|Year : 2022 | Volume
| Issue : 3 | Page : 191-197
Nurses' experience regarding professional ethics in Iran: A qualitative study
, Naser Parizad1, Hossein Habibzadeh2, Audrey Cund3, Gholamreza Esmhoseini4
1 Patient Safety Research Center, Clinical Research Institute, Nursing and Midwifery School, Urmia University of Medical Sciences, Urmia, Iran
2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
3 Institute for Mental Health, School of Health and Life Sciences, University of the West of Scotland, Paisley, Scotland, UK
4 Islamic Education Group, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
|Date of Submission||25-Apr-2021|
|Date of Decision||31-May-2022|
|Date of Acceptance||11-Jun-2022|
|Date of Web Publication||05-Sep-2022|
Dr. Gholamreza Esmhoseini
Faculty of Medicine, Urmia University of Medical Sciences, Urmi
Source of Support: None, Conflict of Interest: None
Context: Professional ethics are less understood in the literature and refer to the complex decision-making processes made by nurses as they deliver care.
Aims: This study aimed to add new information to the growing body of evidence around professional ethics and explore the experiences of Iranian nurses who work in the hospital setting.
Setting and Design: This is a qualitative study that was carried out from January 2017 to August 2017, utilizing conventional content analysis.
Materials and Methods: In this qualitative study, data were collected using semi-structured interviews. Twenty-eight participants with various occupational backgrounds and positions were interviewed. All participants work in educational hospitals in the North West of Iran. Data were analyzed using the conventional content analysis.
Statistical Analysis Used: Statistical methods were not used in this study.
Results: One overarching category and three sub-categories emerged during data analysis. The overarching category was “the road to professional ethics,” which was supported by the following sub-categories: ethical development, spirituality and values development, and promoting ethical competencies.
Conclusions: Professional ethics are difficult to separate, which may be why it is less understood in the empirical literature. Multiple factors contribute professional ethics, and these ethical principles motivate nurses to provide safe care. Professional ethics in nurses' performance can help managers in the recruitment and ongoing supervision of nurses to improve their professional performance.
Keywords: Content analysis, Ethics, Nurses, Professional, Qualitative research
|How to cite this article:|
Alilu L, Parizad N, Habibzadeh H, Cund A, Esmhoseini G. Nurses' experience regarding professional ethics in Iran: A qualitative study. J Nurs Midwifery Sci 2022;9:191-7
|How to cite this URL:|
Alilu L, Parizad N, Habibzadeh H, Cund A, Esmhoseini G. Nurses' experience regarding professional ethics in Iran: A qualitative study. J Nurs Midwifery Sci [serial online] 2022 [cited 2023 Jan 27];9:191-7. Available from: https://www.jnmsjournal.org/text.asp?2022/9/3/191/355619
| Introduction|| |
Nurses play an important role in the delivery of care, and their practice is guided by the legal and ethical principles of honesty, integrity, and to do no harm. These principles are endorsed worldwide and expressed as values and the moral philosophy of nursing. Several authors point out that nurses are also human, and they hold personal values, beliefs, and assumptions that guide their morals and behavior. A range of inner qualities is promoted and sought as the core characteristics of the nurse. These qualities are referred to as caring, compassion, trustworthiness, and commitment. Despite proactively seeking out these characteristics in nurses' several public concerns about negligence, patient safety, and unprofessional conduct continue to be cited worldwide, which calls into question nurses' moral and professional behaviors and the selection of people for the role.
Professional ethics refer to the nurse's decision making, personal and workplace conduct, and moral philosophy in terms of how they deal with ethical issues and dilemmas as a professional and within the work environment. Although it is essential to meet professional, ethical requirements regarding patient care, studies have shown that professional ethics and standards are empirically less understood. Studies have mainly focused on ethical behavior; for example, one qualitative study of 28 Iranian nurses revealed a unique culture-based set of values among their nurses. Embedded within this culture, nurses described the ethical values of respect for the dignity, professional integrity, and a commitment to developing a therapeutic relationship. Notably, Iranian nurses emphasized preserving the patient's religious beliefs in a gender-appropriate environment. In another study of ethical leadership in nursing performed in Iran highlighted those ethical values lead to increased job satisfaction, patient satisfaction, and inspire ethical behavior amongst nurses.
A literature review has shown that nurses displayed professional ethics in terms of observing the patient's basic rights such as accepting the patient as a unique person, observing his/her right for selection, respecting the patient's privacy, and providing the best services for him/her in nursing development., Further, the other study believed that observation of the patient's legal rights as the core of ethical performance in nursing and pointed out the importance of observing these rights in professional nursing. Interestingly, reviewing the literature showed that patients' rights were rarely respected., Furthermore, the nurses' role in promoting patient independence was frequently disregarded. On the other hand, Chinese and Switzerland nurses experienced reduced communication with patients due to heavy workload., Central to these studies is the message that nurses should follow a code of ethics.
Increased pressure on nurses to do more with less financial and staff resources leads to professional standards slipping. With these pressures facing nurses, it is not surprising that this impact the quality of care delivered. The study on the nursing work environment's moral habitability found evidence that nursing work is highly stressful and has unclear, overwhelming role expectations. They also revealed that nurses working in these environments changed their behavior leading them to be less collegiate and resistant to change. Recent research has shown that clinical areas with reduced resources impact patient safety and lead to poorer job satisfaction and poor staff recruitment and retention., This study extends the discussion of professional ethics and presents the findings from a recent study involving experiences of nurses working in Iran. The study aimed to explore Iranian nurses' experiences about professional ethics in their clinical practice.
| Materials and Methods|| |
Study design and setting
This qualitative study was conducted in Urmia, the populous city of Iran located in the North West between January 2017 and August 2017.
Participants were selected purposefully among female and male nurses from four educational hospitals and eight medical and surgical wards. The researcher recruited and interviewed 17 medical-surgical nurses using purposive sampling and employed theoretical sampling to select and interview three matrons, five head nurses, two supervisors, and one emergency nurse. The inclusion criteria for participation in the study were having at least Bachelor's degree in nursing and a minimum of 5 years of work experience in clinical and educational environments.
Data were collected through interviews. Each semi-structured interview lasted an average of 1 h and took place in the staff room. At the beginning of the interview, questions were asked to get more familiar with the participants and help them relax. All the interviews began with the question: “As a nurse, please tell me the ethical issues that you encountered in your work environment?” All participants were asked how they experienced professional ethics? Based on the participants' responses, probing questions such as, “Could you explain it more?” were asked. All the interviews were recorded with the participants' permission by a portable audio recorder and transcribed verbatim.
The interviews were analyzed using a qualitative content analysis method described by Graneheim and Lundman. Data analysis began simultaneously after the first interview and continued until data saturation. In the primary encoding, the transcription of each interview was read several times, and the sentences with special meanings were identified and underlined as the unit of analysis. They were then coded using commonly identified words and phrases; on this basis, various codes were compared in terms of similarities and differences and then re-categorized into hierarchical categories. From this, the interview transcripts, codes, and categories were studied several times to distinguish the relationships between the codes and categories and, accordingly, determine the main themes.
In this research, four techniques were used to support the work's trustworthiness, including conformability, dependability, credibility, and transferability. Credibility was confirmed using an appropriate method for collecting data, and the interviews were performed by the researcher who was familiar with the nursing performance context. Moreover, besides the researcher's long-term involvement, members check was also used to increase the data credibility. Further, in addition to encoding, the transcribed interviews were returned to the participants to ensure the codes' accuracy and relevant interpretations. Dependability was confirmed by describing the details of data analysis and direct reference to the individuals' professional experiences to reveal the base of the performed analysis. The references used in this study were translated from Farsi into English by a professional translator to maintain the accuracy and context as much as possible. Conformability and consistency of the analysis were confirmed by holding sessions for the authors to discuss the primary findings, and the emerging codes and themes were also discussed until reaching an agreement. To increase transferability of the findings, a description of the context, the selection and demographics of the participants, data collection, and analysis process was provided so that the reader can decide if the results can be transferred to another context.
This study was approved by the Ethics Committee of Urmia University of Medical Science (IR.UMSU.REC. 1396.46), Iran. All the participants were briefed about the research objective and informed that participation in the study was optional, and they can leave the study whenever they wanted. Further, they were ensured that the interview transcripts would remain anonymous and confidential. Before the study, written informed consent was gathered from participation in the study, recording the interviews and publishing their statements.
| Results|| |
Demographic information of participants
Overall, 28 nurses were recruited and interviewed. The participants included 11 males and 17 females aging 29–53-year-old. Among the participants, there were three matrons, five head nurses, two supervisors, and the rest of the participants (17 nurses) were clinical nurses. Six participants had a Master's degree, and 22 had a Bachelor's degree in nursing [Table 1].
Data analysis yielded 346 primary codes, which were categorized into three sub-categories and one main category. The extracted category was “the road to professional ethics,” which was supported by the following sub-categories: ethical development, spirituality and values development, and promoting ethical competencies [Table 2].
The road to professional ethics
All nurses had to go through various stages to achieve professional ethics. They began by focusing on the development of morality, using spirituality, and promoting ethical capabilities.
This sub-category was supported by three primary concepts of “attention to patients' rights,” “individual moral development,” and “humanitarian services.” In this study, the participants emphasized the nurses' ethical role in respecting the patient's dignity and expressed this as one of the most important ethical principles in nursing and should not be faded or forgotten. One participant explains:
“I've frequently seen that patients are not satisfied with the nurses at the time of discharge because their opinions were ignored, or even they were disrespected. This shows that a nurse must take into account the ethical consideration along with the technical skills.” (P17)
The nurses' performance is rooted in moral development and interaction with others; thus, the nurse's ethical duty in terms of professional practice is to maintain and develop relationships with patients, family members, and other co-workers. One of the participants voiced in this regard:
“Nurses must be fair when they care for an unconscious patient, you can just record his vital signs without checking them, and nobody can prove whether you have done your job or not.” (P21)
Taking care of a person in need is not limited to what is written in the patient's records and care plans. A large part of the nurses' practice is hidden from the medical team's sight and even the patients. The participants usually identified these ethical values of caring and compassion, and those hidden professional behaviors could inherently motivate good practice. One nurse participant reflects this key issue well:
“I am working in the emergency department, and we face various cases every day. In one of my cases, a patient said at the time of discharge, 'I got so much better when you talked to me like a brother and considered my calmness. These ampoules are effective when they are used by someone like you.” (P4)
Participants often mentioned the essential role of compassionate care in developing Iranian nurses' ethical identity and its unconscious effect on their professional performance.
Spirituality and values development
Data analysis related to spirituality and nursing values revealed two primary concepts of “Spiritual interest” and “spiritual commitment.” Many study participants acknowledged that they felt comfortable and indescribable because of serving patients and providing nursing care. The nurse said:
“I don't like being sick at all. So, I can do my nursing job well. It even happened that the elevator was broken. We had to take the stretcher and took the patient upstairs. I don't work with annoyance, boredom, or coercion.”(P14)
Many participants in this study emphasized the effect of spiritual beliefs on the nurses' motivation and commitment to deliver high-quality care against the pressures of working in a highly stressful environment with limited resources. In this regard, a nurse said:
“Under the pressure of working conditions, my beliefs give me the power to bear difficulties and try to do my best despite all the difficulties.” (P24)
Some Participants voiced that establishing a spiritual and ethical relationship with the patient influences their practice. One of the nurses shared her experience as follows:
“Because my patient was critically ill, I stayed in the ward until 3 pm (The shift ends at 2 pm according to the law). Evening shift colleagues came, but because I felt my patient needed me, I couldn't leave the ward. My family was indeed upset about my delay, but I stayed until I felt it was necessary to be at my patient's bedside.” (P28)
Many participants believed that nursing is more than a mere responsibility and professional commitment since the nurses work at a level higher than their professional responsibility, which indicated their dedication and sacrifice versus their professional duties and commitments. One participant shared her experience as follows:
“An airplane had crashed down and the injured people were brought to the emergency unit, even those nurses whose shift had been finished stayed voluntarily and didn't leave the unit.” (P23)
Promoting ethical competencies
This sub-category was supported by two primary concepts of “ethical behavior” and “ethical care.” Participants reported the necessity of preserving the boundaries between patients, their companions, and colleagues since any nonprofessional relationship would distract professional duties.
“While sitting in the nursing station, some colleagues focused on marginal discussions instead of talking about the patients' problems. Unfortunately, conversations were changed into friendly gabs, and I tried to change the subject and create a professional atmosphere.” (P3)
Some participants talked about how intimacy with the patient and their family members could be destructive if nurses do not act professionally. One participant shared her experience as follows:
“Because I was so kind to my patient, he asked me out despite knowing I am married. He had found my cell number and made my life miserable for a while. Now I always set a limit to my relationship with the patients.”(P12)
The nurses pointed out that violation of an individual's privacy can spread a heavy shadow on all the good deeds and ethical care of the nurses in a team. The participants believed that patients should be treated with the same respect as they would their own family members. This highlighted an interrelationship between personal values and professional ethics. This is expressed by one participant who said:
“I think of my patients as family members or one of my close relatives, so I try to do my duty as accurately and carefully as possible. Now, I'm happy that I've never failed in the performance of my duties.” (P22)
| Discussion|| |
The findings of the study show that the professional ethics of nurses can be classified into three sub-categories, namely “ethical development,” “spirituality and values development,” and “promoting ethical competencies.” This finding is consistent with the findings of other researchers who revealed that the acquisition of professional ethics is facilitated by factors that could lead to legitimate standards and norms that govern the professional behavior of nurses in their relationships with patients.
The results of the investigation advocate Iranian nurses' attention to human dignity (including the values of humanism, friendship, and nondiscrimination) and reveal that they respect the value and integrity of the individual, values, and beliefs of the patient. Interest in working with people is also the basis for the emergence of nursing professions. Another study, performed in Iran, has shown that Iranian nurses demonstrate value concepts such as compassion for caring, responsible care, commitment to patients' health, and self-esteem in care. This study also found that nurses display care and compassion for their patients. These values motivate staff to deliver safe and effective care. These behaviors closely relate to their identity as a nurse and also their professional ethics.
The present study also demonstrated a strong relationship between nursing and spirituality that affects the nurses' professional ethics. Nurses believe their spirituality gives them the strength to face any clinical challenge., This shows the role of spiritual beliefs in nursing as a factor in the development and progress of nursing ethics. A literature review revealed that spirituality is not a new dimension of care. However, it is a new challenge for healthcare to recognize that the individuals they are working for are not just patients, but also human beings with a precious interior life. This study highlights that the staff's spiritual demands guide their professional behavior and should be considered in developing codes of ethics.
Many of the participants' statements revolved around the third sub-category, “promoting ethical competencies.” Commitment to the role was identified as professional and ethical behavior. Further to this, participants spoke of effective teamwork and the importance of establishing professional relationships with patients. Professional boundaries with patients and companions were viewed as important professional ethics as these boundaries served to protect both the nurses and the organization. The findings show that professional ethics are difficult to separate which may be one reason why it is less understood in the empirical literature. This study shows a close relationship between nurses' ethical development, values, spirituality, and promoting ethical competencies.
| Conclusions|| |
The study has shown that Iranian nurses deal with complex clinical and ethical issues every day, and ethical decisions have become routine aspects of clinical activity. Based on the nurses' experience, professional ethics are multi-dimensional, which are affected by personal, spiritual, and social factors. The nurses also view moral and spiritual ethics as part of their identity as they implement ethical sensitivity in all the nurse-patient communications and interventions. Professional ethics about nurses' performance can help managers and instructors in the recruitment and ongoing supervision of nurses to improve their professional performance.
One of the limitations of the study is that this study was conducted in a small region of Iran with its unique culture. Since culture may affect professional ethics; thus, further studies of different cultures and contexts are required to increase the knowledge of various aspects of professional ethics in nurses' performance.
Conflicts of interest
There are no conflicts of interest.
H.H and NP designed the study; H.H. and L.A. analyzed data; H.H., N.P., L.A., A.C. and Gh.E. reviewed manuscript critically; drafted the article; and finally approved the manuscript.
Financial support and sponsorship
This study was supported by Urmia University of Medical Sciences (Ethical Code: IR.SBMU.RAM.REC1394.606). This article was derived from a thesis research project.
We would like to thank Urmia University of Medical Science for providing permission for this study and financial support. Hereby, we would like to appreciate all the participants who shared their valuable experiences.
| References|| |
Maarefi F, Ashk Torab T, Abaszadeh A, Alavi Majd H, Eslami Akbar R. Compliance of nursing codes of professional ethics in domain of clinical services in Patients Perspective. Educ Ethic Nurs 2014;3:27-33.
Kaya A, Boz İ. The development of the professional values model in nursing. Nurs Ethics 2019;26:914-23.
Shahriari M, Mohammadi E, Abbaszadeh A, Bahrami M, Fooladi MM. Perceived ethical values by Iranian nurses. Nurs Ethics 2012;19:30-44.
Grace PJ. Nursing Ethics and Professional Responsibility in Advanced Practice. Burlington, Massachusetts: Jones & Bartlett Learning; 2017.
Barkhordari-Sharifabad M, Ashktorab T, Atashzadeh-Shoorideh F. Ethical leadership outcomes in nursing: A qualitative study. Nurs Ethics 2018;25:1051-63.
Simões Â, Sapeta P. The concept of dignity in nursing care: A theoretical analysis of the ethics of care. Rev Bioet 2019;27:244-52.
Abedi G, Shojaee J, Moosazadeh M, Rostami F, Nadi A, Abedini E, et al.
Awareness and observance of patient rights from the perspective of Iranian patients: A systematic review and meta-analysis. Iran J Med Sci 2017;42:227-34.
Kuo RJ, Wu YH, Hsu TS. Integration of fuzzy set theory and TOPSIS into HFMEA to improve outpatient service for elderly patients in Taiwan. J Chin Med Assoc 2012;75:341-8.
Buka P. Patients' Rights, Law and Ethics for Nurses. Boca Raton, Florida: CRC Press; 2014.
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. Int J Nurs Stud 2019;94:166-78.
Albagawi BS, Jones LK. Quantitative exploration of the barriers and facilitators to nurse-patient communication in Saudia Arabia. J Hosp Adm 2017;6:16-24.
Stievano A, Tschudin V. The ICN code of ethics for nurses: A time for revision. Int Nurs Rev 2019;66:154-6.
Vryonides S, Papastavrou E, Charalambous A, Andreou P, Merkouris A. The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies. Nurs Ethics 2015;22:881-900.
Said RM, El-Shafei DA. Occupational stress, job satisfaction, and intent to leave: Nurses working on front lines during COVID-19 pandemic in Zagazig City, Egypt. Environ Sci Pollut Res 2020;28:8791-801.
Hayajneh N, Suifan T, Obeidat BY, Abuhashesh M, Kanaan RK. The relationship between organizational changes and job satisfaction through the mediating role of job stress in the Jordanian telecommunication sector. Manage Sci Lett 2021;11:315-26.
Shimp KM. Systematic review of turnover/retention and staff perception of staffing and resource adequacy related to staffing. Nurs Econ 2017;35:239-66A.
Liu X, Zheng J, Liu K, Baggs JG, Liu J, Wu Y, et al
. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: A structural equation modeling analysis. Int J Nurs Stud 2018;86:82-9.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-12.
Elo S, Kääriäinen M, Kanste O,Pölkki t, Utriainen K, Kyngäs H. Qualitative content analysis: A focus on trustworthiness. SAGE Open 2014;4:2158244014522633.
Yilmaz K. Comparison of quantitative and qualitative research traditions: Epistemological, theoretical, and methodological differences. Eur J Educ 2013;48:311-25.
Dehghani A, Mosalanejad L, Dehghan-Nayeri N. Factors affecting professional ethics in nursing practice in Iran: A qualitative study. BMC Med Ethics 2015;16:61.
Ravari A, Vanaki Z, Mirzaei T, Kazem Nezhad A. A spiritual approach to job satisfaction in nursing staff: A qualitative study. Payesh (Health Monitor) 2011;10:231-41.
Norouzi R, Dargahi S, Aeyadi N, Sarhadd M. The association between workplace spirituality and Job Stress with occupational ethics through mediating role of Job Enthusiasm among nurses in Zahedan City, 2017. J Occup Health Epidemiol 2018;7:3-10.
Linda NS, Phetlhu DR, Klopper HC. Clinical supervisors' understanding of spirituality and spiritual care in nursing: A South African perspective (part 2). Int J Afr Nurs Sci 2021;14:100254.
Murgia C, Notarnicola I, Rocco G, Stievano A. Spirituality in nursing: A concept analysis. Nurs Ethics 2020;27:1327-43.
Pujol N, Jobin G, Beloucif S. 'Spiritual care is not the hospital's business': A qualitative study on the perspectives of patients about the integration of spirituality in healthcare settings. J Med Ethics 2016;42:733-7.
[Table 1], [Table 2]