Factors Affecting the Formation of Ethical Conflicts in the Education of Nursing Students: A Meta-synthesis Study

Abstract

Background:

Ethical conflict is an integral part of the clinical environment, and nursing students face similar conflicts. Identifying these conflicts aids their educational development. This study aimed to explore factors influencing the formation of ethical conflicts in nursing students during their training.

Materials and Methods:

This qualitative review and meta-synthesis, conducted in Iran in 2024, followed Sandelowski and Barroso’s seven-step model. A comprehensive literature search (2000–2023) was performed to identify qualitative studies on nursing students’ ethical conflicts in educational settings. Databases searched included PubMed, Scopus, Web of Science, and ProQuest, alongside the search engine Google Scholar, using keywords such as ethical conflict, clinical education, and nursing students. The identified studies were assessed using the Mixed Methods Appraisal Tool (MMAT).

Results:

From 3469 primary studies, 11 articles showed that the most important factor was the professional-educational conflict in an incompatible environment. In this study, we found three main factors related to professional ethics, organizational interactions, and care skills, and different subgroups were identified in each main category.

Conclusions:

This meta-synthesis identified ethical conflicts in educational environments as a significant factor among healthcare providers. The findings emphasize the need for a deeper investigation of ethical conflicts, particularly in clinical education, using both quantitative and qualitative methods. Additionally, it is recommended that educational programs focus on ethical decision-making, improve organizational support for interactions, and conduct regular ethical assessments to create a more supportive professional environment and ultimately enhance patient care.

Introduction

Ethical conflict is when people face multiple ethical demands or obligations that conflict with each other and make it difficult to choose among options without compromising their values or the wellbeing of others.[1,2] This concept is different from an ethical dilemma, which describes a situation with only two options that a person must choose between. In fact, when faced with an ethical conflict, a person is faced with several options, each of which has a different ethical weight.[3] Understanding and managing ethical conflicts is critical to maintaining professional integrity and ensuring that healthcare providers act according to their ethical duties and obligations. Recognizing ethical conflicts enables people to address these conflicts proactively; ask colleagues, trainers, or organizational resources for guidance; and make informed decisions that match their ethical values and serve the interests of patients and society.[4] The prevalence of ethical conflicts in nursing education is a complicated issue.[5] No study has investigated the exact prevalence of ethical conflicts in nursing student education. Nevertheless, ethical tension, which is a kind of ethical conflict and in some way its result, has received much attention in nursing education. Studies indicate that a significant number of nurses and nursing students experience ethical tension with a reported frequency of 48% in students. This tension has the potential to adversely affect the wellbeing of nurses and the care provided to patients.[6,7,8,9] Ethical issues in nursing education are also prominent, and the importance of ethics education to answer ethical questions in the process of patient care and ethical decisions is always emphasized.[9] Nurses facing ethical dilemmas and moral tension may struggle with conflicts between their values and professional responsibilities, which can affect their performance and overall wellbeing.[8]

Ethical conflicts are an inherent element in the education of nursing students that exist in both clinical and classroom education.[10] The recent studies show that there are ethical conflicts in various fields of undergraduate nursing programs, including ethics education, bioethics, organ transplantation, and tissue care in certain situations, and it is one of the factors affecting dropout among students.[11,12] Evaluating ethical conflicts in nursing education is very important due to its impact on patient safety and quality of care. Understanding and dealing with these conflicts is necessary for the professional growth of nursing students and providing high quality ethical care.[10,13] Furthermore, it is important to prepare nursing students to effectively navigate ethical conflicts in both educational and clinical settings as these experiences significantly influence their future practice.[11]

Despite the existing body of literature, there is a significant gap in current knowledge about ethical conflicts in nursing student education. While individual studies have provided valuable insights, there is a need to aggregate and integrate the findings of these studies to achieve a comprehensive understanding of nursing students’ ethical conflicts. Therefore, it is necessary to conduct a meta-analysis to integrate the results of current studies and provide a complete picture of the existing knowledge on this topic. A meta-analysis can systematically analyze and integrate the findings of previous research, identify important themes, and fill gaps in knowledge. This approach facilitates a deeper understanding of the multifaceted nature of ethical conflicts in nursing education and thereby informs educational practices, curriculum development, and policymaking in this area. This meta-synthesis enables the identification of common themes, changes, and areas that must be further investigated and contributes to the advancement of ethical education in nursing. The purpose of this study was to conduct a meta-synthesis of existing research on ethical conflicts in the education of nursing students, to identify common themes and diversity in the experiences of nursing students, and to provide recommendations for promoting ethical education in nursing.

Materials and Methods

This study used a systematic meta-synthesis approach to analyze and integrate existing qualitative research findings on ethical conflicts in nursing student education. Systematic meta-synthesis is a method of examining what is known and trying to develop it. The data analyzed in this method are the findings of previously conducted qualitative studies.[14] Therefore, a meta-analysis provides new findings and interpretations that are not mentioned in any of the original papers. Thus, it provides researchers with a way to discover new and fundamental themes and metaphors using a systematic approach. The result of this approach is to develop knowledge and provide a comprehensive picture of the structure.[15] This study was conducted in Iran in the beginning of 2024, following the 7-step model proposed by Sandelowski and Barroso[16] including: 1-Setting research questions, 2-Systematic examination of texts, 3-Searching and selecting appropriate sources, 4-Extracting information from sources, 5-Analyzing, and combining findings, 6-Quality control, 7-Presentation of findings.

The research question that guides this meta-synthesis is: What ethical conflicts do nursing students encounter during their education? The focus was on combining the findings of previous qualitative studies that have investigated this phenomenon. The present meta-synthesis included a comprehensive search of electronic databases as well as a manual search of relevant journals and reference lists using EndNote (version 20; Clarivate Plc, Philadelphia, PA, USA). To use all available sources and eliminate the risk of losing valuable data, gray literature was searched in addition to articles published in reputable journals. The search was performed on June 5–7, 2023, with published dates between January 2000 and January 2023. The Guidelines for Reporting Systematic Reviews and Meta-Analyses (PRISMA) were followed to ensure study quality and transparency. A comprehensive search strategy was used to identify relevant articles on ethical conflict in practice education among nursing students. The search was conducted in several databases including PubMed, Scopus, Web of Science, and ProQuest. Searches for each database were based on keywords related to nursing, education, clinical education, educator, ethical conflict, and moral conflict based on MeSh. The process of extracting related articles is demonstrated in Figure 1. Studies were included if they met the following criteria: (1) published in English, (2) conducted on nursing students in any educational field (e.g. undergraduate, graduate), (3) focused on ethical conflicts experienced by nursing students, (4) used qualitative or mixed-method research designs, and (5) were published between 2000 and 2023. Studies were excluded if they were not peer-reviewed, were not original research, or did not meet the standard criteria. Two members of the research team independently reviewed the titles and abstracts of identified studies to determine their eligibility for inclusion. Full-text articles were reviewed for studies that met the inclusion criteria. Data extraction was performed using a standardized form that included study characteristics, the number of participants, the research method, and ethical conflicts experienced by nursing students. Extracted data were combined using a thematic analysis approach to identify common themes and variations in nursing students’ experiences.

Figure 1.

Article entry steps based on the PRISMA2023 checklist

The Mixed Methods Appraisal Tool (MMAT) is a critical appraisal tool that permits the appraisal of the methodological quality of five categories of studies (qualitative research, randomized controlled trials, nonrandomized studies, quantitative descriptive studies, and mixed methods studies), and rates the studies as high, moderate, and low in quality.[17] For data extraction, summary tables were developed that included information regarding the authors, research purpose, methods, sample size and sample characteristics, data collection process and methods, main findings, strengths and limitations, and conclusions. For data synthesis, the findings were collated into raw codes and categories that included ethical challenge issues and nursing student education to develop more meaningful interpretations and themes. This analysis was independently performed by two reviewers, and the third reviewer verified the themes with the extracted information. Extracted data were analyzed using a meta-composite approach to identify common themes and variations in nursing students’ experiences. This synthesis included thematic analysis of extracted data, followed by a meta-analytic approach to identify relationships between themes and subthemes. The research team reviewed the included studies multiple times to fully understand the data and context of each study. Finally, the results were assessed by the team.

The findings and results sections of each study were coded and categorized to identify key concepts and metaphors related to ethical conflicts. Similarities and differences between the studies were identified. Identified concepts and metaphors were analyzed across studies by constantly comparing them to achieve mutual understanding and translation of meanings. The translated concepts were integrated into broader themes that reflect the ethical dilemmas faced by nursing students. Relationships between themes were examined. The final synthesis was presented as an integrated interpretation and explanation of ethical conflicts, supported by descriptive evidence from original studies. Findings were presented using a mixed narrative approach, including tables and figures to show themes and key changes. MAXQDA software (version 2024; VERBI Software GmbH, Berlin, Germany) was used to organize codes and classes.

Ethical considerations

This manuscript is free of plagiarism. The results of the analysis were completely honest. Any data fabrication has been avoided. This article does not contain human participants. All methods of this research were carried out in accordance with the relevant guidelines and regulations in line with the doctoral dissertation in nursing and have been approved by the Ethics Committee of Baqiyatallah University of Medical Sciences (IR.BMSU.BAQ.REC.1401.052).

Results

After the initial identification of 3469 articles from various databases, 1266 duplicates were removed. Subsequently, 2170 articles were screened based on titles and abstracts, and 22 were excluded after full-text review. Ultimately, 11 studies that met the inclusion criteria were selected for inclusion. The main results and characteristics of the reviewed studies are systematically presented in Table 1. In this research, first, all the codes were extracted from qualitative articles; then, according to the concept of each code and based on their similarities and differences, these codes were categorized into similar concepts. In this way, the themes of the research were formed [Table 1].

Table 1.

Summary of the results of studies in the field of moral conflict in nursing education

Code	Authors	Years	Country	Purpose of study	Research tool/Methods	Number of samples	Findings
1	Cameron et al.[38,40]	2001	United States	Examining nursing students’ experience of ethical problems and use of ethical decision-making models	Interview	73 senior nursing students	Ethical problems involving persons with HIV/AIDS Harmful behaviors Quality care Managed care Rationale for the resolution Quality of life/death and dying Disagreement with clients’ behaviors Conflict about the right thing to do Medications and treatments Force-feeding Nursing students’ experience of ethical practice
2	Ramos et al.[41]	2015	Brazil	Ethical conflicts and reflection process in undergraduate nursing students	Focus Group Discussion (FGD)	50 nursing students	Educational procedure The domain of human rights and individuals’ socially conferred rights Clients’ right to trust Professional nursing ethics
3	Sinclair et al.[42]	2016	New Zealand	Recognizing the unique problems and conflicts experienced by nursing students to develop ethical reasoning and competence in nursing students	Open ended Questionnaire	373 nursing students	Bullying End of life care Lack of support and supervision available to nursing students Acts of dishonesty
4	Snopek et al.[41,43]	2016	Czech Republic and Slovakia	Identifying the most common professional dilemmas that nursing students face, how students react, and whether they show moral courage when faced with such situations	Open-ended Questions	39 nursing students
5	Escolar Chua and Magpantay[7]	2019	Philippines	Examining the experiences of moral tension faced by undergraduate nursing students in community health nursing.	In-depth interviews	14 nursing students	Feeling helpless amidst encountered distressing situations Conflicting ideals of healthcare professionals Divergent health ideals versus nursing students
6	Mehdipour Rabori et al.[6]	2019	Iran	Identifying and evaluating ethical conflicts that nursing students face during their clinical training	Mixed Method (interview and questionnaire)	37 nursing students	Lack of authority Low attention of nurses to the patients’ preferences Inadequate support
7	Bremer and Holmberg[38]	2020	Sweden	Description of ethical conflicts in patient relationships experienced by ambulance nursing students during their clinical studies	Written Examination	69 nursing students	Inadequacy in accommodating patients’ needs Uncertainty about and disregarding the patient’s autonomy Inadequate access to patient narratives Unsure about the patient’s decision-making ability Conflicting assessments of the patient’s best interest Patient refusal to co-operate The patient’s limited ability to communicate Lost reciprocal trust Significant others are acting as the patient’s surrogate A lack of support in the student’s own assessment Lost communication Decisions are questioned by significant others Significant others are making the patient insecure Powerless while confronting the patient’s suffering Disruption to patient focus A deficient conversation Absence of trustful relationships Forced to prioritize between the patient’s needs Influenced by prejudices and aversions
8	Araghian Mojarad et al.[39]	2021	Iran	Explanation of nurses’ experiences of moral conflicts in medical educational centers of Mazandaran University of Medical Sciences	Interview	22 nurses	Lack of skill in giving bad news Personnel Shortage Injustice by authorities High expectations DNR order Ineffective communication Education without good communication Dilemmas between rules and ethics Personnel preference in futile jobs Organization related factors Ignoring personnel faults Forgiving violence Being an educational institute Rejecting legal risks
9	Feeg et al.[44]	2021	United States	Discovering students’ and professors’ personal experiences of ethical dilemmas in nursing education and clinical practice	Interview	2200 nursing students and professors	Failure of care-impact on patient Patient and family demands Student integrity
10	Palacios-Cena et al.[45]	2022	Spain	Exploring ethical dilemmas and ethical conflicts of final-year nursing students in the COVID-19 pandemic in Spain	Semi-structured interview	18 nursing students	Difficulties in providing end-of-life care Coping with patient death Coping with patient triage
11	Schneider et al.[46]	2022	Brazil	Getting to know the experiences and understanding of nursing students and professionals about ethical issues and decision-making in hospital nursing practice	Questionnaire With open ended questions	20 nurses and 30 nursing students	Discussing matters in front of the patient Disregard for beliefs and values Harm to another person Affront to principles and rules Disrespect of rights Respect for life, individuality, beliefs The professional disrespecting the patient Lack of interest

The findings of meta-synthesis were categorized into eight subcategories and three categories. The main categories included factors related to professional ethics values, organizational interactions, and caregiving skills [Table 2].

Table 2.

Classification of codes and classes related to conflict situations obtained from studies

Codes selected article	Subcategories	Categories	Theme
[6,39,40,42,46]	Issues related to ethical standards	Factors related to professional ethics values	Professional-educational conflict in incompatible environment
[7,38,40,41,44,46]	Legal issues
[7,38,39,40,42,43]	Issues related to values, beliefs
[38,40,41,43,44,46]	Issues related to educational organization	Factors related to Organizational interactions
[7,38,39,40,42,43]	Issues related to communication and relationships
[38,40,41,43,44,46]	Issues related to skill weakness in the student	Factors related to Caregiving skills
[6,38,40,42,43,45]	Issues related to patient care and dignity
[7,38,45]	Issues related to patient autonomy and decision-making

Discussion

The present meta-synthesis study aims to find the key factors causing ethical conflicts among nursing students during clinical training. It revealed factors that greatly impact learning and the quality of patient care. The most important component extracted from these studies was the professional-educational conflict in an incompatible environment which was categorized into factors related to professional ethics values, organizational interactions, and caregiving skills. Each of these includes different subcategories that highlight the multifaceted nature of ethical issues in nursing education.

Factors of professional ethics values

Recent developments in healthcare education organizations have raised concerns about adherence to professional ethical values.[18] These challenges often stem from a lack of clarity and consensus regarding ethical principles and their practical application in clinical environments. Ethical issues related to legal and professional standards highlight the gap between theoretical knowledge and practical implementation. For instance, Jingwei et al.[19] have indicated that despite nursing students’ moral immaturity, higher scores in professional values are associated with more mature ethical behavior and stronger abilities to effectively address ethical dilemmas. A study by Mehdipour Rabori et al.[6] revealed that nursing students often pay insufficient attention to patients’ preferences, reflecting a gap in understanding patient-centered care. Similarly, the research by Arabameri et al.[20] emphasized that, from students’ perspectives, maintaining patient confidentiality and clinical competence are critical components, while pragmatism and professionalism are deemed less significant. Furthermore, it was noted that increased professional experience could diminish the perceived importance of ethical values.

Tang et al.[21] underscore the importance of enhancing ethical sensitivity among nursing students, arguing that barriers to professional ethical values can hinder the development of ethical decision-making skills. Frequently, theoretical ethical principles fail to translate effectively into clinical settings, resulting in difficulties in identifying and managing ethical dilemmas, ultimately weakening ethical decision-making capabilities.[22,23]

A negative organizational culture that fosters unethical behaviors can undermine students’ ethical commitment.[24] Another significant barrier is the lack of ethical leadership. Research shows that leaders who clarify ethical expectations, make decisions based on ethical principles, and support ethical programs can positively influence organizational culture.[25]

Additionally, work pressures, inadequate support, and high-stress environments are recognized as obstacles to implementing professional ethical principles. These factors may impair students’ ability to adhere to ethical standards.[26]

Factors of organizational interactions

Organizational interaction barriers may include structural and systemic conflicts within healthcare environments, impacting nursing students’ ability to navigate ethical dilemmas. These barriers often encompass communication challenges, interpersonal relationships among team members, care practices, the quality of care, and patient dignity. Various studies support the existence of such obstacles. For example, research highlights the impact of the organizational ethical climate on reporting nursing errors[27] and the barriers to learning healthcare-associated infection prevention and control.[28]

Similarly, Saara Kertu and Nuuyoma[29] and Alamri and Alhamidi[30] explore trust-building conflicts and overcoming communication barriers with patients, indicating that patient-related challenges remain a significant concern for nursing students. Additionally, inefficient communication channels within organizations pose another obstacle. When students struggle to connect with their supervisors and mentors, they are less likely to voice ethical concerns, leading to greater difficulties in addressing ethical conflicts.[31] On the other hand, knowing that nursing managers and clinical nurses play a crucial role in conflict management, the correct handling of conflicts among nursing students, along with open communication and active engagement between students and clinical staff, can lead to positive changes in students’ attitudes.[32]

Factors related to care skills

Patient-related barriers, particularly ethical issues stemming from nursing students’ skill deficits, patient care and dignity, as well as patient autonomy and decision-making, are prevalent in clinical environments. These challenges underscore the complexity of respecting patient autonomy while ensuring quality care, a conflict well documented in the literature. For instance, Nezamzadeh et al.[33] identified moral immaturity in nursing students as a key aspect of their lack of ethical competence. This issue arises from a lack of clinical skills, insufficient supervision, and the gap between theory and practice. Due to their inexperience, nursing students are not fully prepared to manage ethical challenges in clinical settings.[33] Dziurka et al.[34] explored the ethical dilemmas and conflicting emotions nursing students faced during the COVID-19 pandemic, highlighting the difficulty in balancing patient care with personal and professional responsibilities, which can impact care quality.

Dignity-based care, as a fundamental human right, emphasizes honesty, justice, and accountability toward patients, ultimately preserving their dignity.[35] Ethical conflicts in clinical practice typically arise from four primary scenarios: conflicts between patient interests and treatment plans, conflicts between a student nurse’s responsibilities to the patient and their family, ethical responsibilities clashing with professional duties, and situations where students feel powerless over ethical decisions. Students with limited clinical experience and an underdeveloped internalization of ethical values frequently encounter such dilemmas.[36]

Nursing students also face additional challenges, including inadequate training on ethical sensitivity and emotional intelligence. Moreover, insufficient support from faculty and peers during critical moments, coupled with a lack of opportunities for ethical reflection and discussion, further exacerbates these barriers.[37]

The findings of this meta-synthesis align with the current body of knowledge, which consistently highlights nursing students’ ethical conflicts in clinical education. The findings of this study show the complexity and diversity of ethical issues in nursing education, from legal and ethical standards to patient independence and decision-making. In addition, the findings can contribute to the development of educational programs to prepare nursing students to solve ethical dilemmas and ultimately lead to improved patient care and healthcare quality.[7,38,39] In terms of limitations, it is important to acknowledge that the studies reviewed may not be representative of the entire nursing student population as they may focus on specific populations or institutions. Additionally, findings may not be generalizable to other healthcare professions or educational settings. The application of these findings can be seen in the development of more effective ethical decision-making models for nursing students as well as the implementation of strategies to address ethical issues in nursing education, which includes the use of web-based questionnaires to assess ethical problems experienced by nursing students as well as promote a safe and ethical learning environment.

Conclusion

This meta-synthesis study provides valuable insights into the ethical conflicts that nursing students face during clinical training. The findings categorize the effective factors in the formation of conflicts into the factors of understanding moral values, organizational factors in health care environments, and patient-related factors resulting from interaction with patients. This includes things like applying legal and ethical standards, guiding healthcare practices and quality of care, and respecting patient autonomy. This study is consistent with existing evidence that highlights similar ethical conflicts in nursing education. Importantly, it emphasizes the need for a comprehensive and integrated approach to ethics education that addresses all three areas of factors. Nursing programs can increase moral competence among students by fostering an understanding of ethical values, supportive organizational environments, and patient-centered care. Ultimately, this improves the quality of patient care and the ethical climate in healthcare organizations.

Conflicts of interest

Nothing to declare.

Funding Statement

Baqiyatallah University of Medical Sciences