Nursing Ethics

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Ethical decision-making and professional behaviour among nurses : A correlational study

Birgül Cerit and Leyla Dinç
Nurs Ethics 2013 20: 200 originally published online 6 November 2012
DOI: 10.1177/0969733012455562

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Article
Nursing Ethics
20(2) 200–212
Ethical decision-making and ª The Author(s) 2012
Reprints and permission:
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professional behaviour among 10.1177/0969733012455562
nej.sagepub.com
nurses: A correlational study

Birgül Cerit
Abant Izzet Baysal University, Turkey
Leyla Dinç
Hacettepe University, Turkey

Abstract
This study examined the relationship between nurses’ ethical decision-making levels and their professional
behaviours. Data were collected from 225 nurses who were recruited from university hospitals in Ankara
using proportionate sampling. Data were analysed using descriptive statistics and Pearson correlations. Most
of the nurses were familiar with ethical dilemmas in nursing practice. The Nursing Principled Thinking level
was above average, while the Practical Consideration level was average. Nurses’ professionalism level was low.
There was a positive but weak correlation between professional behaviours of the nurses and their ethical
decision-making levels. Increasing nurses’ professionalism level can provide a positive contribution to the ethi-
cal decision-making level.

Keywords
Ethical decision-making, nursing ethics, nursing practice, nursing professionalism

Introduction
Ethics are of utmost importance in health care due to the moral questions raised by the advances in sci-
ence, medicine and biotechnology.1,2 Life-prolonging treatments and technologies, organ transplanta-
tion, genetic testing and stem cell research, for example, raise ethical problems that are confronted
by health-care professionals. Therefore, it is crucial for health-care professionals to be aware of ethical
problems, to have the ability to apply moral reasoning to those problems and to develop ethical decision-
making skills.3,4
According to the International Council of Nurses,5 nursing includes the promotion of health, prevention
of illness and the care of ill, disabled and dying people. Explicit in this definition is caring for people who
are in need. Caring requires more than theoretical knowledge and technical skills; caring has an affective
component that includes awareness of others’ vulnerability, attentiveness to caring needs and a moral
response to the needs.
As caring is a continual process, nurses spend more time with patients than any other health-care profes-
sionals. The close relationship between nurses and patients enables nurses to witness illness experiences and

Corresponding author: Birgül Cerit, Bolu Health School, Abant Izzet Baysal University, 14280/Bolu, Turkey.
Email: birgulcerit@yahoo.com.tr

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Cerit and Dinç 201

suffering of patients, all of which demand that nurses make moral judgements with and for those
patients.6 In the meantime, because of the complex ethical issues raised by developments in medicine
and biotechnology, it is essential for nurses to be involved in ethical decision-making processes.
Ethical decision-making is requisite for being a professional, and it is interrelated with professional
competency and autonomy. Thus, it is important to investigate nurses’ ethical decision-making levels
and professionalism.
Studies report that nurses increasingly confront ethical problems in nursing practice. The relationship
between nurses’ ethical decision-making levels and their professional conduct is also well acknowl-
edged.7–10 However, little is known about the relationship between nurses’ professional behaviours and
their ethical decision-making levels within a secular country with a diverse culture that is mainly affected
by Islamic religious and Mediterranean patriarchal values. As ethical orientation is strongly related to one’s
cultural background and professional behaviours are influenced by various factors, it is of interest to ethi-
cists and nurses across cultures to understand the relationship between nurses’ ethical decision-making
levels and their professional conduct.

Background
Nurses have been striving for professionalism for over a century. Although there is no consensus as to what
constitutes the proper attributes of a profession, Pavalko11 offered the following criteria: a profession should
involve a specialized theory and intellectual technique, should be relevant to basic social values and
processes, should reflect the nature of preparation in terms of the amount and specialization of training and
should motivate members through their service to society, autonomy of practice, sense of commitment,
sense of professional community and codes of ethics. Other investigators also identified similar character-
istics of a profession.12–14 While all of these characteristics are interrelated, the code of ethics is essential for
autonomy, which allows professionals to make their own judgements and decisions about the services they
provide.
Decision-making is a rational process and includes sequential phases of problem recognition, problem
identification and evaluation of alternatives and the selection of an alternative. Ethical decision-making
is also a rational process involving cognitive activity; however, it also involves moral judgement and jus-
tification of the decision.15
Kollemorten et al.16 argue that a clinical decision has an ethical component if it is based on a value
judgement, either to assess the value of the consequences of a decision or to assess the extent to which the
duties of the decision maker and the rights of others are fulfilled. They point out that a value judgement is
based on non-scientific premises.
Lawrence Kohlberg17 suggests that individuals progress through three levels in the ability to make moral
judgements: (a) the pre-conventional level, when moral decisions are based on rewards and punishments
and obedience to authority; (b) the conventional level, when individuals recognize societal laws and rules
and are concerned regarding collective welfare and (c) the post-conventional level, when moral decisions
are based on internalized moral values and abstract principles. Principled thinking occurs at the post-
conventional level; Kohlberg argued that few people attain this level, especially as moral reasoning is
stimulated by cognitive conflicts. For Kohlberg, the highest stage of moral development involves a concern
for justice and human rights based on internalized universal principles. Although Kohlberg did not link his
model of moral development to a process of ethical decision-making, his stages are often used as a measure
of moral judgement.15 However, Kohlberg’s assumption that moral thinking is equated with a justice per-
spective has been criticized. For example, Gilligan,18 who studied with Kohlberg, questioned his research
findings because they were focused solely on males. She found that the moral reasoning and development of
women and men differed; women placed more importance on relationships and caring for themselves and

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202 Nursing Ethics 20(2)

others than on rules and principles. Gilligan has focused on the consideration of care for particular persons
within the context of particular relationships. Some nurse scholars believe that ethics of care can be used as
the basis of ethical decision-making, while critics argue that caring is too subjective19 and is limited as an
ethical basis.20 Others suggest an integrated approach of ethics of justice and ethics of care as a theoretical
basis to inform ethical decision-making.21,22
Although there is no consensus on which ethical theory or moral perspective decisions should be based,
nurses are confronted with ethical problems and are expected to make ethical decisions. However, the
nature of ethical problems that involves complex situations and moral dilemmas, in which the moral solu-
tion is ambiguous, may influence the ethical decision-making process. In addition, how nurses respond to
ethical problems varies by professional experience, autonomy and competency. Social and cultural factors
can influence nurses’ professionalism and ethical decision-making. Thus, it is important to examine the
relationship between nurses’ ethical decision-making and their professional behaviours from different
cultural contexts.
There are numerous instruments for measuring the moral reasoning and moral judgement of individuals,
which have been adapted into Turkish, including the short version of the Defining Issue Test, which was
devised by James Rest23 in 1979 and adapted into Turkish by Cesur24 in 1997, and the Moral Judgment
Abilities Test (MJT; Moralischer–Urteil–Test (MUT)), developed by Lind25 in 1977 and adapted into Turk-
ish by Çiftçi in 2001.26 There are also two instruments, which are specific to nurses and can be used in
Turkish context, including the Moral Sensitivity Questionnaire developed by Lützen et al.27 in 1994 and
adapted into Turkish by Tosun in 2003,28 and the Nurses Ethical Sensitivity Test, developed by Byrd29
in 2006 and adapted into Turkish by Orgun and Khorshid30 in 2009. However, none of these instruments
are specific to nurses’ ethical decision-making. Validated measures of nurses’ ethical decision-making in
a different culture could be helpful for nurses to monitor and develop their ethical decision-making skills
and professional conduct.

The study
Aim of the study
Turkey has a collective and paternalistic culture, which emphasizes interdependence, cohesion and loyalty
within social groups, and gives priority to collective interest over individual autonomy.31 As cultural values
are internalized through the process of socializing, culture can influence individuals’ beliefs, values, ethical
decisions and professionalism. The aim of this study was to investigate the correlation between nurses’ pro-
fessional behaviours and their ethical decision-making in a different cultural context by adapting the Nur-
sing Dilemma Test (NDT) into Turkish.

Design
This study was descriptive and correlational in design and was conducted in two phases. Phase I, in 2008,
included the adaptation, content validity and reliability testing of the NDT. Phase II, in 2009, investigated
the correlation between nurses’ professional behaviours and their ethical decisions.

Study phase I. The first phase of this study included the translation–back translation, content validity and
reliability study and preliminary testing of the NDT, which was developed by Patricia Crisham in 1981
at the University of Minnesota. Using interviews with 130 registered nurses who were asked to provide
actual experiences with ethical dilemmas in nursing practice, Crisham32 formulated six scenarios. Each sce-
nario presents a situation that is likely to generate moral confusion for nurses who are caring for the patient

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Cerit and Dinç 203

and family. The ethical dilemmas are as follows: (a) newborn with anomalies, which considers the issue of
defining and promoting the quality of life; (b) forcing medication; (c) adults’ requests to die; (d) orientation
of a new nurse; (e) medication errors and (f) terminally ill adults. The ‘newborn with anomalies’, ‘forcing
medication’ and ‘adult’s request to die’ dilemmas involve issues regarding the client’s right to autonomy.
The ‘orientation of a new nurse’ and ‘medication error’ dilemmas consider maintaining professional and
institutional standards and the fair distribution of nursing resources in paediatric and surgical nursing. The
‘terminally ill adult’ dilemma addresses a client’s right to know about his personal health care.
In the NDT test, nurses are asked to respond to three sections of questions after each scenario. Section A of each
dilemma asks what a nurse should do. Nurses are expected to choose one of three items. For example, the dilemma
of forcing medication asks whether the nurse should forcefully give the medication or remain undecided.
In section B, nurses must consider six common items in relation to ethical dilemmas in clinical practice.
Nurses are asked to rank the six items in order of importance. The nurses’ responses to this section indicate
their Nursing Principled Thinking (NP) and Practical Consideration (PC). NP refers to an individual level
of reasoning and behaviour that reflects the post-conventional level of Kohlberg’s theory of moral devel-
opment. PC refers to environmental factors, including available resources, institutional policies and per-
ceived management support, that affect ethical decision-making.
In the NDT rankings, the item ranked as the most important for each dilemma received 6 points; each
subsequent ranking was given one point less such that the item ranking sixth received 1 point. The NP score
was calculated by adding the scores of the NP items across the six dilemmas. The NP index represents the
sum of weighted item ranks and is interpreted as the relative importance given to principled moral
considerations. The highest possible NP score is 66, and there are two NP items for each dilemma. The rela-
tive importance given to PC was indexed in a similar process. The PC index represents the sum of weighted
PC ranks and is interpreted as the relative importance given to PC in making a nursing moral decision. The
highest possible PC score is 36 with one PC item for each dilemma.
Section C requires nurses to indicate familiarity with the ethical dilemma. Similar to the NDT, familiar-
ity refers to nurses’ previous experiences with the ethical dilemmas. To measure the nurses’ degree of pre-
vious involvement with a similar dilemma, a 5-point Likert-type scale was used with each dilemma: ‘1’
indicated ‘made a decision in a similar dilemma’, ‘2’ indicated ‘knew someone else in a similar dilemma’,
‘3’ indicated ‘not known anyone in a similar dilemma but dilemma is conceivable’, ‘4’ indicated ‘difficult
to imagine the dilemma as it seems remote’ and ‘5’ indicated ‘difficult to take the dilemma seriously as it
seems unreal’. The Familiarity (F) score was calculated by adding the points that indicated the participants’
degree of familiarity across the six dilemmas, and the F index represents the sum of the familiarity scores.
The classification of the subject as familiar or unfamiliar with the dilemmas was based on the properties of
the F scale: a score of 6–17 indicated familiarity with the dilemmas and a score of 18–30 indicated a lack of
familiarity with the dilemmas.32,33
In phase I of this study, the NDT was separately translated from English to Turkish by three
English language experts. After the translation, researchers prepared the first Turkish version of the
NDT by comparing and assessing three translations. The Turkish version of the NDT and its original
English version were submitted to three experts in areas of nursing, deontology and history of med-
icine and Turkish language and literature. These experts checked the first Turkish version of the NDT
to measure its compatibility with Turkish language and its content validity. The test was then revised
by the researchers to address the critiques and suggestions of the experts. The Turkish version was
translated into English by another English language expert to determine whether it corresponded with
the original content.
For the assessment of content validity, the NDT was pilot tested with a purposeful sampling of 50 volun-
teer nurses who were employed at a public hospital. Nurses stated that they did not have any difficulties
understanding or completing the six dilemma test. Therefore, there was no need for further revision.

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204 Nursing Ethics 20(2)

To determine the internal consistency, the data were entered in the Statistical Package for Social
Sciences (SPSS) program. We found Cronbach’s as of .59 for the NP level and .50 for the PC level (n ¼ 50).
To determine the test–retest reliability, the test was administered at a 3-week interval to 25 nurses
working at a university hospital. Previous studies using tools to measure moral judgement or ethical
decision-making of nurses did not provide information on test–retest reliability of the instrument,32–35
while Corley et al.36 reported an interval of 3 weeks for test–retest reliability. Our rationale for the
3-week interval for the retest was to reduce the carry-over effect, which refers to remembering the
answers from last time, and to reduce the likelihood of work-related factors such as changes in clinical
setting and organizational policies that may occur over time and influence nurses’ ethical decision-
making. According to the literature, if the Pearson correlation coefficient is within the range .70–.89, then
the relationship between the variables is defined as strong.37,38 Our test–retest results showed a positive
relationship (p < .01; NP: r ¼ .77; PC: r ¼ .73).

Study phase II. The second phase of this study was carried out to investigate the correlation between nurses’
professional behaviours and their ethical decision-making.

Sample
In phase I of this study, a purposeful sample of 50 volunteer nurses was recruited from a public hospital to
assess the content validity, and 25 nurses were sampled from a university hospital to assess the reliability of
the Turkish version of the NDT. The participants (n ¼ 75) and settings in phase I were different from phase
II of the study.
The population in the second phase of this study consisted of 630 nurses with bachelor’s degrees who
were employed at three university hospitals in Ankara. The sample size was calculated using the formula
n ¼ N t2 pq/d2 (N  1) þ t2 pq, as suggested by Sekaran.37 Based on this formula, we calculated the sample
size as 242 nurses. Sampling was determined by proportionate stratification. Accordingly, we first identi-
fied the number of nurses working at each hospital and then calculated their proportion to the size of the total
sample. The participating nurses from each hospital were recruited randomly using a random number table.
As 17 nurses refused to participate, the study was conducted with 225 nurses.

Instruments
In the second phase, data were collected with two instruments: the Turkish version of the NDT to measure
the ethical decision-making levels of nurses and the Behavioural Inventory for Professionalism in Nursing
(BIPN) to measure the professionalism behaviour of the nurses.
The BIPN was developed in 1993 by Barbara Kemp Miller, Dona Adams and Lasca Beck.39 The BIPN
includes 48 questions. Questions 1–7 involve demographic characteristics of the nurses, and questions 8–48
cover professional behaviour. The BIPN has nine subgroups: (a) educational preparation, referring to the
highest nursing degree attained; (b) publication, referring to published nursing articles; (c) research, refer-
ring to involvement as investigators or participants; (d) participation in a professional organization; (e)
community service participation; (f) competence and continuing education, including reading and subscrib-
ing to nursing journals; (g) following a nursing code of ethics; (h) familiarity with nursing theory and (i)
autonomy, referring to participation in peer review, nursing audits, quality assurance, self-evaluation and
ethics committees, as well as budgeting for their areas, hiring and firing or consulting with other agencies.39
Behaviours are weighted within each of the nine categories to equal 3, such that a total scale score of 27
(9  3) is possible. Weightings for specific behaviours within each category range from 0.5 to 3. The BIPN

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Cerit and Dinç 205

was adapted in 2004 into Turkish by Karadağ, Hisar and Elbas,40 and its validation and reliability were
confirmed (Cronbach’s a ¼ .78–.87).

Data collection
During the period from 16 March 2009 to 30 June 2009, the two instruments were administered to 225
volunteer nurses through face-to-face interviews (response level ¼ 92.97%).

Ethical considerations
The study protocol was officially approved, and ethical clearance was obtained by the Ethical Commission
of Hacettepe University. The medical and nursing directories of three university hospitals provided written
permission for this study. Nurses were informed about the aims and methods of the study. They were told
that their participation must be voluntary and that they could withdraw from the study at any time. Those
who agreed to participate signed the informed consent form. Written permission was granted by Patricia
Crisham in 2008 for the translation and adaptation of the NDT into Turkish. Similarly, written permission
was obtained from Ayişe Karadağ et al. on 15 February 2008 for the use of BIPN.

Data analysis
The SPSS, version 15.00 for Windows, was used for data entry with appropriate coding and statistical
analysis. We used descriptive statistics to analyse the demographic data. Mean and standard deviation
(SD) were used to identify the NP and PC scores for ethical decision-making and for scores of profession-
alism behaviours. Cronbach’s as were calculated for NP and PC scores as a measure of internal consistency,
and test–retest reliability was tested with a Pearson correlation coefficient. The degree of association
between nurses’ ethical decision-making and professionalism behaviours was also analysed with a Pearson
correlation coefficient. Statistical significance was set at p < .05.

Results
The age of most participants (86%) ranged from 18 to 30 years. More than half of the participating nurses
were working at clinics, and 73% had 5 years of clinical experience. We identified Cronbach’s as of .68 for
the NP level score and .56 (n ¼ 225) for the PC level.
Based on the data from section A of each scenario of NDT, approximately 69% of the nurses were in
favour of resuscitation of a newborn with abnormalities, more than half would administer medication
against the will of the patient and for the third scenario, 88% would provide respiratory support despite
a competent adult patient’s request to die. Almost half of the nurses stated that there is no time allocated
for the orientation of new nurses into the paediatric and surgical nursing clinic, as it would compromise
patient quality of care. The last scenario included a dilemma about a terminally ill adult who wanted to
know his diagnosis in spite of his doctors’ and family members’ wishes. Nurses’ responses to this scenario
were quite different, with 40.5% agreeing with the doctor and family and 33.8% remaining undecided
(see Table 1).
The mean NP score of nurses was 47.89 (SD ¼ 8.16), and the mean PC score was 17.34 (SD ¼ 4.12; see
Table 2). Nurses’ responses to section C of the NDT showed that 71.6% (n ¼ 161) were familiar with similar
ethical dilemmas in clinical practice.
The nurses’ mean BIPN scores were quite low (5.97). The highest average score was the theory sub-
dimension, and the lowest average scores were the sub-dimensions publication, autonomy and public
service (see Table 3).

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206 Nursing Ethics 20(2)

Table 1. Nurses’ responses to section A of the Nursing Dilemma Test (n ¼ 225).

Dilemmas ‘What should nurse do?’ n %a

Newborn with anomalies Should resuscitate the newborn 155 68.9

Cannot decide 32 14.2
Should not resuscitate the newborn 38 16.9
Forcing medication Should forcefully give the medication 127 56.5
Cannot decide 39 17.3
Should not forcefully give the medication 59 26.2
Adult’s request to die Should provide assistance for artificial respiration 198 88.0
Cannot decide 17 7.6
Should not provide assistance for artificial respiration 10 4.4
New nurse orientation Should allocate time for orientation of the nurse 112 49.7
Cannot decide 43 19.2
Should not allocate time for orientation of the nurse 70 31.1
Medication error Should report the medication error now 197 87.6
Cannot decide 14 6.2
Should not report the medication error now 14 6.2
Terminally ill adults Should answer the patient’s questions 58 25.7
Cannot decide 76 33.8
Should not answer the patient’s questions 91 40.5
a
The table entries represent percentages of rows for each dilemma.

Table 2. Mean scores of nurses in Nursing Dilemma Test (n ¼ 225).

Nursing Dilemma Test Minimum Maximum M (SD)

Nursing Principled Thinking 33 64 47.89 (8.16)

Practical Consideration 6 31 17.34 (4.12)
Familiarity 6 30 14.95 (3.98)

An analysis of the relationships between nurses’ professional behaviours and the levels of ethical
decision-making yielded the following results: there was a positive, weak, but significant correlation
between nurses’ principled thinking level and their total professionalism level and several sub-
dimensions of BIPN (nurses’ research activities, participation in a professional organization, competency
and continuing education and autonomy) (r ¼ .172–.287). There was no significant correlation between
nurses’ PC level and their professional behaviours (see Table 4).

Discussion
The first limitation of our study is the unacceptably low internal consistency estimates and no reported test–
retest reliability for NDT, despite its use in several studies without additional testing.33,41 Compared to the
original NDT, we obtained higher Cronbach’s as for NP (.68) and PC (.56) scores, and used test–retest relia-
bility, indicating positive correlation coefficients; however, our results also showed low reliability for this
test. In addition, although NDT content validity was approved by experts, we did not assess construct and
concurrent validity.
The second limitation is NDT scenarios representing ethical dilemmas. Although several instruments
were translated into Turkish to measure the moral reasoning of individuals, no instrument in Turkey

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Cerit and Dinç 207

Table 3. Mean scores of nurses obtained from BIPN (n ¼ 225).

Subscales of BIPN Items Minimum Maximum M (SD)

Educational preparation 8 1.00 3.00 1.06 (0.34)

Publication 3 0.00 2.50 0.07 (0.35)
Research 4 0.00 3.00 0.45 (0.70)
Participation in a professional organization 5 0.00 3.00 0.50 (0.71)
Community service 2 0.00 3.00 0.23 (0.73)
Competence and continuing education 9 0.00 3.00 1.00 (0.82)
Codes of ethics for nurses 1 0.00 3.00 0.72 (1.28)
Theory 4 0.00 3.00 1.74 (1.07)
Autonomy 9 0.00 2.50 0.16 (0.44)
Total Score 45 1.00 19.50 5.97 (3.80)
BIPN: Behavioural Inventory Form for Professionalism in Nursing.

Table 4. Correlations of nurses’ professional behaviours and ethical decision-making levels (n ¼ 225).

Professional behaviours Nursing Principled Thinking Practical Consideration

Educational preparation .078 .040

Publication .080 .021
Research .287* .048
Participation in a professional organization .172* .017
Community service .047 .021
Competence and continuing education .228* .101
Codes of ethics for nurses .127 .001
Theory .042 .107
Autonomy .232* .010
Total Score of professionalism .222* .065
*
p < .01

measured specifically the ethical decision-making level of the nurses. In this study, we also used the NDT
because the scenarios were formulated by Crisham32 after interviews with 130 registered nurses who pro-
vided actual experiences with ethical dilemmas. The current study also provides evidence that most of the
nurses in our sample were familiar with similar ethical dilemmas in clinical practice. Thus, the six ethical
scenarios included in the NDT address a variety of client care challenges in nursing practice. In addition,
the NDT measures not only nurses’ responses to ethical dilemmas, and their level of moral reasoning, but
also the importance given to PCs that may affect moral reasoning. Therefore, we considered the NDT
more applicable to nursing practice. However, some of the ethical dilemmas presented in the NDT might
be regarded as scenarios involving moral distress, rather than really ethical dilemmas. Corley42 suggests
that when nurses cannot do what they think is right, they experience moral distress. According to
Jameton,43 moral distress refers to a negative state of painful psychological imbalance experienced when
nurses make a moral decision but cannot act accordingly because of real or perceived institutional con-
straints. Indeed, nurses are required to make decisions that take into account many factors, including the
institutional policies, organizational ethical climate and the expectations of the organizational authorities
as well as their professional, ethical and legal responsibilities. In the study of Pauly et al.,44 moral distress
intensity and frequency were found to be inversely correlated with perceptions of ethical climate, which is
described by Olson45 as the presence of organizational conditions that allow employees to engage in

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208 Nursing Ethics 20(2)

ethical reflection, and that provides the context for ethical decision-making in the clinical setting.
Although the sixth item of section B in the NDT measures the importance of PCs for each scenario, most
of the ethical dilemmas require nurses to make decisions by considering the orders of physicians for
patient care. For example, whether to resuscitate a newborn with abnormalities or not depends upon the
physicians’ resuscitation order. Similarly, answering a terminally ill patient’s questions about his medical
diagnosis or condition is beyond the nurses’ legal authority in Turkey. Except any condition that poses
risk for a patient, nurses have a legal obligation to carry out physicians’ written order, but they are also
legally obliged to respect patient rights, which require nurses to inform patients about their medical con-
dition. Thus, due to the medical context of the ethical dilemmas of NDT, it is possible for nurses in our
sample to perceive their professional autonomy as under siege and feel unable to make their own ethical
decisions due to external restraints or their professional and legal obligations.
The third limitation relates to representativeness of 225 nurses working at three university hospitals
in Ankara. Although university hospitals differ from public hospitals by combining the health-care
services with education and research activities, regardless of hospital or work setting, nurses are
legally authorized to provide care for the individual, family and community, and to administer treat-
ment and medications ordered by a physician. However, according to Turkish Ministry of Health 2010
data, Ankara has 72 hospitals, 9 (12%) of which are university hospitals.46 This limits the general-
izability of our sample. Further research with a larger sample is required to assess the psychometric
properties of NDT and to investigate the correlation between nurses’ professional behaviours and ethi-
cal decision-making.
Fourth, our data are based on nurses’ responses to hypothetical scenarios in NDT and the closed ques-
tionnaire format of the BIPN. Finally, factors influencing ethical decision-making and professional
behaviour were not focused on separately. Despite these limitations, we believe this study contributes to
nursing ethics in Turkey and offers insights into the relationship between ethical decision-making and pro-
fessional conduct of nurses from a different culture.

Nurses’ ethical decision-making

In this study, most nurses were familiar with ethical dilemmas of NDT. Our findings support studies sug-
gesting that nurses frequently face ethical dilemmas.41,47,48 Familiarity with such dilemmas may contrib-
ute to nurses’ awareness of ethical problems in health care and can increase their capability to reason and
find possible solutions for problems that require ethical decision-making. Nurses’ responses to dilemma 1
(resuscitation of an anomalous newborn) and dilemma 3 (an adult’s request to die) suggested that most of
them favour pro-life rather than life quality. Their responses to dilemma 3 and the last dilemma (a termi-
nal adult’s right to know) revealed their concern for the patient’s life rather than respecting autonomy.
Responses to scenarios on forceful administration of medication and reporting a medication error indi-
cated that they considered patients’ welfare from a paternalistic perspective. These findings can be
ascribed to nurses’ religious orientations and cultural backgrounds. Studies report that culture and
religion can affect ethical decision-making.49–51 Islam, the main religion in Turkey, stresses sanctity
of life, and Turkish culture is highly patriarchal and collectivistic. In this study, nurses’ pro-life and pater-
nalistic choices against patients’ autonomy imply that religious and cultural orientations influence ethical
decisions.
The mean NP score (47.89) was lower than other scores reported33,41 (54.5 (SD ¼ 6.75) in Crisham’s
study).47 PC scores were similar to those in previous studies.41,47,48 Results of this study indicate that nurses
consider principled thinking when making ethical decisions; however, their decisions are influenced by
cultural/work-related factors.

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Cerit and Dinç 209

Nurses’ professional behaviours

In this study, nurses’ professional behaviour levels were very low (5.97 (SD ¼ 3.80)). Karadağ et al.52 also
found low professionalism scores (5.45 (SD ¼ 5.10)), whereas Adams and Miller’s53 average score was
16.70 (SD ¼ 3.60). Nurses’ professional behaviours may influence public perception of nursing and care
quality. Our findings have implications for practicing manager and educator nurses and should also be inter-
preted within the historical development of nursing in Turkey. Formal nursing education started in 1925,
and higher education was accelerated after the 1990s. The patriarchal Turkish culture affects nursing care
quality and nurses’ professional behaviours while shaping the hierarchical structure in hospitals where phy-
sicians are dominant in decision-making. Nurses also reported that differences in education levels; increas-
ing workload in our country, as well as throughout the world; lack of job security and inadequate staff and
resources contributed negatively to their professional behaviours.

The correlation of nurses’ professional behaviours and ethical decision-making levels

Our results showed a weak positive correlation between NP scores and nurses’ professional behaviours, par-
ticularly for participation in research activities and professional organizations, maintaining competence,
and continuing education and autonomy (r ¼ .172–.287).
Competence, continued education and professional autonomy are among basic criteria of professional-
ism. Professional autonomy entails exercising judgement of one’s own work using professional values and
standards. Professional autonomy and competency are important as ethical decision-making requires inde-
pendent reasoning and accountability. In this study, nurses lacking professional autonomy did not consider
themselves active decision makers, a finding consistent with literature.40,53 NP was also correlated with
participation in research (r ¼ .287). Independent research or participation in research is important for ethical
decision-making, which involves collecting data, defining the problem, considering alternative solutions,
finalizing an action and evaluating the results. However, research without ethics can lead to scientific
misconduct. Making ethical decisions requires integrity of researchers, and ability to distinguish right from
wrong while planning, conducting and reporting research. Although participation in research is important,
being ethical is the first and foremost requirement for professionalism. Nurses’ scores were low, despite the
correlation between nurses’ principled thinking and research dimension of professional behaviour. Since
our sample largely comprised clinical nurses not qualified to conduct research, their analytical and
problem-solving skills were lower than expected. The results indicate that nurses’ ethical decision-
making levels are related to their low professional behaviour levels.

Conclusion
This study demonstrated that the NDT can be used for measuring the ethical decision-making levels of
nurses; however, additional testing of the validity and reliability is needed. Our results indicated that nurses
face ethical problems in practice; they considered principled thinking while making ethical decisions but
not at the expected level. Further studies from both empirical and philosophical perspectives may broaden
our understanding of the relationship between nurses’ professional behaviours and ethical decision-making.

Acknowledgements
This study is produced from doctoral dissertation. We would like to thank research assistants Sinem
Bozkurt, Sezen Ergin and Duygu Çurum who translated Nursing Dilemma Test into Turkish and assistant
professor Orhun Yakın for providing the back-translation. We would also like to thank Professor Selma

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210 Nursing Ethics 20(2)

Gorgulu, Gulumser Kublay, Nuket Ornek Buken and Fethiye Erdil who contributed with their expert
opinions during this study. We are also grateful to the participation of all nurses in this study.

Funding
The study was conducted without external funding.

Conflict of interest
There is no financial, personal or academic conflict of interest.

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