Understanding ethical encounters in a hospital setting: a qualitative study

Abstract

Background

Education in ethics is essential for health care workers. Despite mandated ethics education in medical and nursing curricula within Australia and New Zealand, there remains little consistency in format, delivery, or assessment of education. How healthcare workers recognise and respond to ethical challenges in real-world practice remains underexplored. The frequency of experiencing moral distress is significant, particularly among junior doctors and nurses, with triggers including perceived futility, constrained clinical autonomy, and conflicting personal and professional views. We employed a qualitative design to better understand how health professionals experience ethical encounters in their daily practice and how prepared they are to engage with ethical dimensions of patient care. We examine the role of institutional context in shaping ethical awareness while identifying knowledge gaps to inform future ethics training and support requirements.

Methods

Focus groups were conducted with n-26 health professionals in Australia. Data were collected in August 2024. Qualitative analyses were used to develop themes and are presented in a descriptive framework. The study is reported in line with Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

Healthcare workers in this study readily identified the place of ethics in their clinical work. Recognition or awareness of ethics emerged through reflection on their own actions and through collaboration with others. Feelings of voicelessness or powerlessness gave rise to moral distress. Heuristics were often deployed to navigate complexity in ethical encounters. Participants felt prepared to deal with the ethical dimensions of work when they participated in constructive collaboration, had sufficient information and practical experience. The institutional context for ethics was understood as both supportive and as a hinderance. Demarcated responsibilities between professional groups can create challenges while systemic factors, such as financial constraints, also provided challenges and factored into ethical decision making.

Conclusions

Ethics is a routine feature of care, recognised in moments of uncertainty, disagreement, and constrained decision-making. Exposure to previous formal ethics education varied but was commonly minimal, poorly recalled, or weakly connected to real-time decision-making needs. We argue for greater attention to ethics support for health professionals to aid decision making and reduce distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-026-01446-y.

Background

Ethical challenges are pervasive across healthcare settings [1] and have become more prominent in light of recent global pressures, such as the COVID-19 pandemic [2, 3]. These challenges contribute significantly to clinician burnout [4, 5] and moral distress or injury [6, 7], with downstream effects on patient care and healthcare systems [4–10]. In response to this growing pressure, clinical ethics support services and moral deliberation groups have proliferated [11, 12] and increasing attention has been placed on the importance of ethics education for healthcare professionals.

Ethical competence is multifaceted, involving the ability to identify ethical issues, apply relevant knowledge, reflect critically, and make reasoned decisions which are informed by ethical frameworks [13–15]. Institutional contexts, such as denominational affiliation, can have an impact on decision-making, by providing clinical teams with explicit value frameworks which have an impact on decision-making (for example, what care ought to be prioritised, and what services are not provided) [16, 17].

Despite mandated ethics education in medical and nursing curricula in contexts such as Australia and New Zealand [18], validated tools for evaluating ethical competence in practicing clinicians are lacking [11] and there remains little consistency in format, delivery, or assessment of education [18, 19]. Ethics education delivered in classroom settings is insufficient and literature highlights the need for ongoing, context-sensitive interventions that address both individual competencies and systemic factors, including the institutional and cultural contexts in which care is delivered [11, 20, 21].

Contemporary literature identifies a burden of moral injury or distress for clinicians who feel constrained from acting in the way they feel they ought, or from carrying experiences of moral confusion [21–24]. Further research indicates that the frequency of experiencing moral injury is significant, particularly among junior doctors and nurses [25–27]. Common triggers include ethically complex situations involving perceived futility, constrained clinical autonomy, and conflicting personal and professional views [28–30]. Ethical complexity often leads to cumulative moral residue and can adversely impact personal wellbeing, workplace relationships, and career sustainability [10, 31, 32].

It is evident that ethics lies at the heart of health care practice; that education in ethics is essential; that the institutional context plays a critical role; and that failing to equip health care workers to engage with the ethical dimensions of their work undermines both their wellbeing and the quality of patient care. And yet questions related to how HCWs recognise and respond to ethical challenges in real-world practice remain underexplored. This presents as a deficit in the evidence base from which improvements in clinical ethics education and support as well as mitigations against moral distress can be designed. In order to better understand how health professionals experience ethical encounters in their daily practice and how prepared they are to address them this study had four aims:

1. Explore how health professionals identify and raise ethical concerns in daily practice.

2. Assess their preparedness to engage with ethical dimensions of patient care.

3. Examine the role of institutional context, including denominational affiliation, in shaping ethical awareness and response.

4. Identify knowledge gaps to inform future ethics training and support structures.

Methodology

In order to address the study aims, we employed a qualitative approach, grounded in social constructivism [33] using data obtained from focus groups with registered health professionals. This approach enabled participants’ viewpoints, experiences and the meanings they imposed upon them to be captured [34]. The focus group approach allowed for the emergence of ideas and information within the group environment [35] while drawing out the complexities, nuances, and contradictions with respect to the participants’ views on how they encounter ethics in their daily work [36].

Method

• A.Participants

The study adopted a purposive sampling approach which recruited a total of 26 participants who were (1) registered health professionals and (2) currently employed in a large teaching hospital in a capital city in Australia. Potential participants were invited to attend one of four focus groups through email and notice board advertisements around the hospital sites and invited to contact the author JD to express an interest in the study. JD then emailed a participant information sheet and consent form to review. Written, informed consent was obtained from all participants prior to the commencement of the focus groups.

• B.Participating organisation

The research was conducted in a large public teaching hospital in a capital city in Australia with a denominational affiliation. The hospital’s denominational affiliation includes specific ethical commitments which are articulated in the organisation’s mission statement and values and are also used to inform policy, culture and scope of practice. At the time the research was undertaken, the hospital had no formalised clinical ethics service or support structure.

• C.Data collection

In August 2024, the lead author (JD), who had no prior relationship with any participants, facilitated four focus groups with the support of one additional author (DF, TH or SO) for each session. Focus groups were conducted in a meeting room on site at hospital facilities (n-4).

The focus groups followed the same format across all four sessions and lasted 2 h. Participants were invited to introduce themselves and reflect on if and how they learnt about ethics in relation to their profession. A case study was presented in three parts, with each part revealing more information about the case under examination. At each part of the case study, the group reflected on the following questions (1). Does ethics have any relevance in this moment? If so, what relevance (2)? Are there any ethical questions to consider in this encounter (3)? How well prepared do you feel to deal with any ethical questions in this encounter? The focus group guide and case study developed for this study is provided in Supplementary File 1. Focus groups were audio recorded before being transcribed using otter.ai software. Transcripts were checked for accuracy during data familiarisation, at which time the research team listened to the recordings and compared these with transcription.

Data analysis

The research team adopted a reflexive approach from the outset. All research activities were accompanied by open reflective debriefing [37] as all stages of data analysis progressed through immersion, reduction and refinement [38]. During the focus group activities, the co-facilitator took notes which allowed for the documentation and later reflection. The research team met in person after all focus groups were completed to share initial thoughts and to discuss and challenge any biases or assumptions. All audio transcripts were then re-listened to and all transcripts re-read by all members of the research team. This ensured the research team were familiar with the whole data set. Data immersion continued as the team embarked on an initial/in-vivo coding approach [39] in which the words of the participants are used to identify key points of discussion across the group. Once completed, line by line coding was undertaken by all authors. Each author took the lead on initial line by line coding for a focus group, before reviewing and adding to the comments on each of the remaining three focus group transcripts. The team met again to discuss this initial line by line coding and the responses were shared. This provided the groundwork for further analysis and coding development with a view to creating initial and refined themes. This process was managed through Microsoft Word before all transcript text, comments and sub comments were exported into Microsoft Excel. The team paid specific attention to areas of agreement and disagreement and collectively agreed on the next stage of analysis. Two authors, JD and DF, analysed the data using a hybrid approach of both inductive and deductive coding informed by the work of Fereday and Muir-Cochrane [40] which allowed for the development of data themes. Specifically, while we allowed the coding of data to develop iteratively, we also applied the research questions to the data as an analytical lens to organise and group the data and to ensure we were working towards our research aims. As data was organised into initial and developing themes, we categorised narrative summaries under conceptual headings from the research questions. This allowed for the presentation of the results into a descriptive framework. All authors met to discuss and agree the final presentation of results. The analytical approach adopted can be described as a qualitative bricolage [33, 41] whereby multiple qualitative tools were utilised and carefully documented for transparency. Each analytical step from the line-by-line coding of the participants’ words, through to the resultant grouping the data evidenced, was documented in Microsoft Excel. The model of data analysis undertaken by the team is detailed in Supplementary File 2;

Data analysis activities

• D.Trustworthiness/rigour

All team members undertook regular peer debriefing as part of the data collection and analysis process. Field notes of all meetings were captured both during focus group sessions and subsequent data analysis meetings. An audit trail of all decisions made was maintained by JD in consultation with DF, SO, and TH. This process allowed for the recognition of and reflection on any assumptions and biases of the research team and the development of credibility, dependability and confirmability of findings [42]. This systematic process of debriefing, ongoing reflection and documentation of decisions ensured data collection and analysis were rigorous [37] with a view to producing high quality research that was credible, dependable and confirmable [43]. All authors were involved in the development of the study protocol which provided a rationale for the study and also detailed our guiding methodology and methods for data collection, flexibility of data analysis and strategy for reporting of results. The study is reported in line with consolidated criteria for reporting qualitative research (COREQ) [44] and the completed checklist if provided in Supplementary File 3.

Results

Participant characteristics

The views of a total of n-26 participants over 4 focus groups are reported in this study. All participants were currently employed as health care workers across both acute and community care. Professions included nursing (n-14), medical (n-7) and allied health professions (n-4). HCW’s specialties included intensive care (n-9), senior management roles (n-3), neurosurgery (n-2), mental health service (n-2), geriatrics (n-2), general medicine (n-1), disability services (n-1), cancer services (n-1), and end of life care (n-1). Table 1 outlines the participants in this study by participant number/focus group ID, professional group. We use the term Health Care Workers (HCW) when referring to these participants collectively.

Table 1.

Participants in this study

Participant	Professional Group
Participant 1 (FG1)	Medical
Participant 2 (FG1)	Allied Health
Participant 3 (FG1)	Allied Health
Participant 4 (FG1)	Nursing
Participant 5 (FG1)	Medical
Participant 6 (FG1)	Nursing
Participant 7 (FG1)	Medical
Participant 1 (FG2)	Nursing
Participant 2 (FG2)	Medical
Participant 3 (FG2)	Nursing
Participant 4 (FG2)	Nursing
Participant 5 (FG2)	Nursing
Participant 6 (FG2)	Nursing
Participant 1 (FG3)	Nursing
Participant 2 (FG3)	Allied Health
Participant 3 (FG3)	Allied Health
Participant 4 (FG3)	Medical
Participant 5 (FG3)	Nursing
Participant 6 (FG3)	Medical
Participant 7 (FG3)	Medical
Participant 1 (FG4)	Medical
Participant 2 (FG4)	Medical
Participant 3 (FG4)	Nursing
Participant 4 (FG4)	Nursing
Participant 5 (FG4)	Nursing
Participant 6 (FG4)	Nursing

Descriptive framework

The descriptive framework organises the key themes identified through thematic analysis into interrelated domains. The study findings consist of an overarching theme of Encountering ethics and three sub themes (1) Preparedness in encounter (2) Learning and Knowledge gaps and (3) Relevance of institutional context. The descriptive framework is presented in Fig. 1 with illustrative descriptions and quotes presented below.

Fig. 1.

Descriptive framework of study findings

Encountering ethics

Participants described encountering ethics in everyday aspects of their work. Practical action in response to a patient need was, on reflection, identified as having an ethical dimension. As a participant explained:

‘I think health professionals deal with ethics every day… even the smallest decisions they make. Should I put a cannula in? Yes, or no? There are risks benefits. So, I think they’re dealing with every day.’ (FG4).

The realisation that every day encounters were ethical encounters came in moments of reflection on day-to-day work. These reflections came in the form of personal reflection, as outlined above, or reflection in collaboration with others. Participants explained that it was through collaborative discussions, particularly within multidisciplinary teams, that ethical dimensions of care were often raised. Discussion and collaboration with other health professionals raised awareness of the ethical dimensions of an encounter. Constructive collaboration also allowed for the raising of alternative perspectives on the best course of care for a patient and was understood as part of the ethical dimension of an encounter.

Participants in our study described their recognition that an encounter had an ethical dimension through feelings of discomfort, uncertainty and even conflict. This followed a temporal sequence: the encounter related to patient care occurs, the person feels uncomfortable with the decisions that are being or were made, and then on reflection, the reason for the encounter being uncomfortable was related to the ethical issues at play. Some participants noted that the place of ethics in the encounter became clear in decision-making challenges, when it was unclear what decision ought to be made. Participants also described encountering ethics in moments of conflict, particularly conflict over decisions relating to patient care. When alternative perspectives are not listened to, or discarded, this can lead to a withdrawal from or apathy towards the ethical dimensions of patient care. As one participant explained:

‘…you sit in a room and you know the loudest voice or the most reasonable, or the top dog says this is what’s going to happen. And that might mean that that person, that person in the room, that healthcare person won’t have, won’t ever speak up again, and will either get really, really miserable and sad and give up being a healthcare professional, or just never, never want to engage again in that discussion’. (FG4)

Participants discussed feeling voiceless, whether through being unable to speak, or not being listened to, and encountering ethics through distress, specifically moral distress. As one participant explained:

‘And again, it’s challenging, yeah, because that can lead to distress. If you did end up and you were talking about the distress, moral distress, that the resultant distress, that’s interesting around how prepared we are. Other times that we’re prepared, think we’re prepared, but the outcome leaves us distressed…” (FG2).

Participants described moral distress as a feeling of knowing they were not doing the right thing, which generated discontent and yearning for others to make different decisions. This was sometimes accompanied by appeals for greater courage from others in position of power. One participant explained:

‘…what we did today was, wrong. I go. I’m like, I do, and I, you know, I wish those doctors had a bit more courage’. (FG4)

Participants in the study were asked directly how they encountered ethics in their work and were also asked directly how ethics was relevant at different stages of a patient encounter. Several key examples were evident here, including the place of patient consent for treatment, supporting patient autonomy, and imagining oneself in the position of the patient. We found that participants deployed heuristics as shortcuts to identifying and responding to the ethical dimensions of care. For example, in one instance a participant reflected on the concept of consent as correcting an overly technical approach to clinical decision-making:

‘A technical frame to that…there’s informal consent, individual choice that you have to actually work with this young woman so that she understands the pros and cons of the treatment. So that’s information, but it’s also the clinical, the ethical framework around respecting her choices and giving her the opportunity to choose what she wants.’ (FG2).

In identifying the ethical dimensions of their work, participants demonstrated how they used heuristics to focus their ethical questions. In this instance, a participant used the heuristic of imagining themselves or their family member in the place of the patient:

‘But I learned that through doing ethics, research, governance, but in daily practice, I think ethics is about that confidentiality and how I would like to be treated, and how I’d like my family to be treated, and that’s what you base ethical practice on’. (FG3)

In summary, participants described encountering ethics as part of their everyday clinical practice. Recognition or awareness of the place of ethics often emerged through reflection on their own actions and through collaboration with others, particularly colleagues. Discussions related to patient care that resulted in conflict increased this ethical awareness, while participants’ feelings of voicelessness or powerlessness gave rise to moral distress when they were not able to act in a way they felt was right. To navigate the ethical dimension of their work, participants in our study frequently deployed heuristics, revealing how ethics is encountered and navigated as part of their daily practice.

Preparedness

Participants in this study discussed how prepared they felt in dealing with the ethical dimensions of their work. Their reflections focussed on the place of constructive collaboration, sufficient information and practical experience.

Participants told us that constructive collaboration was central to their experience of preparedness. As one participant explained:

‘If I have supportive head of unit and supportive colleagues, and I feel like I can speak to people about my concerns, or I’ve got somebody to go to and say, I’m not sure about this decision that we’ve made, I don’t feel it doesn’t sit well with me. What do you think about it? Do you think if we did this would be different or whatever? Just talk to have people to talk about it with it would be very different, and my preparedness to deal with that situation would be very different than if I was in a team where I felt like I couldn’t speak to anyone at all, or raise my concerns or couldn’t.’ (FG3).

Constructive collaboration was seen as a corrective to deficient ethical decision-making, especially that which was informed by only one perspective:

‘I think you could also very easily do the wrong thing by not having the right people in the room and jumping to conclusions. I suppose it’s…it’s a very when you think about it like that, it’s a very fragile system we have.’ (FG2).

A number of participants also reflected that having sufficient information was related to their preparedness to deal with the ethics of their work. Information referred to the fact-base that was available to them in relation to each instance of patient care. A number of participants put forward that more information about a patient would lead to better ethical decision-making, particularly in relation to the case study they discussed. As one participant explained: “I think it just boils down to the fact that you have to actually know your patient” (FG2).

In addition, sufficient information was sometimes seen as an antidote to both bias and conflict in ethical decision-making. As one participant explained:

‘I just think the, you know, I guess this case for me, also illustrated, that sort of being careful about frequency on superficial information or not having all the information or information that may get just propagated through the notes. So, I think going back to those principles, really, in this sort of scenario, taking the time and…and doing all the exploration work to get all information that’s accurate, that is meaningful, as [FG participant] pointed out, the most, the biggest, loudest voice in the room, their preconceived idea. I think going back to those basic principles…and getting all that information to make, hopefully, the best shared decision, I hope without having…I don’t think frameworks and tick boxes, but I think that basic principle, I hope, will help us to navigate nicely in a way that we feel we’ve done the best we can.’ (FG3).

Participants told us that practice was central to their experience of preparedness. This referred to past experience in responding to the ethics of clinical work. For example, one participant reflected that

‘There was something about like drawing on practice wisdom. And people have been around that, that condensed practice wisdom is invaluable compared to people who haven’t been in as many scenarios.’ (FG3).

Notwithstanding the importance of practice for preparedness, the same participant observed that practice on its own does not secure an ethical outcome:

‘…at the same time as that, just because you’ve done something 100 times doesn’t mean that it’s right to do it again.’ (FG3).

In summary, participants in this study felt prepared to deal with the ethical dimensions of their work when they participated in constructive collaboration with others, had sufficient information and practical experience.

Learning and knowledge gaps

Participants in our study reflected on their learning and knowledge gaps in relation to ethics. Participants were able to recognise and articulate gaps in their ethics education while recognising the benefits and challenges associated with experiential learning. Participants also provided reflections on their prior formal learning.

Participants in our study reflected on their prior learning and what this meant for their practice, with many identifying the absence of formal education and practical experience as a significant challenge. For example, one participant said:

‘And actually, when I think about it, for all the intensive training that we all do and specialties, probably a lot of this, again, is not something that’s really incorporated into how we then think about particularly making really important day to day decisions which we’re all doing. So, it does feel like a pretty I think about it now, looking back at all the training we do, pretty fundamental gap.’ (FG3).

A number of participants reflected on perceived gaps in learning related to ethics. These gaps were often seen as detrimental for their capacity to engage with the ethics of their work. Participants also noted a gap in opportunities for contextual learning, for example following complex or contentious episodes of patient care. These were seen as missed opportunities both to learn about ethics and to mitigate against moral distress. As one participant reflected:

‘How well do we support our staff individually to try and work through some of those for there might be an ethical challenge. Do we? Do we create the education opportunity, the opportunity to review some of those individual cases because, you know, we will still have staff that will go home and think, gee, I wasn’t comfortable with that decision.’ (FG2).

Several participants reflected on experiential learning in relation to ethics. Some participants offered reflections about their learning through their experience of ethical complexity in clinical cases and the collaborative problem solving that occurs in these settings. As one participant explained:

‘Well, I if I think back to my undergrad, we didn’t learn about ethics in training, it’s probably been just more of an on-the-job experience, particularly in ICU, where you come across some ethical situations and decision making.’ (FG4).

Others drew attention to the difference between this kind of experiential learning and the theoretical study of ethics. As one participant explained:

‘So looked at the full spectrum of nursing care going back to Uni training, we definitely did subjects… But it was on the job that I started to develop a greater understanding of how my taking ethical considerations into consideration was part of the job, which I think fell more back on how my upbringing as opposed to anything I learned at university.’ (FG4).

This was frequently described as a contrast between academic training (for example, in university study) and experiential learning. The latter was seen as more important for preparedness and addressing gaps.

All participants were invited to share how they had learnt about ethics as part of their introduction in the focus group. A significant number of participants could not recall prior learning in ethics. For example one participant reflected,

‘I can’t honestly say at any point during any academic training that I really ever learned about ethics’. (FG3).

Other participants reflected on the limitations of prior formal education and learning. One participant noted that prioritisation of technical skills in training meant that the curriculum had limited space for ethics, and others similarly noted their experience of a relatively narrow focus on ethics as part of training. Several participants also noted that their experience of ethics in the workplace led to a desire to learn more about ethics, which in turn stimulated further, self-initiated learning. For example, one participant noted:

‘I learned about ethics in my undergrad, but don’t remember being particularly interested at the time, but then having had a bit of experience in hematology and oncology and considerable frustration with ethical decision making, especially around treatment versus end of life care, sort of led me to want to study ethics a bit more closely’. (FG4).

Consistent with the contrast between formal and experiential learning noted above, participants did not articulate a clear link between formal learning of ethics and preparedness.

Relevance of institutional context

In our study, participants offered reflections on the relevance of their institutional context for ethical decision making. Participants discussed their perceptions of the institutional context as being either supportive or a hinderance, while also reflecting that the institutional context could be challenging, particularly the demarcation of responsibilities of health professionals based on professional backgrounds. Participants reflected on systemic factors within the institutional context and their influence on the ethics of their work.

Some of our participants reflected on the way in which an institutional context has a direct impact on the ethics of their work in both supportive and hindering way. At the supportive edge, participants noted how positive culture, trusting relationships with senior staff, and an organisation’s mission can have a positive impact on ethics. For example, one participant noted that:

‘…think, for whatever reason, and it may well come from its denominational past… [hospital] is the most compassionate organisation I’ve ever worked at, in terms of, you know, the default position being doing what the patient needs, over and above all and having a higher threshold for considering some of those less person-centered drivers than any other place I’ve been.’ (FG4).

Consistent with this quote, the hospital’s denominational affiliation was noted by some participants as a supportive and enabling factor for ethical decision-making, with some considering this in terms of the organisation’s culture and others articulating a resonance with their own set of values.

In terms of hindering, some participants reflected that the institutional context could hamper the ethics of work in teams characterised by mistrust or a hierarchical culture that creates an impediment for raising ethical issues. The latter was bound together with fear of repercussions in settings where a more junior staff member sought to raise ethical questions or concerns with the decision-making of a senior. Some participants also considered the hospital’s denominational affiliation as a hinderance in relation to ethics, particularly in areas, where organisational parameters contrast with patient care preferences.

A number of participants reflected on their place within the institutional context as bound together with their particular responsibility for ethical decision-making. For example, a number of participants who represented nursing and allied health professions recognised that ultimate decision-making was often in the hands of medical staff. Some participants experienced this as mitigating against the weight of decision-making. For example, one participant noted that it helped them to distance themselves from decision-making. Others experienced it as creating conditions of moral distress. For example, one participant noted that their relative powerlessness in the institutional structure left them feeling constrained from acting in the way they believed was right and resulted in a feeling of distress.

Several participants reflected on the place that systemic factors had in the ethics of their work, a subtheme which included reflections on resource availability and distribution as well as the place of institutional policies and procedures. In relation to resource availability and distribution, one participant noted that:

‘What does it mean in our in our current, you know, stretched environment where we know we’ve got patients that we can’t accommodate coming through the emergency department, trying to kind of balance, you know, who’s got the greater need versus, you know, it’s not just the individual.’ (FG2).

In relation to institutional policies and procedures, another participant noted that organisational policies placed limits on the decision-making of staff in particular circumstances. The example provided was compulsory COVID-19 vaccination, an organisational decision which staff were obliged to follow. Here the participant was not providing critique of the decision but drawing attention to the way in which organisational policies also set the parameters within which HCWs experience the ethics of their work.

‘It’s where we have policies and procedures for a whole lot of things, and when, when we had COVID on, for example, we made a decision as a health service that people should be having an involuntary vaccination. We made a decision. It was an ethical decision that made as an organisation, staff still had a choice of not being involved in this, but the ethical decision needed to be rolled out within the organisation’. (FG3)

Participants’ reflection on the relevance of institutional context for ethics was understood as both supportive and as a hinderance. Demarcated responsibilities between professional groups can create challenges while systemic factors, such as financial constraints, also provided challenges and factored into ethical decision making.

Discussion

Identifying and raising ethical concerns

HCWs readily identify the place of ethics in their clinical work. This reflects an awareness of the intrinsic place of ethics in healthcare – that is, HCWs appreciate that their work is more than technical, it relates to questions of human dignity, professional virtue and ethical decision-making [45]. Such awareness becomes more focused when the acuity and complexity of decision-making increases.

In each of these settings, HCWs experience ‘moral disequilibrium’. A precursor to moral distress, moral disequilibrium refers to the experience of disquiet or disturbance in a HCW who both recognises their ethical responsibilities and struggles to design and enact a plan of action which reflects these responsibilities [46]. The cause of such disequilibrium varies: in our study it included the identification of bias (the risk of, or actual), encountering conflict among treating teams, lack of clarity about how ethical principles apply, or in experiencing constraints such as resourcing.

Preparedness

HCWs preparedness to address the ethical dimensions of their work varies. We found that they regularly draw on heuristics, collaboration, and past experience to guide ethical decision-making. While potentially constructive, these tools carry inherent limitations when it comes to HCWs preparedness. If inadequate heuristics, collaborators or past experiential learning form the backdrop for ethical decision-making, the integrity of this decision-making will be undermined. For example, in contexts beset with bias, there is no guarantee that these practices will illuminate bias or help HCWs overcome it [47]. Similarly, overly hierarchical contexts will undermine the potential of collaboration in responding to the ethical complexity of clinical work [48]. Hence, efforts to improve HCW preparedness can draw on the strength of existing practices while working to improve their inherent limitations.

It is significant that our findings around HCWs’ identification and preparedness for the ethics of their work are temporally located during episodes of patient care. That is, HCWs primarily identify and work through the ethics of their work in the moment, in proximity to particular situations and the ethical questions these give rise to. This finding supports those approaches to ethics designed to enable HCWs to increase their sensitivity to the ethical dimensions of their work, and also prepare them to meet the ethical complexity of their work with confidence in the moment, work constructively through disagreement, and draw on practice wisdom that is relevant for the issue at hand [49]. This greatly relativises the impact of ethics education offered at a distance from the real-world challenges and experiences of HCWs.

Knowledge and learning gaps

Starkly absent in our findings is a clear relationship between formal education – whether as part of training or professional development – and preparedness. Indeed, many in our focus groups could neither remember any formal education in ethics, nor describe a link between this and their preparedness to attend to the ethics of their daily work. This demonstrates the translation gap between bioethics and clinical practice in literature focused on translational bioethics [50]. Given the importance of ethics for clinical decision-making, this raises urgent questions about current methodologies for teaching ethics to HCWs and the relative priority given to technical skills in HCW training when compared to ethics [51, 52].

This insight can be fruitfully read alongside our findings on HCWs’ identification of ethics. We argue that the impact of clinical ethics education may be improved through a more deliberate focus on education which is directly attached to clinical practice, such as through simulation or case-based deliberation [53, 54]; collaboration, such as through shared decision-making frameworks; and further developing HCW sensitivity to the ethical salience of their work, such as through ethics communities of practice [55, 56].

Institutional setting

Scholarship in ethics over the past two decades has paid increasing attention to the intersection between social and institutional context and individual ethical sensitivity and decision-making [48, 55, 56]. Our findings demonstrate that HCWs experience both their positionality within the social context of the organisation (e.g. as a nurse working with a doctor) and the institutional context as such as having an impact on their identification of ethical issues and their preparedness to respond to these in their work.

This was an ambivalent finding. Some focus group members experienced this intersection as having a positive impact on identification and preparedness, particularly in relation to organisational values, denominational affiliation and culture. Others experienced this intersection as having a negative impact, particularly in relation to constraints around decision-making, whether because of team culture and safety, the organisation’s denominational affiliation, or resource constraints. This provides a degree of confirmation for those theorists who have recommended attention to systemic virtue (and vice) alongside the agency of individuals [57]. The finding has important implications for those initiatives focused on improving clinicians’ capacity to engage in the ethics work. The success of such initiatives rests on a combination of attention to the ethical competency of individual clinicians, and the institutional cultures and structures in which they enact this competency [58]. One without the other will not work.

Further research

Earlier, we noted several findings that were temporally located prior to or during moments of ethical decision-making. It is also important to note a supplementary finding in our work which rests on the other side of decision-making, namely moral distress. Moral distress in this context can be understood as the feelings of frustration or failure HCWs experience [59] when caused by a perceived or real inability to act in a way which they understand to be right and correct [60], and/or being compelled to act in a way that violates their integrity [61].

This well-discussed phenomenon featured prominently in our focus group discussions, such that we will be devoting another paper to its analysis. Suffice it to say by way of summary, it was clear that moral distress contributed to HCW identification of the ethics of their work. Further, the way in which participants in our study identified that they carry the experience of compromising on ethical values contributed to emotional and psychological distress and burnout, providing support for those studies which have articulated the link between moral distress and HCW wellbeing [62].

Our study provides further evidence of the gaps that exist in HCW knowledge of ethics and capacity to apply ethical frameworks to their decision-making. Held alongside our findings around the lack of effectiveness of prior learning, this suggests need for further research focused on the effectiveness of methods of education in ethics for HCWs which are more closely related to their clinical decision-making. This coheres the landmark review conducted by Ignatowicz et al., [11] which found that little progress has been made in understanding the way in which HCWs integrate ethical decision-making in practice, and the interventions that reliably improve this critical dimension of their practice. Our study confirms this finding and adds urgency to the need identified.

Strengths and limitations of this study

Our methodological approach allowed for the development of an understanding of ethical encounters from the perspective of a multidisciplinary team of nurses, doctors and allied health professionals. We have presented defining features of how health professionals encounter and manage ethical situations in a hospital setting typical of large, relatively well-resourced cities in liberal democracies. It may be that similar findings would be observed in similar hospital and health settings. Involvement in the study was voluntary and participants who did volunteer were potentially more attuned to identifying ethical considerations in their work. This can be considered a possible strength in that it allowed our focus groups participants to express more nuanced descriptions and do so with more advanced reflexivity.

The study was performed within a single hospital and presents insights from a breadth of professional groups in that setting. Capacity to attend during work hours or in participants’ own time meant that the sample favoured those with more seniority in the organisation, as well as those with an enthusiasm for the topic. A study with less experienced or junior HCWs, or those less intrinsically motivated about the ethics of their work may uncover different yet interesting perspectives related to ethical awareness, motivation and encountering ethics in a hospital setting.

Conclusions

This study has shown that for the participating HCWs, ethics is a routine feature of care, recognised most clearly in moments of uncertainty, disagreement, and constrained decision-making. Participants described “encountering ethics” through reflection on everyday actions. Participants identified that engaging in collaboration can flag ethical salience and provide important solutions. Their preparedness to respond to ethical challenges was grounded less in prior formal education and more in constructive collaboration, adequate patient-specific information, and practice wisdom. It was noted that experience alone does not secure ethically sound outcomes.

Substantial learning and knowledge gaps were evident. Exposure to previous formal education varied but was commonly minimal, poorly recalled, or weakly connected to real-time decision-making needs, leading clinicians to rely on heuristics. These can help to navigate ethical challenges but also conceal bias. While institutional context exerted a decisive influence, it was not universally positive: cultures of psychological safety, values alignment, and inclusive team practice enabled ethical engagement, whereas hierarchy, role demarcation, policy constraints, and resource pressures hindered it and amplified distress – especially for those whose voices were less well heard.

On the basis of these findings, we argue for greater attention to ethics support which is embedded where ethical salience is recognised and decisions are actually made. Priorities include: [1] integrating case-based deliberation, simulation, and timely debriefs into routine workflows; [2] strengthening multidisciplinary forums that surface diverse perspectives and mitigate hierarchy; [3] ensuring reliable access to patient-centred information to counter bias; and [4] pairing individual skill-building with organisational work on culture, policy, and resourcing. Finally, given the weak translation from traditional undergraduate ethics teaching to bedside practice, evaluation and support should shift toward ethical decision-making in situ. Our companion analysis on moral distress will extend these insights, but the present results already indicate that improving clinicians’ ethical competence requires simultaneous attention to and support for individuals, teams, and the systems in which they work.

Authors’ contributions

All authors made substantial contributions to the conception and design of this project. All authors were involved in data collection, analysis and the interpretation of the data into the resultant framework presented. All authors collaborated to writing and re-writing the original draft preparation and further reviewing and editing. All authors agreed on the final version of this manuscript.

Funding

None.

Data availability

The data that supports the findings of this study are available in the supporting information of this article.

Declarations

Ethics approval and consent to participate

The study received Institutional ethics approval from the St Vincent’s Hospital Melbourne Human Research Ethics Committee (Approval Number 2024/SSA00079). Further, this study was performed in accordance with the ethical principles of the Declaration of Helsinki (June 1964 and amended 1975, 1983, 1989, 1996, 2000, 2008, 2013 and Note of Clarification 2002 and 2004) [63]. The study was promoted using emails to staff groups and posters placed in public locations around the hospitals. Participants were provided with a participant information sheet, a consent form, and a withdrawal from participation form. Written informed consent was obtained for all participants. Participants are quoted using participant/focus group numbering to maintain confidentiality. Participants were offered and encouraged to access to psychological support services if they felt distressed at any time during or after the study. No participants withdrew from the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.