Original Manuscript

Nursing Ethics
2019, Vol. 26(7-8) 2427–2437
The relationship between ª The Author(s) 2018
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ethical conflict and nurses’ 10.1177/0969733018791350
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personal and organisational
characteristics

Zahra Saberi, Mohsen Shahriari and Ahmad Reza Yazdannik

Isfahan University of Medical Sciences, Iran

Abstract
Introduction: Critical care nurses work in a complex and stressful environment with diverse norms,
values, interactions, and relationships. Therefore, they inevitably experience some levels of ethical conflict.
Aim: The aim of this study is to analyze the relationship of ethical conflict with personal and organizational
characteristics among critical care nurses.
Methods: This descriptive-correlational study was conducted in 2017 on a random sample of 216 critical
care nurses. Participants were recruited through stratified random sampling. Data collection tools were a
demographic and professional characteristics questionnaire, the Ethical Conflict in Nursing Questionnaire-
Critical Care Version, and the Organizational and Managerial Factors Questionnaire. The data were
analyzed using the SPSS software (v. 22.0).
Ethical considerations: All participants were informed about the study’s aim and were assured that
participation in and withdrawal from the study would be voluntary.
Findings: The mean score of exposure to ethical conflict was 201.91 + 80.38. The highest-scored conflict-
inducing clinical situation was “working with professionally incompetent nurses or nurse assistants.”
Married nurses, nurses with official employment, nurses with master’s degree, and nurses with the
history of attending ethics education programs had significantly higher exposure to ethical conflict than
the other nurses (p < 0.05). The significant predictors of exposure to ethical conflict were marital status,
educational status, reward system, organizational culture, manager’s conduct, and organizational structure
and regulations (p < 0.05). These predictors accounted for 37.2% of the total variance of exposure to ethical
conflict.
Conclusion: Critical care nurses experience moderate levels of exposure to ethical conflict. A wide range
of personal and organizational factors can contribute to such exposure, the most significant of which is the
professional incompetence of nursing colleagues, nurse assistants, and physicians. Therefore, many
improvements at personal and organizational levels are needed to reduce critical care nurses’ exposure
to ethical conflict.

Keywords
Critical care nurse, ethical conflict, organizational characteristics, personal characteristics

Corresponding author: Mohsen Shahriari, Nursing & Midwifery Care Research Center, School of Nursing & Midwifery, Isfahan
University of Medical Sciences, Hezar-Jerib Ave., 81746-73461, Isfahan, Iran.
Email: shahriari@nm.mui.ac.ir
2428 Nursing Ethics 26(7-8)

Introduction
Nurses form the largest group of healthcare providers around the world.1 They have pivotal roles in
healthcare delivery.2 For quality care delivery, they need to directly communicate with patients, families,
and other healthcare providers. Such extensive communications together with nurses’ little authority in
healthcare systems and their inability to fulfill some patients’ needs expose them to serious ethical conflict.3
Ethical conflict is an intrapersonal and interpersonal problem,4 which is defined as “an opposition between
two or more moral positions (principles, virtues, or values) or between moral and no moral positions.”5 The
main element of ethical conflict is the moral obligation to follow sound practice. Ethical conflict is affected
by a wide range of factors, such as personal, professional, and organizational values; moral principles; sense
of responsibility; and moral sensitivity.4 For instance, the mismatch between personal and organizational
values can lead to ethical conflict for nurses.6
Nurses may experience different ethical conflicts and moral status, namely, moral indifference, moral
well-being, moral uncertainty, moral dilemma, moral distress, and moral outrage. Moral well-being is a
positive state in which moral thinking conforms moral practice. In moral indifference, a nurse does not feel
responsibility and is indifferent toward immoral practice.7 Moral uncertainty happens when a nurse is
doubtful and uncertain. He or she understands that moral norms are involved in the given situation but is
uncertain or even unaware whether a moral problem exists. Moral dilemma arises when there are convin-
cing reasons for two or more actions; however, the performance of one of these actions denotes the
abandonment of the others. Moral distress is experienced when a nurse knows the moral principles of
sound practice but is unable to apply them in his or her practice due to some limitations.5 Moral outrage
occurs when a nurse feels frustrated at others’ immoral practice.7
Although ethical conflict is a personal problem, it is greatly affected by environmental conditions.8 For
instance, critical care nurses are at greater risk for ethical conflict than their colleagues in other hospital
wards due to high levels of stress, care complexity and diversity, severely ill patients, and sophisticated
equipment in critical care units.9–11 Studies show that the prevalence of conflict among critical care staff,
including nurses, is as high as 71.5%12 and 51%.13
As a serious occupational problem and stressor, ethical conflict can significantly affect nurses’ physical
and mental health, professional performance, social relationships, organizational commitment, and patient
advocacy role and may result in moral distress, job dissatisfaction, job burnout, absence from work, and
high turnover rate.3,6,14–16 Yet, only a few critical care nurses are aware that they may experience ethical
conflict. Therefore, improving their knowledge about ethical conflict can help them better understand
ethical conflict and enable them to use strategies for its prevention and management.13
Many research works have been conducted so far into the different aspects of ethical conflict. However,
there is a paucity of studies regarding the effects of personal and organizational characteristics on ethical
conflict. The only study in this area showed that the most common reasons behind critical care nurses’
ethical conflict were their pre-awareness of the ineffectiveness of some treatments and their obligation to
administer treatments without having any significant role in clinical decision making.8 Exploring the
reasons behind ethical conflict is the first step to its prevention and management.17

Aim and research questions

The aim of this study is to analyze the relationship of ethical conflict with personal and organizational
characteristics among critical care nurses. The main research questions were as follows:
 What is the level of ethical conflict among critical care nurses?
 What are the most important situations that expose critical care nurses to ethical conflict?
Saberi et al. 2429

 Are critical care nurses’ personal and organizational characteristics correlated with their ethical
conflict?
 What are the personal and organizational predictors of ethical conflict among critical care nurses?

Methods
This descriptive-correlational study was conducted in 2017 in 14 adult intensive care units (ICUs) of five
teaching hospitals affiliated to Isfahan University of Medical Sciences, Isfahan, Iran. In total, 491 critical
care nurses were working in these 14 ICUs at the time of the study. The sample size formula
ðn ¼ ðN þ Z 2  S 2 Þ=ðN  d 2 þ Z 2  S 2 ÞÞ indicated that with a confidence level of 0.95 and a d of one-
tenth of standard deviation,18 216 nurses were necessary. Therefore, 240 nurses were recruited through
stratified random sampling. The number of nurses recruited from each ICU was proportionate to the total
number of nurses in that unit. Inclusion criteria were bachelor’s or higher degree in nursing, ICU work
experience of at least 1 year, agreement for participation, and no affliction by serious physical, mental,
familial, or social problems (based on their personal health records). Sampling and data collection were
performed from January to April 2017.

Data collection
Three instruments were used for data collection, which are explained as follows:

1. A demographic and professional characteristics questionnaire. This questionnaire had items on

nurses’ age, gender, marital status, employment status, educational status, nursing work experience,
ICU work experience, number of weekly work hours, and a history of attending ethics education
programs.
2. Ethical Conflict in Nursing Questionnaire-Critical Care Version (ECNQ-CCV). This questionnaire
was developed by Falcó-Pegueroles et al. to assess the frequency and the severity of 19 nursing
scenarios, which are potential sources of ethical conflict. The frequency and the severity of each
scenario were, respectively, evaluated via a 0–5 and a 1–5 Likert-type scale. Then, frequency scores
were multiplied by severity scores to generate the index of exposure to ethical conflict (IEEC),
which showed the level of exposure to ethical conflict. The IEEC of each scenario and the total IEEC
of ECNQ-CCV were 0–25 and 0–475, respectively. Higher IEEC scores represented higher expo-
sure to ethical conflict. Besides frequency and severity, ECNQ-CCV also asked respondents to
choose from six options the best option that described their moral state in each scenario. These
options were moral indifference, moral well-being, moral uncertainty, moral dilemma, moral dis-
tress, and moral outrage. Motaharifar et al.19 translated ECNQ-CCV into Persian and reported
satisfactory validity and a Cronbach’s alpha of 0.92 for the Persian ECNQ-CCV.
3. Organizational and Managerial Factors Questionnaire. This questionnaire was developed by
Yaghoobi et al. and contained 46 items in 5 domains, namely, organizational structure and regula-
tions, reward system, manager’s conduct, organizational culture, and organizational relationships.
Item scoring was done on a 1–5 Likert-type scale. The scores of the domains were changed into a
1–100 scale, and hence, the maximum possible score for each domain was 100. Higher scores
represented better organizational conditions. Yaghoobi et al.20 confirmed the content validity of
the questionnaire and found that its Cronbach’s alpha was 0.80.
2430 Nursing Ethics 26(7-8)

Ethical considerations
This study has the ethical approval of the Ethics Committee of Isfahan University of Medical Sciences,
Isfahan, Iran, with the approval code of IR.MUI.REC.1395.3.898. Primarily, all participants were provided
with information about the aim of the study. They were also assured that participation in and withdrawal
from the study would be voluntary, questionnaires would be anonymous, and data management would be
performed confidentially. Informed consent was obtained from each participant and a gift was given to him
or her in order to appreciate his or her participation.

Data analysis
The data were analyzed using the SPSS software (v. 22.0). Descriptive statistics measures, such as fre-
quency distributions, mean, and standard deviation, were used for data presentation. Furthermore, the
independent-sample t test, the one-way analysis of variance, Pearson and Spearman rank-order correlation
analyses, and multiple regression analysis were used for data analysis.

Findings
Among 240 participants, 221 returned their questionnaires. Five questionnaires were excluded due to partial
answering. Thus, 216 questionnaires were analyzed (a response rate of 90%). The means of participants’
age, nursing work experience, and ICU work experience were 33.45, 9.44, and 6.53 years, respectively.
Most of them were female (89.4%) and held bachelor’s degree in nursing (89.8%). Only 35.3% of parti-
cipants had attended ethics education programs.
The mean score of nurses’ exposure to ethical conflict was 201.91 + 80.38, implying a moderate level of
exposure. The relative frequencies of mild, moderate, and severe ethical conflict exposures were 31.5%,
58.3%, and 10.2%, respectively. The highest mean scores of exposure to ethical conflict were related to the
scenarios of “working with professionally incompetent nurses or nurse assistants” (mean score ¼ 18.37),
“working with professionally incompetent physicians” (mean score ¼ 16.98), and “lack of means,
resources, and time” (mean score ¼ 14.21), respectively. These three scenarios were related to the inter-
professional relationships and the ethical environment dimensions of ECNQ-CCV. On the other hand, the
lowest scores were related to the scenarios of “administrating treatments according to family’s wishes
despite knowing their clash with patient’s interests” (mean score ¼ 4.43), “failure to keep patients’ clinical
data confidential” (mean score ¼ 5.03), and “administrating treatments without patient’s family knowing
their objectives, benefits, and risks” (mean score ¼ 5.87), respectively (Table 1). In other words, working
with professionally incompetent colleagues caused the highest levels of ethical conflict, while administrat-
ing treatments requested by family members despite their conflicts with patients’ interests and preferences
caused the lowest levels of ethical conflict.
The highest and the lowest frequencies were related to “administrating treatments for a patient who is not
critically ill” (mean score ¼ 4.55) and “failure to keep patients’ clinical data confidential” (mean score ¼
1.71), respectively. In other words, the most and the least frequent conflict-inducing situations were related
to the administration of treatments for patients who are not critically ill and the inability to maintain the
confidentiality of patients’ clinical data. On the other hand, the most and the least severe areas of ethical
conflict were “working with professionally incompetent nurses or nurse assistants” (mean score ¼ 4.9) and
“administrating treatments without informing the conscious patient about their aims and risks” (mean score
¼ 2.82). Accordingly, working with incompetent colleagues caused participants the most severe ethical
conflict, while administration of treatments without adequate patient education about treatments caused
them the least severe ethical conflict.
Saberi et al. 2431

Table 1. The mean scores of exposure to EC in each scenario in descending order.

Number Mean score of

scenario Nursing care scenarios exposure to EC

12 Working with a nurse or nursing assistant who I consider to be professionally incompetent. 18.37
9 Working with medical staff who I consider to be professionally incompetent. 16.98
19 Lacking the means (space) and/or resources (time) that would enable the clinical team to 14.21
consider the ethical problems they have to face.
13 Acting contrary to my own moral beliefs due to not having enough time to care properly for 14.62
the patient.
3 Caring for a patient who I believe should be on an ordinary hospital ward rather than in a 13.66
critical care unit.
7 Realizing that the analgesia and/or sedation being given to the patient is not effective enough 12.65
and that the patient is suffering.
8 Using all available technical and/or human resources despite believing that they will produce 12.40
no significant improvement in the clinical status of the critical care patient.
1 Administering treatments and/or performing tests that I consider unnecessary because 11.44
they serve merely to prolong a terminal, irreversible process.
18 Failure to respect properly the privacy of the patient’s body when carrying out procedures 11.36
and/or exploratory tests.
11 Administering treatments and/or carrying out procedures that are too aggressive given the 11.33
status of the patient and in so doing causing the patient additional suffering.
17 Administering treatments and/or carrying out procedures without, as a nurse, having been 11.05
previously involved in the decision to do so.
4 Carrying out interventions that put institutional or health service interests before those of 10.75
the patient.
16 Caring for a patient without knowing whether or not he or she has made a living will 9.16
declaration, or in the event that such a document exists not knowing its content.
15 Finding it difficult to give timely information to the patient and/or his or her family because 6.80
the medical team discourages nurses from taking the initiative in this regard.
2 Having to administer treatments and/or carry out procedures without the critical patient, 6.61
who is conscious, knowing their purpose and the risks involved.
14 Administering treatments in the context of a clinical trial or research project without, as a 6.08
nurse, being given all the information I consider necessary to carry out this task.
6 Administering treatments and/or carrying out interventions without the patient’s family 5.87
knowing the objectives, benefits, and risks involved (when the patient has consented to
the family being informed).
5 Failure to keep a patient’s clinical data confidential by sharing them with third parties or 5.03
with people who are not directly involved in the patient’s care.
10 Administering treatments and/or carrying out interventions in accordance with the family’s 4.43
wishes, despite knowing that these clash with the patient’s interests.
EC: ethical conflict.

Moral dilemma was the most frequently experienced moral state in 9 scenarios, while moral indifference
was the least frequently experienced moral state in 18 scenarios. In simpler words, moral dilemma and
moral indifference were, respectively, the most and the least prevalent moral states experienced by parti-
cipants. Around 41.8% of nurses had experienced moral outrage in dealing with scenario 12, which was the
highest-scored scenario, while moral uncertainty was the most commonly experienced moral state for
scenario 10, which was the lowest-scored scenario.
The mean score of exposure to ethical conflict had significant relationships with marital status,
educational status, employment status, and the history of attending ethics education programs. In other
2432 Nursing Ethics 26(7-8)

Table 2. The relationship of nurses’ exposure to EC with their demographic and professional characteristics.

Score of IEEC
Characteristics N % Mean + SD p value

Gender Female 193 89.4 202.1 + 80.4 0.93

Male 23 10.6 200.6 + 81.6
Marital status Married 147 68.1 208.3 + 78.9 0.04
Single 69 31.9 188.3 + 82.3
Educational status Bachelor’s 194 89.8 197.6 + 78.3 0.02
Master’s 22 10.2 239.8 + 90.1
Employment status Post-graduation service 31 14.4 174.9 + 76.5 0.046
Conditional official 71 32.9 205.8 + 71.7
Contractual 96 44.4 203.3 + 85.3
Permanent official 18 8.3 225.3 + 89.1
Work shift Fixed 36 16.7 201.1 + 80.8 0.75
Rotating 180 83.3 205.7 + 79.5
Attendance at ethics education programs Yes 76 35.2 219.3 + 83.4 0.02
No 140 64.8 192.5 + 77.4

EC: ethical conflict; SD: standard deviation; IEEC: index of exposure to ethical conflict.

words, married nurses, nurses with official employment, nurses with master’s degree, and nurses with the
history of attending ethics education programs had significantly higher exposure to ethical conflict than,
respectively, single nurses, nurses who were doing their mandatory post-graduation service, nurses with
bachelor’s degree, and nurses who did not have the history of attending ethics education programs (p <
0.05). However, the mean score of exposure to ethical conflict was not significantly correlated with age,
gender, work shift, type of hospital, number of weekly work hours, nursing work experience, and ICU
work experience (p > 0.05; Table 2).
The mean scores of the five domains of organizational and managerial factors were as follows: organi-
zational structure and regulations: 44.4; reward system: 28.9; manager’s conduct: 37.4; organizational
culture: 32.9; and organizational relationships: 48.8. These findings denote major weaknesses in reward
system, organizational culture, and manager’s conduct domains. Pearson correlation analysis showed that
the mean score of exposure to ethical conflict had significant inverse correlation with the first four domains.
In other words, poor organizational structure and regulations, ineffective reward system, improper manag-
er’s conduct, and inappropriate organizational culture were associated with higher exposure to ethical
conflict (p < 0.05). However, the correlation of ethical conflict exposure mean score with the organizational
relationships domain was not statistically significant (p ¼ 0.34; Table 3).
Multiple linear regression analysis was used to predict ethical conflict score based on personal and
organizational characteristics. Its results illustrated that the significant predictors of ethical conflict were
marital status, educational status, reward system, organizational culture, manager’s conduct, and organiza-
tional structure and regulations, (p < 0.05). These predictors accounted for 37.2% of the total variance of
ethical conflict. The strongest predictors were reward system, organizational culture, educational status, and
manager’s conduct (Table 4).

Discussion
The aim of this study is to analyze the relationship of ethical conflict with personal and organizational
characteristics among critical care nurses. Its findings indicated that critical care nurses were moderately
exposed to ethical conflict. This is consistent with the findings of four earlier studies.8,21–23 However, a
Saberi et al. 2433

Table 3. The correlation of the mean score of EC with organizational and managerial characteristics.

Ethical conflict

Characteristics Mean SD r p value

Organizational structure and regulations 44.4 11.9 –0.204 0.003

Reward system 28.9 20.8 –0.230 0.001
Manager’s conduct 37.4 17.5 –0.217 0.001
Organizational culture 32.9 15.7 –0.223 0.001
Organizational relationships 48.8 14.6 0.065 0.34

EC: ethical conflict; SD: standard deviation.

Table 4. The results of multiple regression analysis for EC prediction based on personal and organizational
characteristics.

Unstandardized Standardized p
Characteristics coefficients coefficients t value

Personal Marital status –14.621 –0.185 2.52 0.02

Educational status 26.601 0.210 2.67 0.003
Employment status 8.75 0.092 1.36 0.17
Attendance at ethics education programs –14.26 –0.087 1.24 0.22
Organizational Organizational structure and regulations –0.674 –0.175 2.46 0.02
Reward system –0.393 –0.215 2.77 0.002
Manager’s conduct –0.250 –0.205 2.64 0.004
Organizational culture –0.429 –0.211 2.68 0.003
Organizational relationships 0.745 0.081 1.19 0.23
EC: ethical conflict.

study in Iran showed a great severity of ethical conflict experienced by critical care nurse. This contra-
diction is due to the fact that the study solely assessed the severity of ethical conflict-inducing situations
without addressing their frequencies.24
This study also showed that working with professionally incompetent nurses or nurse assistants was
ethically the most conflicting situation for critical care nurses. Another study in Iran also reported the same
finding.24 This finding highlights the necessity of developing strategies by nursing authorities to improve
nurses’ and nurse assistants’ professional competence. Similarly, two other studies showed professional
incompetence (manifested by immoral conduct, poor moral sensitivity, and low-quality care delivery) as a
significant factor behind critical care nurses’ moral distress.25,26 However, other studies reported that
ethical conflict was determined mostly by factors, such as inconsistent clinical decisions, low-quality
end-of-life care, ineffectiveness of analgesics and tranquilizers, inability to alleviate patient’s pain, and
witnessing patient’s agony.8,27,28
Findings also indicated that the least significant factor behind critical care nurses’ ethical conflict was the
administration of treatments according to family’s wishes despite knowing its incongruence with patient’s
interests. Falcó-Pegueroles et al. also reported the same finding and attributed it to the use of certain ethical
conflict prevention strategies by critical care nurses.8 This finding in this study can be due to families’
inactive involvement in the process of clinical decision making.
Moral dilemma and moral indifference were, respectively, the most and the least prevalent moral states
experienced by our participants. Each clinical situation, which exposes nurses to ethical conflict, can lead to
2434 Nursing Ethics 26(7-8)

certain moral state. The complexity of ICU environment and the unique characteristics of critical care
services together with nurses’ own moral sensitivity can present them with moral dilemmas. Another main
reason behind moral dilemma is to be located in situations that require nurses to adhere to either organiza-
tional regulations or professional values.
Most of our participants had experienced moral outrage when working with professionally incompetent
nurses, nurse assistants, and physicians. Nurses’ moral outrage is usually due to their inability to prevent or
change an immoral action.7 Promoting nurses’ moral courage can empower them to cope with immoral
practice and help them manage their ethical conflict. An earlier study showed that greater moral courage
was associated with lower moral distress among nurses.29 Besides, improvement of nurses’ inter-
professional relationships can alleviate their ethical conflict and moral outrage.
Another finding of this study was the insignificant correlation of ethical conflict with age, nursing work
experience, and ICU work experience. Some studies also reported that moral distress did not significantly
correlate with age,8,22,30 while a study found higher levels of conflict among younger nurses31 and another
reported a direct correlation between age and moral distress.23 Nurses with greater professional experience
are probably more competent in using effective defense mechanisms and hence experience less moral
distress.32,33 At the same time, they are more exposed to situations that bring them into moral distress.34
Yet, the relationship of ethical conflict with age and work experience is an area of controversy because
moral challenges are too complex to be explained solely by age and work experience. We also found that
ethical conflict had no significant relationships with gender, number of weekly work hours, type of hospital,
and work shift. An earlier study also reported the same findings.8 These findings may be due to the fact that
all participants of this study were selected from the same hospital wards (i.e. ICUs), had similar organiza-
tional affiliation, and worked almost the same work hours per week. However, a study on a limited number
of nurses showed higher levels of moral distress among female nurses.11 This contradiction may be due to
the limited number of nurses in that study.
Our findings also showed that married nurses were significantly more exposed to ethical conflict than
single nurses. In our country, married and single nurses have the same job specifications and there are no
certain facilities for married nurses. Accordingly, they may experience ethical conflict in relation to both
work and family. The expanded roles of married nurses and the conflicts between their familial and
professional responsibilities increase the likelihood of ethical conflict among married nurses.
Another finding of this study was that nurses who had the history of attending ethics education
programs were significantly more exposed to ethical conflict than those who had not such history.
Previous studies also reported the same finding.8,12,35 It seems that nurses who attend ethics education
programs learn more about the principles of professional ethics, become more competent in understand-
ing mismatches between theory and practice, and hence, experience higher levels of ethical conflict.
Besides, nurses who know the accurate methods of doing things but are unable to do them accurately due
to organizational limitations are more prone to ethical conflict. Accordingly, improving nurses’ knowl-
edge about professional ethics without improving their workplace environment for moral practice may
not be effective in alleviating their ethical conflict.
Findings also revealed that organizational regulations in the study setting were a major barrier to
change, dynamism, and creativity. Moreover, nurses’ inability to participate in clinical decision making
and the lack of necessary information and facilities for doing their professional tasks had negatively
affected their work. All these factors had increased their exposure to ethical conflict. Previous studies also
reported barriers and limitations caused by organizational regulations as predisposing factors for ethical
conflict.3,35,36 Developing organizational rules and regulations while taking nurses’ viewpoints into
account may reduce the mismatch between professional values and organizational regulations and
thereby minimize the likelihood of ethical conflict for nurses. Given the heavy costs of ethical conflict,
Saberi et al. 2435

managers need to develop strategies to minimize ethical conflict in healthcare settings and thereby reduce
healthcare costs and improve care quality.37
We also found organizational reward system as another significant factor behind nurses’ exposure to
ethical conflict. In the study setting, rewards were not merit-based and thus nurses’ sound professional
practice had no significant effects on their career advancement. Such inefficient reward system can expose
them to ethical conflict, reduce their job motivation, cause them job burnout, and give them a sense of
worthlessness.15 Therefore, developing an efficient merit-based reward system is an absolute necessity for
reducing ethical conflict among nurses.
Study findings also indicated the significant correlation of ethical conflict with organizational culture
and manager’s conduct. Nurses in the study setting had no considerable professional autonomy and their
managers did not greatly value their capabilities and merits. Previous studies also reported that organiza-
tional factors, such as significant differences between physicians’ and nurses’ power in healthcare settings
and nurses’ limited professional autonomy, cause them ethical conflict and moral distress.26,35,38

Limitations
This study was conducted in teaching hospitals in the sociocultural context of Iran; therefore, findings need
to be cautiously generalized to nurses in non-teaching hospitals and nurses in other sociocultural contexts.

Conclusion
This study shows that inter-professional relationships and organizational characteristics have more signif-
icant roles in causing ethical conflict for nurses than the characteristics of medical and nursing interventions
and nurses’ relationships with patients and their families. The most significant factors behind nurses’
exposure to ethical conflict are incompetent nursing colleagues, nurse assistants, and physicians and poor
work conditions. Although complete resolving of ethical conflict is impossible, managers and authorities
can minimize ethical conflict in their organizations through strengthening inter-professional relationships,
conducting in-service staff training programs to promote nursing staff’s clinical competence, making
organizational and workplace improvements, developing formal and informal support systems, and improv-
ing reward systems and organizational culture.

Acknowledgements
The authors would like to acknowledge the Nursing & Midwifery Faculty, Isfahan University of Medical
Sciences, for supporting this work. They also thank all persons who made this study possible.

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: This work was supported by Nursing & Midwifery Faculty, Isfahan University
of Medical Sciences.

ORCID iD
Mohsen Shahriari https://orcid.org/0000-0002-7833-0187
2436 Nursing Ethics 26(7-8)

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