical dilemmas, they sought advice from their colleagues, fostering collaborative thinking and consensus building. This approach allowed them to benefit from diverse perspectives, ensuring that ethical principles were upheld through shared understanding.

“We discuss with the team and seek opinions of my seniors. Then from there, we think through and as a team, we come to a consensus.” (Penny)

Furthermore, participants took the initiative to understand and address the dilemma by seeking additional information. In Crystal’s situation, she conducted a literature search to explore the implications of receiving excessive blood transfusion within a short time frame, reflecting a commitment to evidence-based practice, and fulfilling her duty of care.

“I also (did) my own background check (to find out what happened when) you have too many blood transfusions within a short time frame. You will have what we call, transfusion reaction allergy.” (Crystal)

Seeking interventions from other healthcare professionals

At times, participants experienced challenges in fulfilling the principles of beneficence and non-maleficence for patients when interventions beyond their expertise were needed. For instance, one participant, recalling her time as a junior nurse, was worried about a deteriorating patient and continuously sought the doctor’s assistance to manage the situation. By seeking intervention from other healthcare professionals, nurses demonstrated the importance of collaborative teamwork and acknowledged the value of multidisciplinary collaboration in addressing complex healthcare needs.

“So basically, the patient (was) very ill (during my) night shift. So, I kept asking the doctor to do something, but he's not doing anything. Then I was very worried about patients’ condition. But (at) that time, I was very new, I did not understand EOC (extend of life care). Now, I can understand.” (Sue)

Theme 4: Self-reflecting and finding consolation

This theme surfaced as participants began to mitigate their ethical dilemmas by consistently engaging in self-reflection, regardless of the outcome of their actions. Additionally, they sought closure when unable to adhere to ethical principles strictly.

Reappraising own actions

Participants engaged in reflective contemplation of their decisions by revisiting their actions and assessing their alignment with ethical standards. By reappraising their actions, nurses ensured they remained committed to ethical principles. Mel stressed that if her actions deviated from ethical standards, she would reflect on them and experience feelings of guilt.

“If at the end of the day, I don't do anything right, I always recall what I did (and) I will feel guilty. Then, I cannot sleep.” (Mel)

Self-regulating to deliver safe care

Participants’ recognition of the demanding nature of their profession and its potential negative impact on personal well-being illustrated their commitment to ethical principles, especially those concerning patient safety and care quality. By implementing self-regulating strategies such as taking breaks and seeking peer support, nurses prioritised their well-being to ensure they could deliver safe and compassionate care. Prioritising self-care and resilience-building enabled nurses to fulfil their professional responsibilities effectively and ethically, highlighting the connection between personal well-being, ethical practice and quality of care.

“This job is quite demanding. So, if at any point of time I feel that my personal life is very affected, then it's safer for me to take a break from my work. Because our work involves a lot of legal issues, you know life and death.” (Jane)

“It can really eat into you in that sense, or maybe affect you emotionally. And yeah, personally. Taking a step back and talk to (your) peers… finding people to talk to is important.” (Phoebe)

Seeking knowledge

Participants, similar to Mel, upheld ethical principles by actively seeking knowledge. This proactive approach ensured their actions aligned with their professional capacity and ethical standards. This commitment to ongoing education reflected a proactive stance towards professional development and ethical practice, benefiting nurses and the patients under their care.

“So I only do things within my capacity, means I really have to read up and know my nursing knowledge.” (Mel)

Learning the morals from past ethical cases

Participants emphasised the importance of learning from past ethical cases. Reflecting on her nursing journey, Sally acknowledged making mistakes but highlighted the importance of turning those experiences into learning opportunities. As a supervisor, she fostered a culture of accountability within her team by encouraging them to take ownership of their mistakes. This approach promoted continuous improvement and responsible decision-making, enhancing patient care and safety through ethical reflection and learning.

“Who doesn't make an error? I say, (do) you think throughout my 16 years of nursing life, I (have) never made any mistake? No! I have tonnes of mistake(s). I always tell them (Sally’s staff), don’t ever hide (your mistakes) because one day, this thing will come back to you.” (Sally)

Making patients’ last days meaningful

Three participants expressed difficulty in strictly adhering to beneficence when dealing with actively dying patients. They sought solace when their actions strayed from doing good for the patients. Sally faced the dilemma of not disclosing a diagnosis to a rational long-stay patient at the family’s request. As the patient had a prognosis of less than a month, she offered his favourite sweets to alleviate his mood while meticulously monitoring his blood sugar levels due to the patient’s diabetic condition. In Joan’s narrative, despite the son’s request to discontinue all nutritional support, she ensured the comfort of her uncommunicative, dying patient by keeping his mouth moist. Similarly, Tom recognised constraints in treating dying patients and prioritised their comfort, exploring options such as low-dose intravenous fentanyl in consultation with doctors.

“I know he has diabetes, but I do understand that he's already in the last stage (of his life) ... So, I will buy gummy sweets. I just want to make him feel better, and you know, he’s always been so depressed...Of course, I know my limit(s). I will check his latest blood sugar.” (Sally)

“By doing what we can, like wetting the mouth and all, it’s like beneficence, like doing good for the patient. Helping the patient (to) be comfortable.” (Joan)

“For patients (with) ROSC (return of spontaneous circulation), you know that they’re brain dead, but they still have pulse and spontaneous breath(ing). Sometimes, I would ask the doctors if they would want (to prescribe) IV Fentanyl...to keep them comfortable...I mean this is the least I can advocate for the patient.” (Tom)

Discussion

This study explored how RNs adhered to ethical principles when dealing with ethical dilemmas at work. The findings from the interviews suggested that participants navigate through four distinct phases, representing the major themes of this study. The subthemes shed light on their approaches to upholding ethical principles for each theme.

Dealing with ethical dilemmas is a crucial starting point for nurses in their commitment to ethical principles in the workplace. ³⁵ This initial step involved identifying situations where conflicting values or principles create uncertainty, clearly focusing on patient safety and interests. This emphasis on patient safety was the cornerstone of ethical decision-making for nurses, marking the first phase where ethical principles were actively considered and applied.^36,37 By prioritising patient safety and acknowledging potential threats to their well-being, nurses set a foundational tone for subsequent ethical actions. This underscores the significance of understanding nurses’ challenges as the first step in addressing ethical issues. ³⁸

The study participants thoroughly considered all ethical principles, empathised with the patient’s perspectives and foreseen the consequences of ethical violations. Similar practices of healthcare professionals weighing conflicting principles in discussions about ethical challenges were identified in other studies.^39,40 Another study highlighted that gaining insight from the patients’ perspectives leads to a better understanding of their experiences, empowering healthcare professionals to provide more patient-centred care.^41,42 Foreseeing the repercussions of ethical breaches enabled nurses to make informed choices, fostering a culture of accountability and responsibility within the nursing profession. A significant discovery was participants recognising the influential role of their senior colleagues in their nursing journey, highlighting role models in shaping ethical behaviours. ⁴³

The participants acknowledged that making well-informed, ethical decisions involved patients and healthcare professionals. This aligned with another study highlighting the importance of including healthcare professionals, patients and their families in decision making. ⁴⁴ This underscored respect for the patient’s autonomy and self-determination. The participants honoured patients’ autonomy by involving them in decision-making and providing necessary information for informed choices. Patient involvement in decision-making was crucial as it enabled healthcare professionals to incorporate patients’ values, preferences and needs into their care.^45,46 Apart from gathering information to comprehend ethical challenges, participants sought advice and assistance from their colleagues. They shared that, at times, to adhere to principles of beneficence and non-maleficence, they required the expertise of doctors, significantly when their patients were deteriorating. This collaborative approach echoed the importance of teamwork and collaboration in providing holistic and safe care to patients.^13,20

The participants tried to keep close to the ethical principles by consistently engaging in self-reflection and seeking solace when needed. Reflecting on past behaviours and experiences allowed them to learn more deeply. ⁴⁷ This helped them to identify any mistakes or lapses in ethical judgements and align their actions with ethical standards. Self-regulation also served as a proactive strategy for managing nurses’ negative emotions, providing immediate relief and fostering sustained adherence to nursing ethics. ²² The participants could recognise their limits and sought ways to manage stress, whether through confiding in others or taking a break from work. ⁴⁸ They emphasised the importance of pursuing knowledge to understand ethical boundaries better. This enabled them to conduct their professional responsibilities within the established ethical framework. ⁴⁹ In addition, it was found that participants employed a strategy to uphold ethical principles by leveraging their past experiences as learning opportunities. They used this method to cultivate a culture of accountability by taking ownership of their mistakes and fostering transparency within the workplace.

Most of the participants’ narratives described their best to adhere to biomedical ethics, except for three participants who expressed difficulties in strictly adhering to beneficence outweighed self-determination in caring for actively dying patients, like in other studies.^50,51 Another narrative was disregarding autonomy and justice when a patient’s family instructed not to disclose the patient’s diagnosis and not to consider his views of treatment. Despite these, they continued providing compassionate care when possible. These conflicts caused the participants to seek consolation by uplifting the patient’s mood and ensuring comfort during the final phase of their lives. Insights from the interviews and research findings suggest that nurses exemplify ethical principles akin to planting a seed, as articulated by one of the participants. This metaphor means that although nurses comprehend ethics and its virtues, applying and integrating them into practice requires time and nurturing.

Study strengths and limitations

The study’s strength is the variation sampling, involving nurses from different departments and job positions. The various experiences and perspectives enrich the depth and breadth of this study. Second, the recruitment took place one to 3 months post-workshop, giving the participants some period for exposure to clinical areas before sharing their narratives of adhering to ethical principles. Regarding study limitations, the sample was recruited from one teaching hospital with its own values and systems for rendering healthcare services, which may differ from other hospitals. The study also focused solely on RNs, which could impact their generalisability to other job positions, such as enrolled nurses.

Implications

The study findings highlight the nurses’ ability to recognise their ethical dilemmas and identify conflicting ethical principles. This demonstrates their capacity to apply knowledge in practice, underscoring the importance of ongoing learning for nurses in a hospital environment. Encouraging nurses to contemplate, engage in self-reflection, and seek consolation is essential for promoting safe care delivery within the healthcare organisation.

Conclusion

Nurses spend the most time with patients. Their work experiences and ethical knowledge give them a sense of attentiveness to delivering care within the biomedical ethical framework. Nurses must continue to have a voice as moral agents for the patients under their care. Similarly, their voices must be heard in their struggles to adhere to ethical principles in complex cases.

ORCID iD

Valery Wong https://orcid.org/0009-0005-0814-5815