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evidence & practice / research
DECISION-MAKING
Strengthening ethical decision-making:
the experience of Iranian nurses
Esmaelzadeh F, Abbaszadeh A, Borhani F et al (2017) Strengthening ethical decision-making: the experience of Iranian nurses.
Nursing Management. 24, 6, 33-39. Date of submission: 5 January; date of acceptance: 10 July 2017. doi: 10.7748/nm.2017.e1610
Fatemeh Esmaelzadeh
Doctoral student and clinical
instructor, Nursing Research
Center, Razi Faculty of Nursing
and Midwifery, Kerman
University of Medical Sciences,
Kerman, Iran
Abbas Abbaszadeh
Professor of nursing, School
of Nursing and Midwifery,
Medical Ethics and Law
Research Center, Shahid
Beheshti University of Medical
Sciences, Tehran, Iran
Fariba Borhani
Associate professor of nursing,
Medical Ethics and Law
Research Center, School of
Nursing and Midwifery, Shahid
Beheshti University of Medical
Sciences, Tehran, Iran
Hamid Peyrovi
Professor of nursing, Nursing
Care Research Center,
Department of Critical Care
Nursing, School of Nursing and
Midwifery, Iran University of
Medical Sciences, Tehran, Iran.
Correspondence
faribaborhani@msn.com
Conflict of interest
None declared
Peer review
This article has been subject
to external double-blind
peer review and checked
for plagiarism using
automated software
nursingmanagement.co.uk
Abstract
Aims Ethical decision-making is a complex process that nurses perform daily. The aim of this study
is to explain how ethical leaders in Iran strengthen ethical decision-making in their nursing teams.
Method Data were collected using deep and semi-structured interviews with 20 Iranian nurses in
2015. Analysis was based on constant comparative analysis.
Results Ethical leaders strengthen ethical decision-making by promoting ethical commitment,
developing an ethical atmosphere and guiding ethical decision-making.
Conclusion The development of ethical decision-making in nursing can improve ethics-based
nursing care.
Keywords
constant comparative analysis, ethical decision-making, ethical leadership, nursing, nursing
management, qualitative research
Introduction
Ethical leadership is ‘leadership based on
appropriate normative behaviour using
measures, personal actions, and interpersonal
relationships, and development of these
behaviours in followers, through interpersonal
relationships, reinforcement, and decisionmaking’ (Brown et al 2005). In today’s
complex workplaces, messages that focus
attention to ethical standards can be missed.
However, ethical leaders can help staff notice
and attend to them, and can influence their
teams’ ethical behaviours by setting, and role
modelling, high ethical standards (Brown et al
2005, Brown 2006).
Ethical decision-making is an essential
element of nursing (Berggren and Severinsson
2000, Ebrahimi et al 2007), and helps nurses
identify issues, through analysis based on
ethical standards, and make decisions about
these issues based on ethical norms (Cottone
and Claus 2000, Newfield et al 2000). In
today’s healthcare systems, developments
in medical technology, resource allocation,
increased healthcare costs, consideration of
human rights and changes in nursing roles can
result in ethical dilemmas that require nurses to
make appropriate ethical decisions for patients
(Ebrahimi et al 2007).
Ethical decision-making is a complex process
in which nurses must assess whether there is a
problem, identify the cause and decide how to
solve it legally and in a timely way. Research
indicates a weakness in nurses’ ethical
decision-making processes (Borhani et al 2010,
Joolaee et al 2010), and one Iranian study
found that they do not use ethical principles
appropriately in their decisions (Joolaee et al
2010). Nurses make decisions based on their
competencies, skills and ethical abilities
(Hagbaghery et al 2004, Jahanpour et al
2010), and ethical leaders, as role models, can
help them develop these.
Iran is a religious country, in general, and
religion and Islamic cultural beliefs affect
all aspects of life, including the healthcare
system and the nursing profession (Fooladi
2003, Shahriari et al 2011). Respecting human
beings, and ethical values, are important
aspects of Iranian Islamic culture, and the
nursing community (Joolaee et al 2006,
Shahriari et al 2015), and the Nursing Council
of Iran has developed a nursing code of ethics
(Sanjari et al 2008).
However, some of the challenges faced by
Iranian nurses, for example nursing shortages,
job dissatisfaction, poor social position and
lack of education about ethics (Farsi et al
2010, Shahriari et al 2011) can increase their
‘ethical distress’, affect their ethical decisionmaking, and lead to burnout and resignations
(Shorideh et al 2012, Borhani et al 2015).
volume 24 number 6 / October 2017 / 33
evidence & practice / research
Gallagher and Tschudin (2010) stated that
all nurses are involved in ethical leadership,
and can be ethical leaders. In Iran, ethical
leaders can act as ethical role models, with
whom nurses can identify, and who can
support their staff to resolve ethical dilemmas
and develop ethical decision-making abilities.
Ultimately, they can guide nurses’ ethical
performance, for the benefit of patients,
colleagues, organisations and the profession.
Aim
Despite the importance of these issues in
nursing in Iran, there is no research on nurses’
experience of ethics. The aim of this study,
which is part of a larger, qualitative and as yet
unpublished study, is to explore Iranian nurses’
experience of ethical leadership, and explain
how ethical leaders can strengthen ethical
decision-making in Iranian nursing.
Methods
Design
Qualitative methods of data collection
and analysis were used to gain an in-depth
understanding of nurses’ experiences.
Participants
Participants were selected from full-time nurse
employees of government teaching hospitals,
affiliated with Mashhad University of Medical
Sciences, Mashhad. The study began with
purposive sampling, and continued with
theoretical sampling, based on primary analysis
of the interviews.
Participants were introduced to the
researchers by nurse practitioners, and then
interviewed. Inclusion criteria were willingness
to participate, and at least six months’
experience. To achieve maximum variation
sampling, participants had different lengths
of nursing experience, worked on different
types of wards, had various positions and
worked rotating shift patterns. 20 nurses,
including two matrons, five supervisors, four
head nurses, eight nurses and one master’s
degree nursing student, who also worked as a
supervisor, were interviewed. Overall nursing
experience ranged between six and 29 years.
Table 1 lists demographic information.
Data collection
Interviews were conducted over nine months,
from September 2014 to May 2015. In each
case, the researcher (FE) introduced herself
to the participants, and briefly explained the
subject and objectives. If the nurse consented
to participate, the researcher collected the
demographic information and conducted
34 / October 2017 / volume 24 number 6
the interviews, which were in depth and
semi‑structured. The main research requests
and questions included the following:
»» Please explain your experiences of the ethical
decision-making of your ethical leader.
»» How did your ethical leader make
ethical decisions?
»» As an ethical leader, how do you make an
ethical decision?
»» How does your ethical leader strengthen
ethical decision-making in others?
»» As an ethical leader, how do you strengthen
ethical decision-making in other people?
Interviews lasted between 30 and 100 minutes,
with a mean duration of 45 minutes, and were
recorded with participants’ permission. Field
notes were taken to complement the data,
and compensate for gaps in the extracted
codes. Data saturation occurred with the 17th
interview (Salsali et al 2007).
Ethical considerations
Approval was given by the ethics committee of
Kerman University of Medical Sciences, and
participants were assured of confidentiality,
their right to withdraw at any time and how
to access the final results. They submitted
informed, written consent.
Data analysis
The interview transcripts were analysed using
constant comparative analysis (Hewitt-Taylor
2001). They were transcribed verbatim onto
Microsoft Word 2007. The researcher listened
to the recorded interviews, and read the field
notes and interview transcripts several times,
to ensure accuracy. Codes were allocated
to sections that summarised participants’
input. This was done in parallel with further
data collection, to refine the questions
for future interviews.
The codes were reread, and each item
was checked and compared with the rest of
the data, and in the context of development
of new codes on subsequent transcripts,
then discussed by the research team. This
was repeated until no new codes emerged.
The coded data were grouped into broader
categories with the highest level of abstraction
using a similar process (Hewitt-Taylor 2001).
The transcripts and extracted codes were
reviewed several times to ensure inclusion
of all data in the extracted categories,
and to improve data classification.
Data rigor
Data credibility was assured by checking
individual interviews, and peer checking. Clear
descriptions of participants’ characteristics,
nursingmanagement.co.uk
data collection, the process of analysis
and several quotes were used to ensure
that the findings fitted the data to support
transferability. Dependability was ensured
through constant comparative analysis,
clarifying the data analysis process and peer
review (Polit Beck 2009).
The extracted categories express nurses’
perception of how ethical decision-making is
strengthened through ethical nurse leadership.
Results
A total of 108 codes were extracted from
the interviews, after eliminating repetitive,
and integrating similar, codes. Constant
comparison and analysis resulted in three main
categories, and nine subcategories (Table 2).
Promoting ethical commitment
Ethical attitude
According to the participants, ethical leaders
have an ‘ethical attitude’, which means they
have ethical consistency and place ethics
over other things, such relationships with
staff. They challenge their own morality,
consider ethical principles and values before
and after every nursing intervention, and
emphasise the need for all nurses to do
TABLE 1. Participant demographic information
Number
Gender
Years
of work
experience
Work experience
Matron
Supervisor
Head
nurse
Nurse
Current
position
Current ward
Last previous ward
Last
previous
position
P1
Female
13
-
✓
✓
✓
S
Management
Intensive care unit (ICU)
HN
P2
Female
10
-
✓
✓
✓
S
Management
Emergency
N
P3
Female
6
-
✓
✓
✓
HN
ICU
Management
S
P4*
Male
10
-
✓
✓
✓
S + NS
Management
Emergency
HN
P5
Female
27
✓
✓
✓
✓
M
Management
Management
S
P6
Female
25
✓
✓
✓
✓
S
Management
Management
M
P7
Female
23
✓
✓
✓
✓
S
Management
Eye operation room
H
P8
Female
19
-
-
✓
✓
HN
Open heart Surgery ICU
Open heart Surgery ICU
N
P9
Female
26
-
-
✓
✓
HN
Nephrology
Open heart Surgery ICU
HN
P10
Female
15
-
✓
✓
✓
N
Poisoning
Trauma
HN
P11
Female
12
-
-
-
✓
N
Poisoning
Poisoning
N
P12
Female
15
-
-
-
✓
N
Skin
Dialysis
N
P13
Female
10
-
-
-
✓
N
Emergency
Emergency
N
P14
Female
23
-
-
✓
✓
HN
Urology
Urology
P15
Female
15
-
-
-
✓
N
Nephrology
Children
N
P16
Female
10
-
-
-
✓
N
Open heart Surgery ICU
Emergency
N
P17
Female
17
-
-
-
✓
N
Open heart Surgery ICU
Open heart Surgery ICU
N
P18
Female
28
✓
✓
✓
✓
HN
Operation room
Management
S
P19
Female
29
✓
✓
✓
✓
M
Management
Operation room
HN
P20
Female
16
✓
-
✓
-
S
Management
Emergency
N
M: Matron S: supervisor HN: Head nurse N: Nurse NS: Nursing student * P4 was a supervisor and concurrently a master’s degree student in nursing
(Esmaelzadeh F et al 2017b)
nursingmanagement.co.uk
volume 24 number 6 / October 2017 / 35
evidence & practice / research
the same. One supervisor said: ‘She first
considers morality in all practices. It means
that she always had the challenge with
herself before and after each practice. Is that
an ethical practice or not? Is it patient’s
preference or not?’
Participants also perceive that ethical leaders
adhere to religious beliefs, which affects their
ethical performance and decisions. One head
nurse commented: ‘Sometimes religious beliefs
greatly affect my behaviour, on the true way
of behaving with patients, and how to do my
job, or how to decide.’ Ethical leaders follow
ethical principles and values, perceived by
participants as confidentiality, fairness and
honesty. A head nurse noted: ‘She (a matron)
had taught me honesty through her
behaviours. She is being honest with all and
does not lie ever.’
Ethical leaders are aware of professional
ethical values, can distinguish right from
wrong in ethical issues, and encourage
staff to respect professional ethical values
by demonstrating their own commitment.
As one matron said: ‘They respect my
words when they know these are imperative
to me, and I committed to those values.’
Ethical leadership, encompassing ethical
attitudes, and compliance with ethical issues,
guide participants towards adhering to ethics
in their practice.
and their conditions regarding physical
or psychological, their stresses... were
important more than anything.’
Commitment to nursing duties
Participants believe that ethical leaders are
committed to nursing duties, and develop
and strengthen ethical decision-making
through patient-focused care, showing that
they believe patients are the centre of nursing
practice and care. They consider patients and
their conditions in all decisions. A matron
commented: ‘When she (an ethical leader)
wanted to decide for patients, the patient
Participation
According to the participants, ethical leaders
employ participation in ethical decisions,
through consultation with colleagues, using
their suggestions and comments, and fostering
collaboration. One supervisor said: ‘It is
very useful to consult with other people in
making decisions; I emphasise this to all
my colleagues’, while a head nurse noted:
‘I tried to use the suggestions if they were
constructive or if they were helpful for me
to make the decision.’
TABLE 2. Main categories and subcategories of strengthening ethical
decision-making by ethical leaders from the perspective of Iranian nurses
Main category
Subcategories
Promoting ethical commitment
»» Ethical attitude
»» Commitment to nursing duties
»» Adherence to laws
Development of an ethical atmosphere
»» Human relationships
»» Participation
»» Strengthening the ethical atmosphere
Guiding ethical decision-making
»» Educating professional ethics
»» Ethical role modelling
»» Ethical decision making
36 / October 2017 / volume 24 number 6
Adherence to laws
Ethical leaders are law abiding, and pioneer
rule and law enforcement, according to the
participants. They insist on implementation
of the law in their decisions, encourage others
to do the same, and monitor adherence.
One supervisor noted: ‘She (head nurse) was
law abiding, and decided according to the
laws. Because of her belief in the law, she
always set the rules in the ward that everybody
has to follow.’
Development of an ethical atmosphere
Human relationships
Participants believe that ethical leaders form
appropriate relationships with their healthcare
teams, and that this shapes team members’
behaviours and relationships with colleagues
and patients. They describe these relationships
as ‘ongoing and friendly’ and as helping
everyone make ethical decisions. One head
nurse said: ‘Our supervisor tried to be
serious with staff as well as to have a friendly
relationship. It means that there is a balance
between seriousness and sincerity, so that we
could say our ethical work problems to her
and ask for help.’
Strengthening the ethical atmosphere
Ethical leaders try to strengthen the ethical
atmosphere, to guide ethical decision-making,
by creating and maintaining trust between
healthcare staff, including nurses, and
patients, and by embedding ethics in nursing
practice by, for example, displaying rules about
ethical and unethical actions, or by valuing
ethics in practice and supporting ethical values
in staff. Ethical leaders create the conditions
that help prevent staff from performing
unethical actions or making wrong decisions.
One supervisor said: ‘She (the head nurse)
governed ethics in the ward, for example,
nursingmanagement.co.uk
by putting up ethical rules, and we have
to act according to those rules.’
Guiding ethical decision-making
Educating professional ethics
Participants believe that teaching professional
ethics is important, and that ethical leaders
make staff consider ethics in practice by
raising their awareness of the subject.
One head nurse said: ‘I try to show staff during
the practice what the right action and decision
is. Once one of our patients died, and we
discussed our decisions about him, which has
caused all to be careful about their decisions
about patients.’
There is a need for more education on
professional ethics in colleges, according to the
participants, and one supervisor commented:
‘I do not remember anyone talking to us
about the professional ethics in college;
for example, they did not teach us how to
decide ethically, which decisions are right,
which decision is wrong.’
Ethical role modelling
Ethical leaders act as ethical role models
by displaying the correct behaviours, and
participants said they observed and repeated
their ethical role models’ behaviours.
One head nurse commented: ‘The first step in
being an ethical leader is to be a role model.
It means that I do everything according to
the appropriate and ethical way, or make
decisions on the basis of ethics’, while a
supervisor said: ‘I had good leaders who
were good role models for me, so they had
a positive effect on me.’
Ethical decision-making
Participants believe that ethical leaders make
decisions according to their conscience,
and regard those based on irrational
justifications, transient sentimentality or
personal interests as unethical. They suggest
that ethical leaders do not allow those with
no ethical performance to make decisions
about patients. One supervisor said: ‘She
was selecting a way that her conscience told
her, making a decision based on conscience’,
while a matron commented: ‘I got people
who do not make ethical decisions away from
the patients. People who decide on the basis
of irrational decisions, should not decide
about the patient.’
Discussion
The results show that ethical decision-making
in nursing is strengthened by ethical leaders
by promoting ethical commitment, developing
nursingmanagement.co.uk
an ethical atmosphere and guiding ethical
decision-making.
Ethical leaders have an ethical attitude,
and promote ethical practice over other issues
such as relationships. Several studies confirm
the moralism of ethical leaders (Stouten et al
2010, Mayer et al 2012, Mahdad et al 2015),
their commitment to ethical values and
the development of ethics in practice
(Trevino et al 2000, 2003).
Participants believe that ethical leaders
adhere to religious beliefs, which affects their
ethical performance and decision-making.
Islam places great emphasis on ethical issues
(Rafiee et al 2013, Shahriari et al 2015), and
it appears that nursing in Iran is affected by
this religious culture. Iran’s religious culture,
and adherence to the principles of Islam, mean
nurses have a positive attitude towards people
with religious beliefs and accept them as
ethical leaders.
This study shows that ethical leaders are
committed to ethical principles, and can
distinguish between these and unethical
issues, which is supported by other research
(Trevino et al 2003, Brown et al 2005, Brown
2006, Resick et al 2006, Nayeri et al 2010).
They encourage staff to respect professional
ethical values in decision-making by showing
commitment to these principles.
Participants believe that ethical leaders are
committed to nursing duties, and that they
strengthen ethical decision-making in others
by focusing on patients’ needs. Bjarnason and
LaSala (2011) found that nurse ethical leaders
are aware of patients’ demands, desires and
needs, and try to meet these, but there appears
to be no research of the relationship between
ethical leaders’ commitment to duties and
ethical decision-making.
The study found that ethical leaders adhere
to laws when making ethical decisions,
and commit others to rules and legislation
by implementation of laws. Brown (2006)
described ethical leaders as ‘principled people’,
but there appears to be no research on the
relationship between ethical decision-making
and adhering to laws.
Ethical leaders try to strengthen ethical
decision-making by creating an ethical
atmosphere in various ways, for example
by strengthening human relationships,
encouraging participation in decision-making,
developing and maintaining trust, and
embedding ethics in practice.
Participants describe ethical leaders as
having ‘ongoing and friendly’ relationships
with team members, and according to
Brown et al (2005) ethical leadership requires
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volume 24 number 6 / October 2017 / 37
evidence & practice / research
excellent communication with followers.
This is supported by Zhu et al (2011), who
suggest that ethical leaders pay particular
attention to communication, and human
relations, in the workplace. This is also shown
in their encouragement of participation in
ethical decisions, through cooperation and
collaboration with colleagues, teamwork and
using others’ suggestions, and this finding
is supported by other work (Frisch and
Huppenbauer 2014, Mosahebi et al 2015).
Various authors highlight the importance
of teamwork to ethical leaders (Moorhouse
2002, Resick et al 2006), and Bjarnason and
LaSala (2011) suggest that they encourage
reaching consensus on decisions through
effective interpersonal communication with
team members, and by emphasising teamwork,
cooperation and consultation.
Ethical leaders try to create and
maintain trust in nurses’ relationships
with others, particularly patients
(Trevino et al 2003, Brown et al 2005, Brown
2006, Walumbwa et al 2011), and this can
help team members make ethical decisions.
Embedding ethics in practice also fosters
an ethical atmosphere, which is a critical
component of organisational culture (Olson
2002), and reflects organisations’ guidelines
and rules in relation to ethics (Martin and
Cullen 2006). Olson (2002) suggests that an
ethical atmosphere is a framework for ethical
decision-making in clinical environments and
supports nurses’ professional actions.
Nurses in this study said that ethical
leaders try to govern morality on wards by
displaying instructions and rules about ethics
in practice, and by trying to prevent unethical
behaviour in employees. This is supported by
other authors (Brown et al 2005, Mayer et al
2010, Shin 2012), while Trevino et al (2003)
found that ethical leaders set ground rules
for ethical behaviours in organisations, and
institutionalise values. Participants in this
study believe that an ethical atmosphere
is a vital factor in ethical performance
and decision-making.
Ethical leaders strengthen ethical decisionmaking through education and role modelling.
Participants believe that their ethical leaders
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educate them by drawing their attention to
ethics in practice, and demonstrating how to
use them in practice and in making decisions.
This is supported by Brown et al (2005), who
suggest that ethical leaders raise awareness of
ethics through clear ethical messages.
The participants believe there is too little
formal education on ethics, and studies show
that the subject is lacking in the Iranian
nursing curriculum. Although ethical issues
are discussed in different courses, there
is no specific programme on professional
ethics or ethical decision-making (Nikbakht
Nasrabadi et al 2004, Izadi et al 2013, Jafari
Manesh et al 2014). Given the importance and
effects of ethics on nurses’ practice, this should
be addressed (Nikbakht Nasrabadi et al 2004).
The study shows that ethical leaders
act as role models in nursing practice and
ethical decision-making, and that their
actions are observed and repeated by
others. This is supported by other research
(Trevino et al 2000, 2003, Brown et al 2005,
Brown 2006), which shows that ethical
leaders do not just talk about correct
Mayer D, Aquino K, Greenbaum R et al (2012)
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a Delphi investigation. Electronic Theses and
Dissertations. Paper 709. dc.etsu.edu/etd/709
(Last accessed: 29 August 2017.)
behaviours; they demonstrate them in practice
too (Brown 2006).
Ethical leaders make decisions according
to their conscience, and believe that decisionmaking based on irrational justifications and
transient sentimentality or personal interests
is unethical. Trevino et al (2000) state that
ethical leaders make decisions based on
ethical principles, and as decision makers
are strong, purposeful and fair. Moorhouse
(2002) explains that ethical leaders consider
all options before deciding, and are resolute in
their ethical decision-making.
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Conclusion
Ethical nurse leaders are role models of ethical
nursing practice, and try to strengthen ethical
decision-making through ethical commitment,
developing an ethical atmosphere and guiding
others towards ethical decision-making.
The study findings can be used to develop
ethical decision-making by clinical nurses,
nurse managers, and teachers. Developing
ethics in nursing practice will improve
ethical‑based nursing care in Iran.
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volume 24 number 6 / October 2017 / 39
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