Ethical Care: Nurses’ Experience of Moral Judgment in Intensive Care Units

Background: Ethical care is concerned with aspects of work that may influence nurses’ ethical behavior. Intensive care units might expose nurses to moral judgment while caring. This qualitative study aimed to explain the nurses’ experience of moral judgment in intensive care units. Methods : The present qualitative study was conducted using the conventional content analysis method. The participants of the study included 23 nurses working in the intensive care units (ICU, CCU, NICU) of four hospitals affiliated with Sabzevar University of Medical Sciences who were selected using purposive sampling. The data were collected through semi-structured interviews. The questions asked in the interviews included, “Would you please describe one working day of yours caring in the intensive care units?” and “While caring, did you have to hesitate to make a decision ethically? If yes, would you describe that situation?” The Data were analyzed using the qualitative content analysis method proposed by Graneheim and Lundman. Results : Data collection and analysis led to the identification of 1 theme, 6 categories, and 23 subcategories. The identified theme was “intensified tension and conflict following ethical patient care in the intensive care units” and the categories were “repeated exposure to stress in ethical patient care in the intensive care units”, “ethical care originated from the nurses’ beliefs”, “moral judgment in care affected by the patient’s clinical condition”, “moral judgment as a consequence of clinical judgment”, “ethical care based on organizational and legal conditions in the moral environment”, and “requirements of ethical care”. Conclusion : The nurses in the intensive care units deal with ethical issues and are under a lot of stress. The results of this study can help nursing authorities pay more attention to developing ethical knowledge and ethical considerations in hospitals and provide organizational support to identify the moral tensions of nurses in intensive care units.


Introduction
Patient care is crucial and nurses require personal, social, ethical, and spiritual qualifications to be able to provide proper ethical care (1). Due to the complexity of patient care in the intensive care units, nurses can make a variety of moral judgments. Nurses working in the intensive care units (ICUs) endure more stress due to the special conditions ruling their workspace and the patients admitted (2,3), frequently exposing them to moral judgment (4).
One of the main qualification criteria for nurses' professional competence is moral judgment (5). Nurses must make judgments about ethical issues to make the right decisions in their profession since by identifying ethical barriers and making appropriate ethical decisions, they provide the conditions for increasing motivation in patients and themselves and feeling satisfied and competent. Not paying attention to ethical issues may lead to ignoring them in stressful work environments (1,6). Research has shown that ethics education needs to be developed and evaluated more realistically (7). Jung and et al. concluded in their study that nursing education influences students' moral judgment (8).
Moral judgment is acceptable when fundamentally and ethically accepted by a larger group or community. Ethics can improve the ethical judgment of people in different situations as well as the factors affecting their behavior, especially in uncertain ethical situations (9,10).
Despite the differences in concepts such as emotion, perspective, self-representation, memory, etc., moral judgment is not exempt from the effects of these factors. Thus, in addition to influencing the goodness or badness of an action, workplace culture also makes a difference in its extent as well as the conflict created in responding to it. Nurses suffer from stress during patient care and face numerous situations in which they have to make moral judgments considering the consequences of which is of great importance (11).
Ethics is of paramount significance in the intensive care units and requires immediate attention as it can cause ethical conflict and burnout. The special conditions of patients in the intensive care units and the importance of the mental health of nurses are major factors affecting the ethical considerations of nurses working in the intensive care units. Critical care nurses are more susceptible to ethical conflicts due to the nature of their work in caring for patients, particularly end-of-life patients. This would lead to moral distress associated with potential impacts on patient and family care (12,13). Moral distress mostly occurs when nurses are involved in situations in which caregivers feel pressured to continue unwarranted aggressive treatment. Nurses in the intensive care units face many situations in which they have to make ethical judgments and decisions due to their daily encounters with patients with special conditions such as those in coma, critically ill, or with multiple trauma, and even the death of patients, which require reasoning and moral judgment. Proper understanding and analysis can lead to making the right ethical decisions (14).
Achieving such a goal requires in-depth consideration of the nurses' real experiences with respect to situations that are subject to ethical judgment. Following a real understanding of the nurses' experiences, a clear image of the above concept and the factors affecting it can be achieved using a qualitative approach. Given that moral judgment is a subjective, complex, and multidimensional concept, it would be more appropriately investigated using qualitative research methods. Assessing the concept of ethics and nursing care from the perspective of nurses is another strength of using qualitative methods. Moreover, more and deeper concepts are presented based on the opinions of nurses who are one of the main members of the care team in the intensive care units. Besides, qualitative research pays close attention to describing matters that may be trivial or insignificant details usually not taken into account in quantitative research methods (15,16).
To date, most of the studies on moral judgment have been quantitative. However, this phenomenon cannot be assessed using pre-defined questionnaires since nurses are one of the most important medical staff with great responsibility for patient care in the intensive care units; therefore, in-depth studies are required in this respect. Accordingly, the present study aims to explain the nurses' experience of moral judgment in the clinical environment using the qualitative content analysis approach.

Methods
This study used a qualitative approach to reach a deeper understanding of factors affecting the nurses' experiences pertinent to moral judgment in intensive care units. A total of 23 nurses working at the hospitals affiliated with Sabzevar University of Medical Sciences participated in this study. The participants were selected using purposive sampling. The nurses had at least one year of full-time work experience in the intensive care units, had a bachelor's degree in nursing, and were willing to describe their care experiences through verbal communication.
The present qualitative study was conducted using the conventional content analysis method. The data were collected through semi-structured interviews and analyzed using the qualitative content analysis method proposed by Graneheim and Lundman.
Purposive sampling was performed from October, 2019 to July, 2020 in four teaching hospitals affiliated with Sabzevar University of Medical Sciences. The data were collected from semi-structured interviews. The sample interview questions included, "Would you please describe one working day of yours caring in the intensive care units", "While caring, did you have to hesitate to make a decision ethically? If yes, would you describe that situation? What did you do then?", "Did you face ethical judgment in the workplace? Can you explain more?", and "What solutions do you suggest to face this ethical challenge and get out of this situation?" Furthermore, exploratory and clarifying questions such as: "Would you please explain more?", "Would you please provide an example?", and "Would you please clarify the issue?" were asked. Each interview lasted from 45 to 90 minutes. Afterward, the interviews were transcribed verbatim. The interviews continued until data saturation i.e., to the point where no new information was obtained from additional interviews.
Data were analyzed using the qualitative content analysis method proposed by Graneheim and Lundman (17). At the end of each interview session, the audio files were carefully transcribed. The transcribed interviews were read several times to come to an indepth understanding. The initial codes were extracted by a continuous comparison and then classified according to their similarities and differences. Data analysis was performed using MAXQDA software (version 12).
To increase the trustworthiness of the study, the four criteria of credibility, dependability, confirmability, and transferability proposed by Lincoln and Guba were utilized (18,19). Therefore, continuous engagement with data and confirmation of data by the participants, allocation of sufficient time to the study, and establishing a sympathetic relationship with the participants were considered to ensure confirmability. Precision was maintained while collecting, implementing, and recording data and sufficient time was allocated for data collection. To improve the dependability, the two members of the research team coded the interviewers separately. The interviews and the initial coding and contents were reviewed by the participants, research colleagues, and four experts qualified in qualitative research. Using maximum variance sampling (concerning age, gender, employment status, work history, and place of work) and selecting the participants from different medical centers increased the transferability of the data.
To comply with the ethical considerations in this study, the following measures were taken: obtaining permission from the ethics committee; explaining the purpose of the research, the purpose of using the tape recorder, and how to collect data to the participants; obtaining written informed consent for participation; and ensuring the anonymity of the participants and the right to withdraw from the study. The credibility of the results was ensured by repeated and long-term review of the analysis over one month (20).

Results
In this qualitative study, 23 semi-structured and in-depth interviews (16 main interviews and 7 supplementary interviews) were conducted with nurses, head nurses, and shift managers in intensive care units (ICU, CCU, NICU) of Sabzevar University of Medical Sciences. The participants included 14 females and 2 males of 26 to 43 years of age and 3 to 19 years of work experience in the intensive care units.
Data collection and analysis led to the identification of 1 theme, 6 categories, and 23 subcategories. The main theme identified was "intensified tension and conflict following ethical patient care in the intensive care units" and the categories were "repeated exposure to stress in ethical patient care in the intensive care units", "ethical care originated from the nurses' beliefs", "moral judgment in care affected by the patient's clinical condition", "moral judgment as a consequence of clinical judgment", "ethical care based on organizational and legal conditions in the moral environment", and "requirements of ethical care" (Table 1).

Repeated exposure to stress in ethical patient care in the intensive care units
The first category identified from the participants' experiences included 5 subcategories as presented in Table 1.

Increased stress in patient care in ICU
According to the participants, nurses are under a lot of stress when frequently exposed to death, especially after the death of young patients. "We had a young patient, quite conscious. After surgery, we took care of him for two months until he died, it's very upsetting and painful" (Participant 11).

Lack of communication with the patient due to fear of dependence
The high mortality rate in the intensive care units causes some nurses to refuse to communicate with the patients because of fear of dependence. "In the case of critically ill or metastatic cancer patients, we know that he/she is more likely to die, so we do not get very close to him/her because our feelings would engage for several days..." (Participant 4).

Death syndrome following multiple exposures to critically ill patients
The high number of deaths of patients in the intensive care units causes the development of death syndrome in nurses and hence a lot of stress. "Working for a long time in the intensive care units has created death syndrome in nurses in such a way that we say he would finally die..." (Participant 5).
The need to support the patients' families in the ICU by nurses Very often in the intensive care units, it is difficult to tell the truth to families whose patients are young and at risk of death. Facing family stress in these circumstances would expose nurses to a lot of stress. "We explain the situation of patients to their families; they do not understand because of the shock; they need a lot of attention" (Participant 11).
Nurse's mental stress following exposure to unethical cases Nurses face many unethical issues like making unethical decisions or facing situations that contradict their ethical beliefs. "Unfortunately, sometimes you read a nursing care done in the nursing report, but practically nothing was done for the patient..." (Participant 2).

Ethical care originated from the nurses' beliefs
This category extracted from the statements of the participants included 3 subcategories as presented in Table 1.

The effect of nurses' beliefs on patient care
The nurse's attitudes and beliefs may affect the ethical care of patients (ethically-oriented care). "Doubt in caring is related to the nurse's personality because some nurses make moral judgments based on their beliefs in caring for the patient" (Participant 13). Obligation to provide care until the last moment owing to ethical commitment Nurses, ethically committed to having respect for human dignity, are committed to providing care for patients until the last moment. "Even the doctor ordered not to resuscitate critically ill patients, but I still do all their care until the last moment" (Participant 2).

Moral judgment in care affected by the patient's clinical condition
This category was extracted from 3 subcategories as presented in Table 1.

Ethical doubts in care due to the patient's specific clinical condition
Nurses providing care for patients in critical conditions such as coma and double mydriasis, the elderly, and especially dying patients, have ethical doubts in decision making that brings a lot of stress to them. "As for dying patients, sometimes the question arises, should we give him drug? While the patient is really suffering ..." (Participant 5).
The effect of nurse's personal judgment on patient care measures Some nurses make moral judgments about caring as they believe the patients' treatment could be useless. "The critically ill patient's dopamine is running out, but because he is dying, they say it is not necessary and leave it" (Participant 6).
Emotional duality in the care of the elderly Patient's (especially the elderly's) condition affects the ethical decisions of nurses, causing them to make ethical judgments. "The nurse's practice would change concerning critically ill elderly and cause ethical judgment in them, under the pretext that caring for such patients is no longer useful" (Participant 2).

Moral judgment as a consequence of clinical judgment
This category was extracted from 3 subcategories as presented in Table 1.

Consequences of the nurses' clinical judgment
Cutting off medication, even for brain-dead patients or patients whose families are not satisfied with the continuation of treatment, causes the nurse to feel conscience-stricken. "In the case of brain-dead patients, some nurses may not give medication to the patient because it is expensive and practically useless, it hurts my conscience for a few days ..." (Participant 15).

Unethicality due to the attitude of the uselessness of care
Sometimes in the intensive care units, some nurses are reluctant to care for dying patients because they think it is useless. "Because the patient will die, I will not take any more medical measures; it is useless…" (Participant 11).

Ethical care based on organizational and legal conditions in the moral environment
This category was extracted from 5 subcategories as presented in Table 1.

The effect of physician's attitude on nurse care performance
The physician's performance affects the nurse's ethical judgment, particularly regarding critically ill patients. "The doctor has ordered not to resuscitate critically ill patients despite their suffering; the doctor's order must be legally obeyed and I will not resuscitate them…" (Participant 11).
Non-observance of ethics in care due to management system problems The management system problems, such as multiple work shifts, result in fatigue especially in young and novice nurses, providing the basis for clinical errors that would consequently lead to ethical contradictions. "I'm still tired of the previous shift, but the next shift begins. Certainly, the care will be affected and there will be cases of negligence" (Participant 1).

Non-observance of ethical standards of care as a result of organizational conditions
Numerous organizational factors affect the observance of ethical standards in care. "Writing the nursing report of an expiring patient is very difficult, and sometimes I prefer to do my best so as to avoid the patient expiry during my shift" (Participant 14).

The effect of nursing system problems on ethics in care
In the intensive care units, a nurse spends a lot of time writing the required reports rather than taking care of the patient that would cause mental involvement. "In the intensive care units, report writing is very sensitive, long, and tedious. Head nurse is very strict, which causes more stress in me, even when I am at home" (Participant 18).

The effect of law on the observance of ethical standards in care
The law, as an influential factor on commitment, affects the care of all patients, especially in the ICU. "Nurses sometimes feel that caring for a patient is useless ... but in such cases, they do so for fear of the law" (Participant 7).

Requirements of ethical care
In the intensive care units, due to the special situation of patients, some requirements are essential for ethical care. These requirements were extracted from four subcategories as presented in Table 1.

Facilitators for resolving ethical doubts in care
This category represents facilitators addressing ethical doubts in care. Education is one of the factors influencing the observance of ethical issues in care. "Some critically ill old patients, such as GCS 3 patients, usually do nothing, while nurses should be taught that ethics should be observed for all patients" (Participant 7).
Obligation to comprehensive care in ICU Patients are able to hear until the last moment of their life; most nurses at the beginning of their shift are required to communicate with patients even at a low level of consciousness. "I control my patient's level of consciousness in the daily assessment, even with greetings so that he/she does not suffer from feelings of deprivation..." (Participant 5).

The effect of nurse experience on the ethical care
The experience and competence of the nurse are effective in having correct judgment and preventing unethicality in the clinic. "Experienced nurses can make judgments about critically ill patients and take care of them according to their conditions" (Participant 2).

Feeling calm as a result of ethical commitment in care
Ethical commitment to care makes the nurse feel more satisfied and relaxed. "If we work in the workplace with a clear conscience, our minds will no longer be involved in matters outside the workplace and we have peace" (Participant 13).

Discussion
The present qualitative study aimed to explain nurses' experiences of ethical judgment in the clinical environment of the intensive care units. The analysis of the data led to the identification of one theme, "intensified tension and conflict following ethical patient care the intensive care units". The review of the literature revealed the theme has never been explicitly mentioned in previous studies. Thus, the present study resulted in a more complete explanation of these concepts compared to other studies. The results of the study by McAndrew et al, investigating the state of contemporary knowledge related to ethical distress and its effective factors in nursing-specific clinical settings, found contradictory results concerning measuring ethical distress, so that problems related to the professional clinical environment, communication problems during end-of-life decisions, and reduced quality of nursing care were pointed out as a result of ethical distress and low-effect interventions (21). The results of this study were consistent with the resonance of internal stress and conflict in the intensive care units in the present study. As moral judgment imposes a lot of stress on the nurse, this would eventually affect the quality of patient care. Nurses, regardless of the environment, bring their legacy of understanding and ethical development to the clinical environment. The main goal of the nursing profession is to promote the personality and human dignity of all those who are cared for (22).
The results of a qualitative content analysis conducted by Atashzadeh-Shoorideh et al showed that nurses in the intensive care units were faced with numerous ethical distress and ethical stress must be described in a cultural context. The categories identified in this study were organizational obstacles and constraints, communication problems, patients' death/illness, futile actions, healthcare malpractice and errors, and the misallocation of responsibilities (23). The study by Beikmoradi et al also showed moderate moral distress for nurses in ICUs (24). Other studies have shown that commitment and ethical sensitivity are directly related to clinical work experience (25,26). Due to the similarity of the results of these studies with the categories identified in the present study, the need to pay attention to the organizational and legal conditions governing the healthcare system is already felt by considering the educational needs of nurses in the intensive care units. Experienced nurses can make better clinical judgment and consequently better moral judgment about their patients.
A qualitative study by Ravanipour et al, with the content analysis approach, processed the concept of professionalization and determined its indicators. The categories obtained from this study included promoting empowerment, ethics and professional commitment, resources and structure, and reforming social status (27). The results of this study were consistent with the categories of the present study particularly "requirements of ethical care" as becoming a nurse is not only acquiring special knowledge or skills but also obtaining ethical and professional values leading to fundamental changes in the attitude and professional status. The results of a review study by Weaver showed that clinical experience could increase ethical sensitivity, so that sometimes less ethical sensitivity can be seen in people with little professional experience (25). In fact, ethical sensitivity and subsequently ethical judgment require experience in clinical settings. Neville believed that being a nurse is an ethical activity, and that every decision a nurse makes has an ethical dimension, which affects not only life and death situations but also all daily affairs (28).
Reviewing various studies showed that ethical judgment is not only the result of logical reasoning, but also under the influence of emotional and personality factors. Adherence to ethical standards is an effective factor in improving the performance of nurses in providing quality care (1,20,29,30). Nursing care provides the basis for ethics and issues related to human beings. This is the ethical aspect of nursing care that makes it unique (31). Alhavaz et al. analyzed the nursing students' experiences of medical ethics, and considering their real understanding, reached the conclusion that patients are entrusted to nurses. Following this real understanding, they (the nurses) try to observe ethics in dealing with the patients (32). This concept is consistent with the categories identified in the present study. The other category that emerged from the nurses' experiences was the effect of organizational and legal conditions on the observance of ethical standards of care. Nurses blamed system problems and lack of support from their managers as a factor for lack of motivation and, in some cases, reduced quality of patient care.
In a qualitative study by Rezai Sepasi et al, the main theme was gaining human-professional power based on individual and organizational capacities. The findings of this study suggested that success in gaining power in nursing requires a cumulative focus on human, ethical, professional, individual, and organizational capacities (33). This result was consistent with the category of "ethical care based on organizational and legal conditions in the moral environment" in the present study. Nurses, as one of the largest groups of health care providers, face complex ethical problems due to their important role in caring for patients, especially in the intensive care units. Scientific, social, economic, and healthcare changes have made ethical problems more complicated and more difficult to solve than ever. For this reason, nurses today are more at risk of ethical conflict as a distressing feeling (34).
One limitation of the present study was that the participants were volunteer nurses from hospitals affiliated with Sabzevar University of Medical Sciences. Replication of the same study either in other hospitals or in other regions might provide further insight into exploring the phenomenon under study.

Conclusion
The result of this study showed that nurses are exposed to moral judgment in caring for patients in ICUs, sometimes preventing them from performing ethicsoriented care. Moreover, nurses suffer from ethical stress due to daily exposure to death and situations in which they have to make judgments and ethical decisions toward critically ill patients. Therefore, nurses need the effective application of ethics, reasoning skills, and ethical judgment as well as understanding and analysis to develop ethics in the intensive care units. According to the results of the present study and ethical content in the literature, ethical knowledge is an integral part of the nursing profession and nurses deal with ethical issues every day and hour, and the more nurses develop their ethical knowledge, the more they exhibit appropriate judgment and consequently proper performance in patient care. The results of the present study showed that nurses endure a lot of stress during patient care and face many ethical conflicts, while moral judgment is not well developed in them and there is not enough transparency in this regard. Therefore, medical university education systems and hospitals are recommended to offer special training programs on teaching ethics to nursing students to consider their spiritual and emotional needs. Qualitative research pays special attention to the human factor. In this regard, the views of the subjects are valued. Qualitative descriptions of this study played an important role in the possibility of predicting relationships, causes, effects, and processes affecting ethics and care, which can be used to create scenarios related to moral judgment. Using the data of this study (ethical scenarios) in modern teaching methods in workshops and continuous training of the staff helps make the right decisions and reduce the moral stress of nurses.