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Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis


  • Bernadette Dierckx De Casterlé,

    1. Bernadette Dierckx de Casterlé PhD RN
      Associate Professor of Nursing Ethics
      Centre of Health Services and Nursing Research,
      Catholic University Leuven,
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  • Shigeko Izumi,

    1. Shigeko Izumi PhD RN
      Postdoctoral Fellow
      Oregon Health & Science University School of Nursing,
      Portland, Oregon, USA
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  • Nelda S. Godfrey,

    1. Nelda S. Godfrey PhD RN
      Assistant Dean, Academic Affairs
      Clinical Associate Professor
      School of Nursing,
      University of Kansas,
      Kansas City, USA
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  • Kris Denhaerynck

    1. Kris Denhaerynck PhD RN
      Research Associate
      Institute of Nursing Science, Faculty of Medicine,
      University of Basel,
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B. Dierckx de Casterlé: e-mail:


Title. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis.

Aim.  This paper is a report of a study to explore nurses’ responses to ethical dilemmas in daily nursing practice.

Background.  Concern about nurses’ ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses’ ethical practice, little is known about how nurses involve themselves in ethical decision-making and action in daily care.

Method.  A meta-analysis of nurses’ ethical behaviour was conducted using data from nine studies in four countries (= 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses’ ethical responses, based on an adapted version of Kohlberg’s theory of moral development. Data were analysed using random-intercept regression analysis.

Findings.  All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision-guiding criteria rather than patients’ personal needs and well-being.

Conclusion.  Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses’ ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.