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Nursing Ethics
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Ethical conflict among nurses ª The Author(s) 2018
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Amir-Hossein Pishgooie
AJA University of Medical Sciences, Tehran, Iran
Maasoumeh Barkhordari-Sharifabad
Yazd Branch, Islamic Azad University, Yazd, Iran

Foroozan Atashzadeh-Shoorideh
Shahid Beheshti University of Medical Sciences, Tehran, Iran
Anna Falcó-Pegueroles
University of Barcelona, Barcelona, Spain

Abstract
Background: Ethical conflict is a barrier to decision-making process and is a problem derived from ethical
responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this
phenomenon. A deep study of the phenomenon can help prevent and treat it.
Objectives: This study was aimed at determining the frequency, degree, level of exposure, and type of
ethical conflict among nurses working in the intensive care units.
Research design: This was a descriptive cross-sectional research.
Participants and research context: In total, 382 nurses working in the intensive care units in Iranian
hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in
Nursing Questionnaire-Critical Care Version (Persian version).
Ethical considerations: This study was approved by the Medical Research Ethics Committee. Ethical
considerations such as completing the informed consent form, ensuring confidentiality of information, and
voluntary participation were observed.
Findings: The results showed that the average level of exposure to ethical conflict was 164.39 + 79.06.
The most frequent conflict was related to “using resources despite believing in its futility,” with the
frequency of at least once a week or a month (68.6%, n ¼ 262). The most conflictive situation was
violation of privacy (76.9%, n ¼ 294). However, the level of exposure to ethical conflict according to the
theoretical model followed was the situation of “working with incompetent staff.” The most frequently
observed type of conflict was moral dilemma.
Conclusion: The moderate level of exposure to ethical conflict was consistent with the results of previous
studies. However, the frequency, degree, and type of ethical conflict were different compared to the results
of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to

Corresponding author: Foroozan Atashzadeh-Shoorideh, Department of Nursing Management, School of Nursing and Midwifery,
Shahid Beheshti University of Medical Sciences, Vali-Asr Avenue, Cross of Vali-Asr and Hashemi Rafsanjani (Neiaiesh) Highway,
Opposite to Rajaee Heart Hospital, Tehran 1996835119, Iran.
Email: f_atashzadeh@sbmu.ac.ir
2 Nursing Ethics XX(X)

consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent
ethical conflicts, and improve the nursing work environment.

Keywords
Ethical conflict, intensive care units, moral dilemma, moral distress, nurses

Introduction
Given the interpersonal nature of the relationships in the healthcare system and the ethical responsibilities
involved in caring for people with health problems, ethical conflicts become clearly evident in healthcare
professionals.1 In the recent decades, ethical conflicts have increased in the field of nursing due to the
increasing complexity of care and scientific and technological advancements.2 This issue sometimes con-
tradicts the values of healthcare service providers.3 In other words, the behavior and decision-making of
nurses are influenced by factors related to their personal, organizational, and professional environment.4
When personal and professional ethical values are not compatible with the organizational values or employ-
ees are pressured by managers to act against their values, this leads to the organizational–personal and
organizational–professional conflicts.5–7
In fact, the phenomenon of ethical conflict is a complex construct that involves not only the inability to
perform an ethical action due to the existence of obstacles (moral distress), but also other problems such as
the lack of recognition of values and ethics (moral uncertainty), having difficulty in choosing two moral
values (moral dilemma), and a feeling of inability to deal with the immoral act of others (moral outrage).1
Such ethical conflict, as a phenomenon, implies the verification of a situation where the ethical and
bioethical principles assumed by one in relation to the care of the patient are violated. Ethical conflict is
a barrier to the decision-making process and is a problem derived from ethical responsibilities that nurses
assume with care.8
Nurses working in the intensive care units (ICUs) are subject to ethical conflicts.2,9,10 ICU is one of the
most critical and stressful parts in a hospital. In this unit, a team composed of several specialists provides
necessary care to the patients with critical conditions and life risk using all of the medical equipment and
facilities.9,11 Issues such as the problem of informed consent, failure to observe confidentiality or lack of
protection of patient rights,12 provision of some overly aggressive treatments, ineffective pain management,
and failure to perform life-saving measures (end-of-life care)1,13,14 cause the emergence of more ethical
conflicts among the nurses working in the ICUs. The dynamic nature of the work environment including the
lack of complete involvement of nurses in the decision-making process, moral disagreements between
doctors and nurses about certain decisions or practices or lack of time to provide high-quality critical care,
and difficulty in meeting issues of bioethical nature1,9,12,15–17 also plays an important role in the prevalence
of ethical conflicts.
Besides its impact on the decision-making process, ethical conflicts may have negative consequences at
other levels. At the individual level, studies have shown that ethical conflicts may cause discomfort,
frustration, anger, and a sense of lack of moral integrity and affect their self-esteem and coping beha-
viors.13,18 At the professional level, ethical conflicts can reduce the level of teamwork, create problems in
interpersonal communication, undermine nurse leadership, and may lead to the abandonment of services or
even profession.17–20 Some other studies have also linked moral distress, a type of ethical conflict, to
burnout.20,21 In this regard, Papathanassoglou et al.22 found that lower level of autonomy in decision-
making, which is the result of ethical conflict, is associated with the increased frequency and severity of
moral distress and lower levels of nurse–physician collaboration. This poor interprofessional collaboration
Pishgooie et al. 3

does not only result in increased injuries to patients,23–25 but also cause moral distress in nurses,26,27
increased costs for additional care for patients due to the errors,26 reduced level of patients’ satisfaction,28
and increased caregivers’ dissatisfaction and quitting the service.23 These results are in contrast to the
efforts of the healthcare organizations to improve the quality of care, safety, and patient satisfaction level,5
which ultimately endanger the interests of these organizations.29
The Islamic Republic of Iran is located in the Middle East and is the home of some of the world’s oldest
civilizations. The official religion of this country is Islam and religious attitudes and beliefs have expanded
in all aspects of Iranian life, including the healthcare system.30,31 Respect for human and moral values has a
special place in the Iranian culture and among nurses, and ethical issues are highlighted in patient care.32,33
Codes of nursing ethics in Iran were approved by High Council of Ethics of Ministry of Health and
Medical Education in 2011 for all nurses in the fields of education, research, management, and clinical
care for shaping nurses’ ethical behaviors, which directly focus on nurses’ performance for patient
care.34,35 These codes are mainly based on International Council of Nurses Code of Ethics.36 Codes of
nursing ethics address value concepts such as maintaining dignity, adhering to professional commit-
ments, responsibility, protecting the privacy of patients, enhancing scientific and practical competence,
and respecting individual autonomy.37
However, Iranian nurses, like many nurses from other countries, face some challenges that affect their
ethics in practice.38,39 These challenges are mainly due to the nursing shortage, job dissatisfaction, and poor
social status,40 which can lead to moral distress in nurses and consequently burnout and abandonment of the
profession.41,42
Given the importance of the concept of ethical conflict in nurses and its impact on the quality of care and
services provided for the patients, patient safety, and the role of this concept in the health of these health
professionals, the need for further studies in this field becomes more relevant. Recognition of ethical
conflict among nurses is a basic and fundamental step in dealing with the issue of ethical conflict to promote
the ethical climate in critical care units. Therefore, the research question of this study was as follows: what
are the level of exposure and characteristics of ethical conflict among Iranian critical care nurses? The aim
was to investigate the frequency, degree, level of exposure, and type of ethical conflict among nurses
working in ICUs in the selected educational hospitals of the Iranian universities of medical sciences.

Method
Research design
This was a descriptive cross-sectional multicenter study conducted during 2016–2017. Considering a total
of 6000 nurses working in the ICUs in the educational hospitals of Iran, the sample size was determined as
361 individuals based on the Krejcie and Morgan43 table. A total of 400 questionnaires were distributed
among the participants considering a subject attrition rate of 10%. After gathering the questionnaires, 382
completed questionnaires were analyzed. The multi-stage random sampling method was applied to select
the sample of the study; using this method, all universities of medical sciences in Iran were divided into five
regions of the north, the south, the east, the west, and the center, and two universities were selected from
each region. Then, two hospitals were randomly selected from each university and the required number of
samples in each class was obtained proportional to the size of the number of nurses employed in the selected
hospital. Random sampling was used to select the nurses from the study population.
The inclusion criteria were as follows: a Bachelor’s or Master’s degree in nursing, a minimum of
6 months of employment in the ICU and willingness to participate in the study. The exclusion
criterion was as follows: the nurses who answered the questionnaires incompletely given the cross-
sectional data collection procedure.
4 Nursing Ethics XX(X)

Data collection tools

A form and a questionnaire were used in this study. The form contained eight questions on the demographic
information including age, gender, level of education, type of employment, type of ICUs (General ICU,
Internal Ward, Neurological Unit, Surgical Unit, and Pediatric Unit), work shift, and work experience
(record of service).
The questionnaire was the Ethical Conflict in Nursing Questionnaire-Critical Care Version (ECNQ-
CCV) originally developed and verified by Falcó-Pegueroles et al.2 in Spanish. It was cross-culturally
adapted and validated by Motaharifar et al.44 in the Persian language. This questionnaire was developed
to empirically validate the ethical conflict model which explains the phenomenon from the analysis of the
relationship between the index of exposure to ethical conflict and the typology of ethical conflicts and
moral states.
Similar to the original version, the questionnaire includes 19 scenarios, each of which describes the
situations in which the nurse may experience ethical conflict (Table 1). For each scenario, three
questions are presented in terms of the frequency of ethical conflict (on a five-point Likert-type
scale), the degree of perceived ethical conflict (on a five-point Likert-type scale), and the type of
the experienced ethical conflict.
The level of exposure to ethical conflict is obtained through multiplying the frequency of conflict by its
intensity. Therefore, the score range of the conflict level for each scenario would be from 0 to 25. A score of
zero represents the frequency of zero (never) multiplied by the intensity 1 (not problematic) and the score of
25 shows the frequency of 5 (at least once a week) multiplied by the intensity 5 (very problematic). The
scores for the conflict level ranged from 0 to 475, and higher scores indicated a greater level of conflict.2
The ECNQ-CCV identifies four types of ethical conflicts including the moral uncertainty, moral dilemma,
moral distress, and moral outrage, while the type of conflict is reported as percentage. Ethical indifference
and moral health indicate lack of ethical conflict.
Based on the study by Bond et al.,45 low (<1 standard deviation (SD) below the mean), high (>1 SD
above the mean), and moderate (between these two ranges) levels of exposure to ethical conflict
were defined.1
The original version of the tool obtained a Cronbach’s alpha of 0.882.2 The Persian version verified by
Motaharifar et al.44 in Iran, showed an acceptable face and content validity for this scale; the value of
Cronbach’s alpha coefficient for the whole scale was obtained as 0.92.

Ethical considerations
This research was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences
(IR.SBMU.PHNM.1396, 806). The form and the questionnaire were submitted to the research units after
obtaining legal permissions from the above-mentioned universities and hospitals. To observe the ethical
principles, the informed written consent was completed by all participants. In addition, the participants were
assured that their information would be kept confidential and all of them expressed their consent to
participate in the study. All participants were aware of the research objectives and the voluntary nature
of their participation. They were told that they could leave the study at any stage.

Data analysis
The data analysis was performed using SPSS 20. The descriptive statistics of the frequency and percentage
and mean and SD were applied to analyze the obtained data. Before conducting the tests, normal distribution
of data was confirmed by the Kolmogorov–Smirnov (KS) test and Shapiro–Wilk test to determine the
Pishgooie et al. 5

Table 1. Scenarios described in the original ECNQ-CCV by Falcó-Pegueroles et al.8

Scenario 1: Running treatments and/or performing tests, which are unnecessary in my opinion because they lead us to
an irreversible and terminal process.
Scenario 2: Having to administer treatments or carry out procedures without the permission of the critical patient who
is conscious but he or she does not know the treatments purpose or the risks involved.
Scenario 3: Caring for a patient who I believe should be on an ordinary hospital setting rather than in the ICU.
Scenario 4: Performing interventions or healthcare that gives institutional benefits more than what they give to the
patient.
Scenario 5: Failure to keep patient’s confidential clinical data by sharing them with third parties or with people who are
not directly involved in the patient’s care.
Scenario 6: Performing treatments and/or carrying out interventions without patient’s families knowing the objectives,
benefits, and risks associated (when the patient has consented to the family being informed).
Scenario 7: Realizing that the analgesia and or sedation given to the patient are not effective enough, and the patient is
suffering.
Scenario 8: Using all available technical and/or human resources despite believing that they will produce no significant
improvement in the clinical status of patients in intensive care.
Scenario 9: Working with medical staff who I consider to be professionally incompetent.
Scenario 10: Perform treatments and/or carrying out interventions in accordance with the patient’s families’ wishes,
despite knowing that these clash with the interests of the patient.
Scenario 11: Performing treatments or applying procedures that are too aggressive given the status of the patient, and in
so doing causing the patient additional suffering.
Scenario 12: Working with a nurse or nursing assistant who I consider to be professionally incompetent.
Scenario 13: Acting against my moral beliefs due to not having enough time to care properly for the patient.
Scenario 14: Administering treatments in the context of a clinical or research project without, as a nurse, being given all
the information I consider necessary to carry out this task.
Scenario 15: Finding it difficult to give timely information to the patient and his or her family because the medical team
discourages nurses from taking the initiative in this regard.
Scenario 16a: Caring for a patient without knowing whether he or she made a living will declaration, or in the event that
such a document exists, not knowing its content.
Scenario 17: Administering treatments and procedures without, as a nurse, having been previously involved in the
decision to do so.
Scenario 18: Failure to observe proper patient privacy during diagnostic procedures or tests
Scenario 19: Lacking the equipment (space) or resources (time) that would enable the clinical team to consider the
ethical problems they have to deal with
ECNQ-CCV: Ethical Conflict in Nursing Questionnaire-Critical Care Version; ICU: Intensive Care Unit.
a
Note that in Table 1: In ECNQ-CCV-Persian version translated by Motaharifar et al.44 into Farsi, Scenario 16 was changed for cross-
cultural adaptation for the Iranian clinical context, for “Scenario 16: Caring for a patient without her or his opinion or option about
what treatments would be performed to keep her or him alive.”

goodness of fit of the distribution of the variable level of exposure to ethical conflict. A confidence level of
95% was assumed.

Findings
Among the 382 nurses who participated in this study, the majority (71.2%) were female, 79.8% held a
Bachelor’s degree in Nursing, 32.5% were professionals working in the general ICUs, and 57.8% had
circulating work shifts. The majority of the participants included nurse practitioners (75.4%) who had
voluntary overtime shifts (68.8%). The average age of the participants was 31.19 years and their average
work experience was 4.82 years (Table 2).
6 Nursing Ethics XX(X)

Table 2. Demographic information and work characteristics of the study participants.

Variable Category N (%)

Gender Female 272 (71.2)

Male 110 (28.8)
Level of education Bachelor’s degree 305 (79.8)
Master’s degree 77 (20.2)
Type of ICU ward General 124 (32.5)
Surgical 72 (18.8)
Open heart surgery 69 (18.1)
Respiratory 52 (13.6)
Neurosurgical 65 (17)
Type of working shift Morning 48 (12.6)
Evening 52 (13.6)
Night 61 (16)
Rotation 221 (57.8)
Job position Registered nurse 228 (75.4)
Head nurse 94 (24.6)
Overtime type Mandatory 119 (31.2)
Optional 263 (68.8)

Mean + SD

Age (years) 23–44 31.19 + 5.34

Work experience (years) 1–15 4.82 + 3.02

ICU: intensive care unit; SD: standard deviation.

Frequency and degree of ethical conflicts

The results of data analysis showed that the greatest frequency of conflict was related to Scenario 8:
“Using all available technical and/or human resources despite believing that they will produce no
significant improvement in the clinical status of patients in intensive care,” with the frequency of at
least once a week (36.4%, n ¼ 139) or at least once a month (32.2%, n ¼ 123), which represents
68.6% of the sample. In the same line, Scenario 1: “Running treatments and/or performing tests which
are unnecessary in my opinion because they lead us to an irreversible and terminal process” has a
high frequency of at least once a month (40.1%, n ¼ 153) or at least once a week (35.6%, n ¼ 136),
with 75.7% of the results. Moreover, Scenario 3: “Caring for a patient who I believe should be on
an ordinary hospital setting rather than in the ICU” had a frequency of at least once a month (40.6%,
n ¼ 155).
At the other extreme, the situation that occurred very infrequently was Scenario 5: “Failure to keep
patient’s confidential clinical data by sharing them with third parties or with people who are not directly
involved in the patient’s care,” which occurs almost never (45%, n ¼ 172) or at least once a year (35.6%, n ¼
136). Considering the frequency at least once a year, Scenario 10: “Performing treatments and/or carrying
out interventions in accordance with the patient’s families’ wishes, despite knowing that these clash with the
interests of the patient”; Scenario 14: “Administering treatments in the context of a clinical or research
project without, as a nurse, being given all the information I consider necessary to carry out this task”; and
Scenario 15: “Finding it difficult to give timely information to the patient and his or her family because the
medical team discourage nurses from taking the initiative in this regard” had similar proportions of the rate
of around 46–48 responses (Table 3).
Pishgooie et al. 7

Table 3. Frequencies and percentages for “frequency with which ethically conflictive situations emerged” (for n ¼ 382).

At least once At least once At least once At least once

Almost never a year every 6 months a month a week
Situations that are
potentially ethical conflict n % n % n % n % n %

Scenario 1 – – 13 3.4 80 29.9 153 40.1 136 35.6

Scenario 2 78 20.4 114 29.8 73 19.2 75 19.6 42 11
Scenario 3 6 1.6 51 13.4 112 29.2 155 40.6 58 15.2
Scenario 4 41 10.7 75 19.6 120 31.4 119 31.2 27 7.1
Scenario 5 172 45 136 35.6 37 9.7 15 3.9 22 5.8
Scenario 6 118 30.9 128 33.5 76 19.9 55 14.4 5 1.3
Scenario 7 64 16.8 109 28.5 86 22.5 67 17.5 56 14.7
Scenario 8 4 1 12 3.2 104 27.2 123 32.2 139 36.4
Scenario 9 12 3.1 40 10.5 74 19.4 130 34 126 33
Scenario 10 123 32.2 178 46.6 31 8.1 31 8.1 19 5
Scenario 11 17 4.4 114 29.8 119 31.2 89 23.3 43 11.3
Scenario 12 1 0.3 29 7.6 101 26.4 145 38 106 27.7
Scenario 13 56 14.7 112 29.3 116 30.4 57 14.9 41 10.7
Scenario 14 152 39.8 185 48.4 45 11.8 – – – –
Scenario 15 108 28.3 159 41.6 44 11.5 39 10.2 32 8.4
Scenario 16 56 14.7 64 16.7 82 21.5 107 28 73 19.1
Scenario 17 26 6.8 80 20.9 128 33.6 73 19.1 75 19.6
Scenario 18 24 6.3 81 21.1 126 33 79 20.7 72 18.8
Scenario 19 34 8.9 70 18.3 136 35.6 75 19.6 67 17.5

As far as the degree of ethical conflict was concerned, independent of the frequency that occurred, there
were not any scenarios that were very problematic. The major rates of responses were between “somewhat
problematic” and “a little problematic.” In this line, Scenario 18: “Failure to observe proper patient privacy
during diagnostic procedures or tests” (76.9%, n ¼ 294) and Scenario 7: “Realizing that the analgesia and or
sedation given to the patient is not effective enough, and the patient is suffering” (78.2%, n ¼ 299) are
highlighted.
On the other hand, Scenario 14: “Administering treatments in the context of a clinical or research project
without, as a nurse, being given all the information I consider necessary to carry out this task” was
considered by 43.8% (n ¼ 167) as not problematic and Scenario 3: “Caring for a patient who I believe
should be on an ordinary hospital setting rather than in the ICU” was considered by 38.7% (n ¼ 148) as not
problematic too (Table 4).

Level of exposure to ethical conflict

According to the theoretical model of exposure to ethical conflict, this exposure resulted from the product of
the frequency and the level of ethical conflict product, named index of exposure to ethical conflict. The
descriptive analysis of the data showed the average ethical conflict level of 164.39 (SD ¼ 79.06, range:
51–435; Table 5). The result of the KS test (statistic ¼ 0.175; df ¼ 382; p < 0.001) and the Shapiro–Wilk test
(statistic ¼ 0.849; df ¼ 382; p < 0.001) indicated that the phenomenon observed in the sample did not fit the
normal curve.
Data analysis showed that the highest reported level of exposure to ethical conflict was for Scenario 9:
“Working with medical staff who I consider to be professionally incompetent” (13.84 + 6.91) and
8 Nursing Ethics XX(X)

Table 4. Frequencies and percentages for “degree of ethical conflict experienced by the nurse” (for n ¼ 382).

Not Little Somewhat Moderately Very

problematic problematic problematic problematic problematic
Situations that are
potentially ethical conflict n % n % n % n % n %

Scenario 1 47 12.3 142 37.2 157 41 17 4.5 19 5

Scenario 2 56 14.7 177 46.3 122 31.9 17 4.5 10 2.6
Scenario 3 148 38.7 100 26.2 82 21.5 33 8.6 19 5
Scenario 4 74 19.1 161 42.1 100 26.2 26 6.8 22 5.8
Scenario 5 123 32.2 144 37.7 63 16.5 30 7.9 22 5.8
Scenario 6 100 26.2 145 38 88 23 24 6.3 25 6.5
Scenario 7 30 7.9 188 49.1 111 29.1 53 13.9 – –
Scenario 8 64 16.8 81 21.2 102 26.7 78 20.4 57 14.9
Scenario 9 4 1 77 20.2 141 36.9 81 21.2 79 20.7
Scenario 10 79 20.7 166 43.5 94 24.5 17 4.5 26 6.8
Scenario 11 21 5.5 125 32.7 131 34.3 55 14.4 50 13.1
Scenario 12 1 0.3 65 17 171 44.8 65 17 80 20.9
Scenario 13 6 1.6 178 46.5 132 34.6 35 9.2 31 8.1
Scenario 14 167 43.8 110 28.8 52 13.6 12 3.1 41 10.7
Scenario 15 80 20.9 135 35.4 105 27.5 13 3.4 49 12.8
Scenario 16 105 27.5 142 37.2 89 23.3 13 3.4 33 8.6
Scenario 17 14 3.7 145 38 120 31.4 57 14.9 46 12
Scenario 18 – – 219 57.3 75 19.6 40 10.5 48 12.6
Scenario 19 6 1.6 180 47.1 109 28.5 43 11.3 44 11.5

Scenario 12: “Working with a nurse or nursing assistant who I consider to be professionally incompetent”
(13.8 + 6.58), both in the same line (Table 5).

Types of conflict and moral states

Moral dilemma was the ethical conflict type most frequently selected by the professionals in 15 of the 19
scenarios of the ECNQ-CCV. Scenario 11: “Performing treatments or applying procedures that are too
aggressive given the status of the patient, and in so doing causing the patient additional suffering” obtained a
greater rate of responses of moral dilemma (58.6%, n ¼ 224; Table 5).

Discussion
The results indicated that the level of exposure to ethical conflict for Iranian critical care nurses were
moderate and less than that for Spanish critical care nurses,1 with data obtained from the same theoretical
model and questionnaire. In the absence of specific studies, this difference could be attributed to cultural
and religious teaching factors, in particular with regard to resilience. Islam, as an official religion in Iran,
can be one of the main sources of resilience in nurses.46 Resilience is the ability to adapt positively to
adverse situations and successfully cope with a crisis. Mealer et al.47 pointed out that resilience offers a
belief in the ability and an optimistic philosophy of life, restores the belief of the individual, and gives the
person the courage to do the job. For Rushton et al.,48 moral resilience is “the ability to be resolute and
courageous in one’s moral action despite resistances or obstacles” and “being able to discern when one has
exerted sufficient effort to fulfill one’s ethical obligations and to be realistic about one’s limitation and the
constraints and pressures of the situation.” In the same line, an experts group recommended an essential step
Pishgooie et al. 9

Table 5. Index of exposure and types of ethical conflict (for n ¼ 382).

Index of exposure
to exposure to Moral Moral Moral Moral Moral Moral
Situations that are ethical conflict indifference well-being uncertainty dilemma distress outrage
potentially ethical
conflict Mean + SD n % n % n % n % n % n %

Scenario 1 10.66 + 5.35 – – 43 11.3 63 16.5 187 49 60 15.7 29 7.5

Scenario 2 7.16 + 5.47 19 5 38 9.9 40 10.5 215 53.6 42 11 28 7.3
Scenario 3 7.98 + 5.89 – – 132 34.6 37 9.7 180 47.1 33 8.6 – –
Scenario 4 7.87 + 5.45 12 3.1 61 16 45 11.7 155 40.6 79 20.4 30 7.9
Scenario 5 5.01 + 5.85 25 6.5 110 28.8 40 10.5 124 32.5 54 14.1 29 7.6
Scenario 6 5.83 + 5.26 3 0.8 89 23.3 48 12.6 154 40.3 66 17.2 22 5.8
Scenario 7 7.65 + 5.11 4 1 14 3.7 24 6.3 176 46.1 161 42.1 3 0.8
Scenario 8 12.51 + 7.19 – – 47 12.3 59 15.4 193 50.5 40 10.5 43 11.3
Scenario 9 13.84 + 6.91 1 0.3 3 0.8 1 0.3 170 44.4 97 25.4 110 28.8
Scenario 10 5.58 + 5.42 32 8.4 53 13.8 126 33 64 16.8 91 23.8 16 4.2
Scenario 11 9.63 + 5.99 – – 15 3.9 45 11.8 224 58.6 55 14.4 43 11.3
Scenario 12 13.8 + 6.58 – – 3 0.8 – – 189 49.5 62 16.2 128 33.5
Scenario 13 8.12 + 5.6 5 1.3 3 0.8 58 15.2 184 48.2 108 28.2 24 6.3
Scenario 14 4.07 + 3.8 14 3.7 121 31.7 84 22 81 21.1 52 13.6 30 7.9
Scenario 15 6.86 + 6.78 8 2.1 58 15.2 51 13.4 171 44.7 61 16 33 8.6
Scenario 16 7.65 + 5.93 – – 99 25.9 105 27.5 90 23.6 56 14.7 32 8.3
Scenario 17 10.42 + 6.83 10 2.6 5 1.3 19 5 201 52.6 64 16.8 83 21.7
Scenario 18 9.77 + 6.87 – – – – 27 7.1 176 46.1 94 24.5 85 22.3
Scenario 19 9.89 + 6.66 – – 7 1.5 49 12.8 142 37.2 105 27.5 79 20.7
Total 164.39 + 79.06
SD: standard deviation.

for addressing moral distress and supporting the cultivation of moral resilience for nurses, as a method to
deal with ethical conflicts.48 However, future research should study the relation of resilience and ethical
conflict in the critical care context and the role of religious teaching.
In Iran, the most frequent ethical conflicts were related to situations about medical futility and
dynamics of the service and the work environment. Running treatments considered as unnecessary, using
resources despite believing that they produce no significant improvement for the patient, and caring for
patient that should not be in the ICU were situations that involve the critical nurses at least every month.
These results are consistent with a study carried out in the ICUs in 24 countries. The results showed that
71.6% of nurses experienced ethical conflict once a week.9 However, despite the high frequency of these
situations, they are not experienced as especially conflictive, a finding that is different from other similar
previous studies.8,49–51
This could be attributed to different reasons. One of these justifications could be that nurses do not feel
that they are involved in decisions related to ICU dynamics because this kind of decisions implies only
physicians or there were not any specific protocols or documents for the decision-making process that help
nurses to know how to prevent futility and how to avoid circumstances that lead to mismanagement of
available resources. Also, it can be attributed to the lack of power in opposing to the different points of view
of physicians’ decisions due to fear of losing work, harassment, and displacement of the ward in the
physician-oriented healthcare organizations. Of course, difference in viewpoints on the purpose of treat-
ment and the definition of practical criteria and judgment in assigning the title of futility to a particular
treatment is also important, in the same line of Azoulay et al.9 and Ferrand et al.52
10 Nursing Ethics XX(X)

The situations of “the risk of infringing confidentiality” or “performing treatments in accordance to

families’ wishes, when these go against the interests of the patient” are very infrequent because the ICU
professionals prevent these potential ethical conflict scenarios. The protection of confidential clinical data
of patients is the most important ethical and legal duty in the field of medical and nursing ethics. According
to a study conducted by Mohajjel-Aghdam et al.34 in Iran, 97.4% of nurses were aware of the confidentiality
of patient information and privacy. Based on the virtue ethics emphasized by Islam, privacy data and
confidentiality are key virtues to build trust in the relationship between treatment team and patient.53
On the other hand, involving patients and their families in the decision-making process is an effective
measure to prevent ethical conflicts between them and the ICU team. One of the sources of ethical conflict is
when the medical team or the patient’s family disagrees with the wishes of the patient about his or her
health.54 A nurse who can understand the patient’s wishes is helpful in reaching the goal. Understanding
patient’s wishes requires patient involvement in decision-making, knowing the treatment choices and key
goals of patient, and sharing professional knowledge with the patient.55 Clarification of the matters related
to the patients’ need plays a supportive role for patients and their families, and decreases anxiety and stress
by increasing awareness.56
With regard to the situations that generate a degree of ethical conflict, although they are a little proble-
matic, there is a general agreement in identifying the failure to keep privacy of patients and to verify that
analgesia or sedation is not effective enough and the patient is suffering. Previous research has shown that
the ethical conflicts experienced by nurses in the ICU due to the decision-making process follow issues such
as confidentiality violation, lack of support of the patient’s benefits, and the provision of some therapies.57
Inadequate pain relief is one of the main causes of ethical conflict1 and moral stress in nurses that, for
example, work with oncology patients.58,59 In the context of this study, the reason for this different result
can be the professional characteristics of Iranian nurses working in ICUs where ethical knowledge plays a
role in controlling ethical conflicts.
When level of exposure to ethical conflict is explored, this means that we consider together variables
of frequency and degree, and two similar conflicting situations emerge. Both are considered as the result
of working with a nurse or a physician who is considered professionally incompetent. These results are
consistent with Mahdavi-Fashtami et al. It was also found that “aid to a doctor who is incompetent in the
view of the nurse” has the highest effective mean in creating moral distress.60 Azoulay et al.9 found that
sources of behavior-related conflicts were about mistrust, communication gaps, or misunderstandings
among the staff. In the same line, Swetz et al.51 pointed out that the most frequent causes of ethical
conflict in the ICUs were identified as the disagreement among professionals about care programs (76%),
end-of-life issues (60%), ineffective treatment (54%), and the unit’s characteristics (40%). Since ICU is
one of the most complex units in the hospitals, a high percentage of nurses or physicians working in these
units are composed of experienced professionals who are able to provide care to patients with critical
conditions. Therefore, it is not unexpected that working with incompetent nurses or physicians would
have the least frequency.
The most frequently observed type of conflict was the moral dilemma which was related to Scenario 11:
“Administering aggressive treatments and causing more suffering in the patients.” In line with the results of
this study, in the study of Laabs,61 moral dilemma was reported to be the most common type of conflict in
primary care nurses, and “the patient’s refusal of proper treatment” had the highest frequency. In the study
by McLennon et al.62 conducted on oncology nurses, the most frequently reported ethical dilemmas
encompassed uncertainties and barriers to truth telling, familial and cultural conflict, and treatment futility.
In the study with the sample of Spanish nurses, moral outrage was the ethical conflict type most frequently
selected by the professionals in 10 of the 19 situations considered in the ECNQ-CCV followed by moral
distress; indifference and moral dilemma ranked the next.8 It can be argued that the individual’s behavior in
Pishgooie et al. 11

the face of professional ethical problems can both depend on the methods of applying the principles, rules,
and values in the analysis of the subject, a question that should be analyzed in future studies.

Limitations and strengths

One of the limitations of this study was the self-report questionnaires used in this research, and like other
self-report tools there was the possibility of fatigue and lack of sufficient time. Therefore, some nurses may
refuse to provide real response to the questions based on social desirability. Another limitation was the
impossibility of controlling the mediating variables such as factors affecting the accuracy and focus of staff
when delivering the questionnaires due to the large amount of workload. Although the study is based on a
validated tool with 19 scenarios, it is necessary to consider that the levels of ethical conflict have been
studied in relation to these situations and not others. However, it is noted that these situations are the most
frequent or provable in the context of the critical care patients.
On the other hand, the strengths of this study are basically three: the sample size, the use of a ques-
tionnaire already validated in previous studies, and evidence levels of the presence of ethical conflicts
among Iranian critical care nurses, a problem that have never been analyzed before from this perspective.

Conclusion
Nurses had a moderate level of exposure to ethical conflicts in the ICUs, lower than other similar studies.
The most frequent ethical conflicts were related to situations about “medical futility” and “dynamics of the
ICU environment” and the most intensity of ethical conflict were related to “failure the compromise to
confidentiality” and “verify that analgesia or sedation is not effective enough and patient is suffering”.
However, when we study the level of exposure of ethical conflict as a whole, “Working with incompetent
professionals” generated the highest level, despite being a rare situation when analyzed specifically. This
provides a polyhedral view of the phenomenon as it can be explored by a model of analysis that studies
several elements that configure ethical conflict in the field of health or healthcare.
Examining the clinical situations experienced by nurses, identifying the factors affecting them in coping
with the ethical conflicts, and helping nurses working in the challenging clinical environments are of great
importance. The results of this study can be helpful in consolidating and reinforcing those measures that
favor low levels of ethical conflict, designing appropriate strategies to prevent ethical conflicts in critical
units, formulating clear rules and procedures to deal with the conflictive situations, and improving the
environmental conditions for nurses and other health professionals as well as the quality of patient care, and
the final result would be more professional adherence to the ethical standards.

Acknowledgements
The authors would like to thank also all the nurses who participated in the study.

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

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: The budget of this project was allocated by Shahid Beheshti University of
Medical Sciences, Tehran, Iran. The authors would like to thank the Deputy-in-Research at Shahid Beheshti
University of Medical Sciences who supported them financially.
12 Nursing Ethics XX(X)

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