Ethical behavior of nurses in decision-making in Iran.

BACKGROUND: Ethical caring is an essential in nursing practice. Nurses are confronted with complex situations in which they are expected to autonomously make decisions in delivering good care to patients. Although a wide range of studies have examined ethical behavior of nurses, there are still many issues requiring further investigation. The aim of this article is to describe the ethical behavior of nurses in decision-making in patients' care in Iran.
MATERIALS AND METHODS: This study was conducted through grounded theory method. Participants were 17 Iranian nurses, employed in Tabriz University of Medical Sciences hospitals. Unstructured, semi-structured, and in-depth interviews were used for data gathering. Interviews were transcribed and coded according to Strauss and Corbin method in open, axial, and selective coding.
RESULTS: Nurses showed three major approaches in ethical behavior: Beyond the legal duty and protection of the patients, which includes dedication and full availability to nurses' job and the client, spending time for the patients and delayed exit from the workplace, and arbitrary practice; legal duty and the protection of patients and nurses, which includes caretaking for the patient, responding to the client, and implementing the physician's prescription; and below the legal duty and the protection of one's self, that is, finding evidence and having witness in case of false documentation, and shortcoming, negligence, and mistake.
CONCLUSIONS: Because of the importance of the ethical behavior of nurses in decision-making, it is necessary to find ways to promote moral reasoning and moral development of nurses. Empowerment of nurses, nurse educators, and nursing students to acquire knowledge and develop ethical behavior skills is important.

INTRODUCTION

Ethical dimension of nursing care is an essential element of nursing practice.[1] Some believe that being a nurse is a moral endeavor and almost every decision that a nurse makes has a moral dimension.[2] Nurses are faced with complex situations where they are expected to provide good care. Good care should be led in a direction that can enhance the health integrity in physical, emotional, relational, social, moral, and spiritual dimensions.[1] However, there is ongoing concern about the ethical practice of nurses. It seems that performing ethical practice in the presence of daily moral dilemmas is difficult.[3] Nurses have a moral commitment not only to provide care for meeting the needs of a specific population, but also to develop the essential skills of critical thinking, ethical decision-making, conflict resolution, and capability for supporting a specific population.[45]

Nursing scientists believe that good patient care has always a moral basis and ethical decision-making is an essential element of the nursing profession. Factors such as advances in medicine and technology, increasingly complex care situations, the lack of evidence-based interventions and insufficient resource allocation, rising costs, increase in aging population, individuals’ rights, and the changing roles of nurses can lead to ethical conflicts. Therefore, nurses are required to consistently and critically show their roles in the health and welfare of the patients. Professional competencies are necessary for nurses to reach a high level of moral maturity. They should use ethical decision-making as a form of organized ethical deliberation for moral conflict resolution.[567]

Decision-making process is complex and influenced by contextual and individual factors. Ethical behavior of nurses is a strong relational and contextual process in which individual and contextual aspects play an important role.[1] Individual factors such as values, faith, experience, knowledge, skills, and also contextual factors such as moral awareness, observation, analysis, and judgment may affect nurses’ ethical behavior and decisions. Nurses rely on education, religious values, their intuition and feelings, guidelines, standards, colleagues’ support, and the potential consequences of their choices to justify their decisions.[148] Also, the patients’ characteristics affect nurses’ ethical decision-making process.[19] In addition, work overload, insufficient time, organizational and financial constraints, staffing issues, physicians’ authority, stressful work environment with complex situations of patients, lack of participation in ethical decision-making, confronting with conflicting values and norms, and a willingness to compromise with others’ expectations often make nurses’ decision-making based on ethical principles as a priority of their actions more difficult. These also may affect, prevent, and change the moral reasoning development of nurses.[14510] However, nurses need to be able to recognize moral dilemmas and make appropriate decisions. They are responsible for their decisions in particular issues in a specific patient.[11] Nurses should be familiar with the process of ethical decision-making and respect the moral rights of the patients without threatening their moral conscience.[1112]

It seems that most nurses are not well prepared to meet moral dilemmas. The findings of a study indicate that nurses do not think critically when making a moral decision.[13] Although a wide range of studies have investigated the ethical behavior of nurses, there are still many issues requiring further investigation. Issues that nurses experience during their ethical practice are related to their work environment difficulties, and identification and understanding of their ethical behavior and the related factors affecting their ethical behavior are necessary.[1] Promoting ethical practice among nurses needs better understanding of the difficulties they experience.[5] Although studies show that nurses’ awareness of their moral responsibilities in nursing care is increasing, they have difficulties in identifying moral dilemmas and determining the appropriate method to solve the moral dilemmas.[14] Unfortunately, despite the advances in health care ethics, there is still little knowledge about how to make ethical decisions and to conduct ethical decision-making process in Iran. Also, there is little knowledge about nurses’ ability to follow the decision and the consequences of their decisions as well as the impact of practice settings on their decisions.[1215] Although studies show a consistent pattern in ethical practices of nurses over time in different countries, with respect to the nursing scholars emphasizing the importance of promotion in nurses’ moral competence and considering the differences in individual, organizational, and social contexts of nurses in different countries, it is necessary to discover what nurses’ ethical behavior is in their decision-making. So, this article aimed to describe the ethical behavior of nurses in decision-making in patient care in Iran.

MATERIALS AND METHODS

This study is a qualitative research conducted through the grounded theory method. Hospitals were used as a natural environment for investigating nurses’ experiences. Purposeful and theoretical samplings were used. Initial participants were selected by assistance of hospital managers and familiarity of the researchers with some participants. Snowball sampling was used to identify the eligible participants in the next stage. Participants were chosen from medical and surgical, and ICU wards of three university educational hospitals. The inclusion criteria were having at least 1 year of work experience as a nurse, being able to speak Persian, having the physical ability to describe experiences, and being willing to participate in the study. To respect the ethical protocols in research, the study proposal was approved by the Research Committee of the Iran University of Medical Sciences. For ethical considerations, an ethical permission was obtained from the study environments and the participants. The participants were informed that they were free to discontinue participation in research at any time and without any explanation. From those nurses who were interested and agreed to participate, an informed consent was taken. Confidentiality of participants’ identity was ensured. Following open coding and initial categorizing, theoretical sampling was done by means of operational and theoretical memos and diagrams. Sampling continued until saturation of the categories, subcategories, dimensions, properties, and initial hypothesis about the possible relationships among them. The study participants were 17 nurses who worked in Tabriz University of Medical Sciences hospitals. They had a bachelor's degree and a mean age of 34.5 years. The participants were 12 females and 5 males. There were nine staff working in ICU, four in surgical ward, two in internal medicine ward, one in the emergency department, and one staff in respiratory assessment unit. The length of their work experience varied from 4 to 22 years. Twelve participants were working as a staff nurses, four as a head nurse, and one as a supervisor and circulating nurse. However, two of the head nurses also had experience in supervision.

In the present study, the duration of data gathering was 24 months, and unstructured, semi-structured, face-to-face, and in-depth interviews were used to collect the data. Interviews were tape-recorded for analysis. They ran based on theoretical sampling. The duration of each interview varied from 35 to 95 min.

For data analysis, coding and constant comparative method of Strauss and Corbin was used[16] in such a way that while the investigators were gathering data through interviews, they began to transcribe them verbatim and do coding. Initially, open coding was done. In open coding, 986 codes emerged. Then, the researchers compared the codes with one another and with those gathered by previous interviews in such a way that the pairs could be classified. After several times of reviewing and constant comparison, they were diminished to 856 codes, and the initial categories and subcategories were identified. In axial coding, researchers tried to complete the categories and subcategories, as well as to find and arrange the relationship between categories, subcategories, their dimensions, and their properties. In this stage, the codes were classified into 20 categories and 84 subcategories. In selective coding, researchers attempted to integrate and purify their own analysis. In this stage, the strategy of “legal duty and protecting” was identified as a one of the main variables in nurses’ ethical decision-making.

To achieve the rigor of study, several methods were adopted. All notes, codes, and categories were preserved. To increase the credibility of the study, prolonged engagement (24 months) and member check were used. Also, the results were given to two nurses who did not participate in the study, and they were asked to compare the results with their work experiences. To perform peer check, in addition to some expert colleagues who were involved in the study, two qualitative researchers approved the primary codes and categories. Transferability was attained by rich descriptions of the data, which allowed the readers to judge about the accurateness and match the findings with their own contexts.

RESULTS

Table 1 shows the entire categories and subcategories of the present study. Three major categories, each comprising of three subcategories, were obtained through analyzing the data collected from participants’ interviews. The emerged categories were: Beyond the legal duty and protection of the patients, legal duty and protection of the patients and nurses, and below the legal duty and protection of self. The following results describe the categories and their subcategories concerning the ethical behavior of nurses in decision-making.

Table 1

Overview of the entire categories and subcategories of study

Approach of beyond the legal duty and protection of the patients

In this approach, nurses act beyond their organizational and legal duty. For nurses, caring and maintaining clients’ health may have high value, and they act beyond the duties determined by their job, their organizational constraints, and laws. In this approach, nurses may help to protect, preserve, promote, and improve the health of their patients by means of dedication and full availability of their job to their clients, spending time for the patients with delayed exit from the workplace, and arbitrary practice.

Dedication and full availability of their job to the clients means that the nurses initially consider the patients’ needs (not their own basic needs) and they are fully available to the patients and take care of them. It seems that the characteristics such as faith and believing in having right performance, ability of understanding, empathy and altruism, as well as moral sensitivity in nurses are related to dedication and full availability of their job to the clients. These characteristics may lead nurses to pay more attention and have high sensitivity to the patients’ care needs, while being unaware of their own basic needs.

Dedication can benefit patients and gives the comfort of conscience, a sense of competence, and self-satisfaction in the nurses, but in such a situation, the nurses may ignore their basic needs that can cause them physical harm or injury. Participant no. 8 says:

“I do not usually go for lunch. Now it is 5 pm and I still have not eaten lunch.”

In addition, dedication in situations such as shortage of nursing staff, work overload, and handling more critically diseased patients can lead to physical damage and excessive stress on the nurses. Participant no. 16 says:

“We devote ourselves to take care of the patients very well. We do not have time to go to lunch, and we gradually harm ourselves.”

Spending much time on the patients and delayed exit from the workplace means that, regardless of time, place, and job obligations, nurses provide high-quality nursing care, respond to the patients’ needs, and spend much time on their patients. This behavior is related to the characteristics such as faith and believing in having the right performance, ability of understanding, empathy and altruism, as well as moral sensitivity in the nurses. These characteristics can lead to nurses’ serious consideration of patients’ care needs, and also nurses’ disregard to legal duty times and a delayed exit from the workplace in organizational and managerial constraints.

Although timely response of nurses to patients’ needs and ongoing care of the patients may result in comfort of conscience, sense of competence, and inner satisfaction in nurses and clients’ satisfaction, delayed exit from the workplace may lead to negative consequences for the nurses, such as stress, problems to their health, and family problems. Participant no. 8 says:

“One who wants to do the job accurately does not mind the length of time. He/she usually leaves the workplace late … Even simple demands of the patients cause the nurses to leave the ward half an hour late … As the patients need your help at that moment, if you help them, their needs will be met, and they will be very happy….”

Arbitrary practice means that nurses respond to patients’ care needs that are beyond their legal and occupational duty. This practice is based on the needs of the patients and is motivated by compassion. Arbitrary practices are usually in the range of medical duties. They can be conducting cardiopulmonary resuscitation (CPR) without the presence of a doctor, chest tube insertion, intubation, and so on. The characteristics such as believing in God, understanding, empathy and altruism, and risk taking of the nurses can be associated with their arbitrary interventions. However, what often pushes the nurses to arbitrary practice is lack of access to a doctor or the lack of timely presence of a physician for the patients. Although this practice can have positive consequences such as saving patients’ life and preventing serious harm to the patients, which lead to the feelings of competence and self-satisfaction among the nurses, sometimes it can have negative consequences for them. Participant no. 5 says:

“I see the patient is suffering from an illness, I think if I can do something for him, it will be good … I have such a feeling, I think if my mother were here, what would I do for her?”

Approach of the legal duty and protection of the patients and nurses

In this approach, nurses not only try to do their organizational and legal duty, but also attempt to respond to their own needs and the patients’ needs. In this approach, nurses fulfill their legal obligations in patients’ care, respond to patients’ needs, and implement the physician's prescriptions. Therefore, the nurses, along with doing their duty, protect not only the patients but themselves as well. They make an adequate balance between their own and their patients’ protection.

Caring is a moral practice. Nurses with ethical practice make ethical relationships through which they understand the needs, feelings, and wishes of the patients and their families. It seems that caring is related to believing in God, altruism, responsibility, experience, knowledge, and occupational interest of nurses. It also may be affected by the lack of equipments, lack of material and human resources, as well as colleagues’ collaboration and cooperation. Participant no. 17 says:

“… But at least, I feel that we are working very well at midnight for our patients … there is someone (God) who sees us.”

Participant no. 5 also says:

“Well, maybe in one shift, I am so tired to be able to take care of the patients well; therefore, I do only my routine tasks. But in another shift, I’m very well, so I even take much better care of very critically ill patients.”

In caring, nurses use prioritization to balance their duties, pay attention to the patients, and also consider themselves. The patient's self-care ability, type of needs, physical condition, and age are the items that are considered in the prioritization. Participant no. 12 states:

“Sometimes, our ward gets so crowded and one of the patients is so ill in such a way that three nurses should only work on him. Therefore, we cannot work on other patients. But during the work, whenever we may have time, we have a look at them to make them sure that we are there.”

Responsiveness means a quick and timely response to clients’ needs and desires, and is commonly accompanied with human emotions.

It seems that nurses’ responsiveness is beyond mere taking care in the legal level of nurses’ duty. It can also be beyond their legal obligations and relates the legal duty approach to the beyond legal duty approach. On the contrary, irresponsiveness can relate the legal duty approach to the below legal duty approach.

According to the findings, nurses’ beliefs, understanding, empathy and altruism, experience, and knowledge can lead to proper responses to the needs and demands of the patients, and this can result in no harm to the patients, their perceived emotional support, sense of comfort and security, and satisfaction, and also provide a sense of comfort, a sense of satisfaction, and competence in nurses. In contrast, lack of time, shortage of nursing staff, lack of equipments, and inadequate system of nursing care can lead to an inappropriate response to the needs and wishes of the clients. These can result in some consequences such as injury to the patients, clients’ distress and dissatisfaction, a sense of insecurity in the clients, and their conflict with the nurses.

Participant no. 7 states:

“Sometimes patients may have unreasonable demands; we try to convince them … we use the placebo. We inject distilled water. In this way, we meet their demands. We use different ways to comfort the patient.”

Also, participant no. 12 says:

“Because we’re working with human being, we should always devote a part of our life to the patients, not only to the patients but also to their families.”

Implementation of physician's prescriptions by nurses has a variety of dimensions and features. It can be done timely or with a delay, accurately and completely, or wrongly and incompletely. However, the quality of implementation of medical prescriptions is influenced by the physician's characteristics.

Unquestioning adherence to physicians’ orders and their implementation is accomplished in the written prescriptions of the physicians. In a situation of possible damage to the patients, two factors are leading the nurses to undisputed compliant and implementation of physician's prescriptions: Believing in more knowledge of the physicians and lack of accountability of the nurses concerning damage to the patients.

Nurses’ reactions to oral prescriptions of the doctors vary regarding the patients’ conditions as well as their constraints. Some nurses do not run oral prescriptions of the physicians in circumstances such as the history of trauma in the patients and the patient's death following the oral prescriptions. Others run oral prescriptions of the physicians when they lead to reduction of patients’ restlessness and relief of their pain. Participant no. 14 states:

“…Well, because it is to patients’ benefit, I do that, unless you have a specific patient, such as a patient with active bleeding. Here, I certainly directly consult with a doctor to know if I should do an intervention or not.”

Approach of below the legal duty and protection of self

In this approach, nurses neither desirably act based on their legal and moral duty nor protect the patients. They try to protect themselves. They can seek the witness and try to provide evidences to prove the absence of their negligence or false recording. They act lower than their legal and moral duty through negligence, error, and malpractice.

Finding an evidence and having a witness is one of the ways that nurses frequently use to protect themselves. One of the factors that cause nurses to behave this way is fear of malpractice imputing it to the nurses, especially when the patients are injured or die. Therefore, this element may prevent imputing the shortcoming to the nurses and their legal prosecutions.

False documentation means although nurses ignore an intervention for the patients, they record doing it in the nursing notes to protect themselves. Most of the nurses not only do it in the practice of routine nursing care and stabilized situations of the patients, but also in the shortage of nursing personnel and their inability to respond to patients’ needs as well as in cases of the fear of accountability and legal prosecutions.

Participant no. 6 says:

“Maybe they say why the pulse rate of this patient has not been recorded? I am doing that to be acquitted from attributed guilt.”

Shortcomings mean failing to do the tasks, incompletely doing them, or refusal to do those that have been delegated to the nurses. It seems that the characteristics such as a lack of belief in correct performance, little knowledge, inability to have empathy, lack of the interest in the job, and low job satisfaction in nurses, as well as features such as work overload, shortage of nursing staff, lack of equipments, and inadequate system of nursing care evaluation, and sometimes inappropriate punishment and reward are related to negligence, carelessness, and making mistakes among nurses. However, these malpractices may be associated with causing harm to patients and result in their death, and also result in guiltiness and sadness in nurses. Participant no. 3 states:

“The day when I have a fault in administration of the patients’ care, I cannot be sure of a comfortable night sleep. I feel ashamed, I feel having conscious torment.”

Also, participant no. 14 says:

“It was never intentional, especially with the work overload that we have, it is inevitable.”

DISCUSSION

According to the findings, nurses adopt three major approaches in their behaviors in ethical decision-making. In the approach of beyond the legal duty and protection of the patients, nurses apply dedication and full availability of their job to the clients, spend time on their patients and have a delayed exit from their workplace, and arbitrary practice that help to protect, preserve, promote, and improve the health of patients. These behaviors, on the one hand, provide comfort of conscience, sense of competence, and self-satisfaction in nurses and satisfaction in the clients. On the other hand, these can cause stress and problems that endanger the nurses’ health. According to Chiovitti, there are ongoing discussions about nursing care in the literature review and analysis of care among the nursing scholars.[17]

Findings showed that the characteristics such as faith and belief in having right performance, ability of understanding, empathy and altruism, as well as moral sensitivity in nurses are associated with beyond the legal duty and protection of the patients’ behaviors. According to the findings of Goethals et al., the effects of nurses’ beliefs and values on their ethical behaviors to provide the best care to the patients are more than organizational expectations and rules. These studies suggest that knowledge, experience, courage, willingness to risk taking, and problem-solving skills of the nurses play roles in their reasoning and ethical behavior, especially in the post-conventional stage of Kohlberg's moral development theory.[1]

This study shows that work overload, shortage of nursing staff, and lack of equipments cannot be an obstacle to use the beyond legal duty and protection of patients’ behaviors by the nurses. Kalvemark et al. showed that nurses, in the best interest of their patients, want to follow their moral decisions, but they are confronted with organizational and legal restrictions in their reasoning and behaviors.[13] Sturm says that because the role of care ethics is to promote moral care in relation with patients’ health and welfare, it is justified even when interfered with the laws and regulations of health services.[4] It is done for the sake of patients and due to nurses’ altruism. If it is not so, the nurse faces conscience torment and moral distress.[3] Neville writes that there are important individual characteristics and virtues that a good nurse should have.[2] Overall, we can say that the nurses in this approach have a high level of moral reasoning, and they apply care beyond the conventional approach (post-conventional stage) in Kohlberg's moral reasoning in ethical behaviors. As Dierckx de Casterle’ et al. say, nurses who are able to argue on the post-conventional reasoning are not influenced by conventional and pre-conventional considerations.[5] In this approach, the nurses’ personal values and beliefs are developed and environmental factors such as legal and structural constraints do not affect reasoning and moral behaviors of nurses.

In the approach of legal duty and protection of patients and nurses, nurses, by caring, responding, and implementing the physician's prescriptions, not only try to perform their organizational and legal duty but also attempt to respond to their own needs and their patients’ needs. Sturm[4] and Goethals et al.[1] showed that contextual characteristics and factors actually restrict nurses’ abilities to make decisions and they act in accordance with their values and norms. Nurses should consider not only the self-moral status but also the physicians’ authority, workplace stress, complex status of the patients, inadequate resources, lack of time, and work overload, as well as the rules and routines governing their organization. Due to these factors, nurses experience various difficulties in making decisions and behaving ethically.

According to the findings, in this approach, nurses protect the patients and themselves, along with doing their duty. They make an adequate balance between protection of the patients and their own protection. Goethals et al. revealed that some nurses are considered middle ground between their own values and colleagues’ and organizational values. Personal characteristics of nurses, nurses’ positions, importance of these positions, implicit and explicit traditions, and negative outcomes may affect the circumstances of these behaviors.[1]

According to Dierckx de Casterle’ and colleagues, nurses who are influenced by contextual and environmental factors (conventional) in their ethical practices have difficulties in implementing the ethical decisions.[5] The results of this study and Goethals et al. showed that good ethical practice of nurses is affected by difficult work conditions. The effect of context on ethical practice of nurses is not only supported by studies but also consistent with Kohlberg's theory of moral development. According to Goethals et al. and Ulrich and colleagues, in moral action, context is not only important but also a problematic factor. Difficult contextual factors cause moral distress and prevent the nurses from practicing what they like. These situations lead to feelings of powerlessness, frustration, dissatisfaction, anger, somatic disorders, exhaustion, and quitting the profession in nurses.[118]

It seems that nurses who use the approach of legal duty and protection of the patients and nurses are in conventional reasoning level in Kohlberg's theory. Ethical decisions and behaviors of these nurses are affected by the professional norms, rules, and regulations, and are congruent with the principles and values, and opinions and expectations of others. It is clear that the accurate and clear organizational rules and regulations as well as sufficient equipments and facilities, parallel with the needs of the patients and the expectations of others can help nurses to develop their moral behaviors.

In the approach of below the legal duty and protection of self, nurses seek the witness and provide evidences to prove the absence of negligence or false recording to protect themselves. They act lower than the legal and moral duty through negligence, error, and malpractice. They neither perform the legal and moral duty at a desirable level nor protect the patients. They try to use various ways to protect themselves rather than to protect the patients.

Nayna and Philipsen write that if a person acts so carelessly that it causes someone to get hurt, he/she has neglected the law (legal negligence), and this is a malpractice in nursing.[19] Johnstone and Kanitsaki say a nursing mistake is an accident without intent, which is done by a nurse and may have an adverse effect on patients’ safety and quality of care.[1920] Chard states that lack of support from healthcare professionals for those who commit an error leads to discouragement of error reporting.[21]

In this approach, we can say that nurses use a very limited form of moral reasoning of Kohlberg's theory in which they rely on the pre-conventional level. It seems that having detailed rules and regulations as well as an integrated system of reward and punishment in an organization can be important. They can have constructive roles in the development of ethical behaviors of nurses. According to Garrett, there is a relationship between nurse staffing levels and patient output in health care. A higher nurse staffing level leads to better patient outcomes, compared to lower levels of nurse staffing.[22] It is important to have staff empowerment to protect patients and nurses in healthcare system. Creating supportive environments with humanistic and problem-solving orientation is necessary. Given that one of the major outcomes of the first and third approaches in ethical behavior of nurses is stress, establishment of ethics training and support systems for the nurses will be crucial.

According to the finding of this study and the results of Goethals et al.[1] and Dierckx de Casterle’ et al.[5], we can say that nurses use different theories and principles in their ethical behaviors and ethical decision-making. They consider both ethics of justice and ethics of care prospectives. Nurses who use the first approach focus on post-conventional reasoning in Kohlberg's theory. Some of the nurses use the legal duty and protection of the patients and nurses approach in behaviors, which emphasizes on conventional reasoning. Some others act below the legal duty and protection of self which shows pre-conventional reasoning. Also, we can say that reasoning level and ethical behaviors of the nurses are changed along with the changes in the individual characteristics, environmental and organizational situations. They developed and transitioned from the pre-conventional reasoning to post-conventional reasoning in Kohlberg's prospective, and from below legal duty and protection of self to beyond legal duty and protection of the patients’ behavior in this study.

It is clear that gaining ability to practice at the post-conventional level of Kohlberg's moral theory and beyond legal duty and protection of the patients is important to help the protection, health improvement, and the patients’ maximum benefit. This can be done by supporting and contributing the moral development of nurses and taking serious steps to remove the barriers for the nurses to behave in the beyond legal duty and protection of the patients approach in healthcare system. If the patients’ health and ethical nursing practice are important for nursing care system, finding the ways to resolve ethical problems to promote ethical competence in nurses and to reduce their functioning below legal duty and protection of self approach will be essential. Through appraising, educating, and clarifying of nursing care managers and policymakers about the ethics of care indicators, it can be justified that removing the legal and structural restrictions for ethical nursing practice is important. Appraising, educating, and empowerment of the nurses can help to develop an ethical environment and motivate the nurses to apply their excellent ethical behaviors.

Further investigations on the personal characteristics and environmental and organizational factors influencing the thinking, reasoning, and moral behavior of nurses are necessary. Nursing education, practice, and research must focus on developing methods and strategies that support ethical behaviors of nurses. Empowering nurses, nurse educators, and nursing students to acquire knowledge and develop skills to give good care and participate in ethical decision-making is important. Encouragement of nurses and nursing students to express their concerns, problems, and ethical issues in teaching, training, and practice can also be helpful.

Among the limitations of this study, restrictions in generalization of the results can be mentioned. As interview method was used for data collection, the veracity of the interviewees might have affected the results. However, in this study, data collection and analysis continued until saturation, but the limited number of volunteers participating in the study and the limitation of study concerning selection of only the educational hospitals of Tabriz University of Medical Sciences might have also affected the transferability of the results. Therefore, conducting more studies focusing on triangulation methods is suggested.

CONCLUSION

Overall, the findings suggest that nurses’ approaches to ethical behaviors in decision-making can be seen on a continuum. On the one hand, there is the approach of beyond the legal duty and protection of patients, and on the other, the approach of below the legal duty and protection of self. The more the nurses act beyond their legal duty and protect the patients, the greater they may feel the sense of competence, comfort of conscience, satisfaction, and other positive psycho-emotions. Nevertheless, they may harm themselves and suffer from job stress due to legal and structural constraints. The more they act below the legal duty and toward protection of self, the greater they may feel the sense of incompetence, discomfort of conscience, dissatisfaction, and other negative psycho-emotions. They may also harm the patients and suffer from moral distress due to violating their values.

Considering the personal and professional characteristics of the nurses and other contextual factors, we can compare ethical behavior approaches of nurses with moral reasoning of both orientations of ethics of justice and ethics of care. Selection of duty approach can be comparable with the ethics of justice,[23] and selection of protective approach can be compatible with the ethics of care.[24] Nurses with the first approach may be morally in post-conventional level, since they behave based on personally developed moral standards. Nurses with the second approach may be in conventional level. Finally, nurses with the third approach may be in pre-conventional level of moral reasoning.