Ethical dilemmas and decision-making in emergency and critical care nursing in Western Amhara region, Northwest Ethiopia: a multi-method qualitative study

This study employed a multi-method qualitative study design to explore ethical dilemmas and decision-making processes among emergency and critical care nurses in the Western Amhara region of Ethiopia. This approach combines various qualitative data collection methods, including in-depth interviews, focus groups, and case studies.

The Four Box Method by Jonsen, Sigler, and Winslade is a structured framework designed to guide ethical decision-making in clinical settings, particularly when nurses and clinicians face ethical dilemmas. The method is commonly referred to as the “Four Box Method” because the features of a case are organized under four categories to ensure that all relevant ethical aspects are systematically considered, promoting a balanced and comprehensive approach to care [20]. In this study, the Four-Box Method was used as a framework for analyzing ethical decision-making in the case studies. This framework was applied during data analysis to structure the ethical dilemmas and guide the interpretation of nurses’ decisions, focusing on aspects such as medical indications, patient preferences, quality of life, and contextual factors. It helped reveal how nurses navigated complex ethical issues in critical care and emergency settings (Table 1).

This component of the Four Box Method focuses on the clinical aspects of the case, including diagnosis, prognosis, and treatment options. It addresses questions about whether the proposed interventions are medically appropriate and likely to benefit the patient. The clinician evaluates the effectiveness, risks, and benefits of various treatments, ensuring that the chosen approach aligns with the principle of beneficence-acting in the patient’s best interest and promoting their health and well-being [20, 21].

This component of the Four Box Method emphasizes the importance of understanding and respecting the patient’s values, wishes, and autonomy. It involves engaging the patient or their surrogate in the decision-making process and ensuring that the patient is competent to make decisions. Key questions here include whether the patient’s preferences are clearly communicated and considered, which reflects the ethical principle of autonomy—respecting the patient’s right to make informed decisions about their own care [20, 21].

This component of the Four Box Method evaluates how different treatment options will affect the patient’s overall quality of life. It considers factors such as physical, emotional, social, and psychological well-being, weighing whether treatment will lead to a life that the patient would find acceptable. This area ties into the principle of non-maleficence, aiming to minimize harm, suffering, or a diminished quality of life [20, 21].

This final component of the Four Box Method accounts for external factors that may influence clinical decisions, including cultural and social factors, financial constraints, legal issues, and institutional policies. These considerations reflect the principle of justice, ensuring that decisions are fair, equitable, and take into account the broader context, including resource availability and social or cultural beliefs that may shape the care process [20, 21].

This study was conducted in selected public hospitals (Felege Hiwot Comprehensive Specialized Hospital and Tibebe Ghion Specialized Hospital) in the Western Amhara region that provide emergency and critical care services. These facilities were chosen based on their involvement in emergency and critical care services, ensuring a range of experiences and perspectives.

Healthcare in this region is primarily organized through a mix of public and private systems, with the public sector providing the majority of services. However, the private sector has been growing, with private clinics and hospitals catering to those who can afford their services. The population in the region, is predominantly Orthodox Christian. The study was conducted over a four-month period, from September 2023 to December 2023.

The study included nurses working in critical care and emergency settings, such as emergency and critical care nurses, as well as other trained nurses, who had been employed in these roles for at least one year to ensure they had sufficient experience with ethical dilemmas and decision-making processes. Emergency and critical care nurses in the Western Amhara region undertake a diverse array of responsibilities, from direct patient care to making critical decisions and collaborating with multidisciplinary teams. Their roles include managing complex patient conditions, performing emergency interventions, and ensuring patient safety. On average, participants had around 7 years of experience, with some having up to 15 years in the field.

A purposive sampling strategy was employed to select participants directly involved in emergency and critical care nursing. This approach ensures that the sample consists of individuals with relevant expertise, including practical experience, formal training, and reflective practice in handling ethical dilemmas in high-pressure settings, making them well-suited to provide valuable insights for the study. The sample size was determined by using a rule of thumb depending on study’s purpose, type of data collection method, data saturation, heterogeneity of the sample, and available resources. By considering all these, the study included 28 participants: 10 nurses for in-depth interviews and 18 nurses who took part in three focus group discussions, each with six participants. Additionally, three case studies were developed, focusing on specific ethical dilemmas faced by nurses.

In-depth interviews were carried out with individual nurses to obtain detailed insights into their personal experiences with ethical dilemmas and decision-making processes in emergency and critical care settings. A flexible, semi-structured interview guide was developed covering topics such as personal encounters with ethical dilemmas, decision-making processes, available support systems, education and reflections. Interviews were conducted in a private room within the healthcare facilities. Each interview was audio-recorded with the participant’s consent and subsequently transcribed verbatim to facilitate thorough analysis of the data. The interviews were conducted in Amharic, the local language, to facilitate open and detailed discussions. In addition to these strategies, several other approaches were employed to address emotional issues that arose during the interviews. Rapport was established with participants, and a comfortable environment was created in a private, quiet space. Clear information about the study was provided, and participants’ emotions were regularly checked throughout the interview. Emotional support was offered, and interviews were rescheduled if necessary.

Focus group discussions were conducted to capture group dynamics and collective perspectives on ethical issues and decision-making processes. The focus group guide directs these discussions, addressing topics such as common ethical issues encountered, decision-making strategies, existing support systems, and recommendations for improvement. These sessions were held in a comfortable and private setting to encourage open and candid dialogue among participants. The moderator is responsible for guiding the discussion, asking questions, probing for depth, staying on topic, ensuring that all participants have the opportunity to share their experiences, and closing the discussion. In contrast, the co-moderator/facilitator supports the moderator by managing logistics, taking notes, recording the session, observing group dynamics, and ensuring a conducive environment. Each focus group was audio-recorded with participants’ consent, and the recordings were transcribed to facilitate thematic analysis of collective insights and experiences shared during the discussions. The discussion sessions were conducted in Amharic, the local language, to facilitate open and detailed discussions.

Detailed case studies were developed from real-life situations reported by the participants. Case studies offered in-depth, contextual examples of ethical dilemmas encountered by nurses in emergency and critical care settings. Each case study was structured to include an introduction to the context, a detailed account of the ethical dilemma, the decision-making processes involved, and the outcomes of those decisions. Cases were selected based on significant ethical dilemmas reported by participants during interviews or focus groups. Data for these case studies were collected through detailed interviews with the nurses directly involved in the cases, as well as through a review of relevant documents to provide a comprehensive understanding of each situation.

The analysis was begun with transcription, where audio recordings of interviews and focus groups were transcribed verbatim in Amharic, local language. Then the transcribed audio-recorded interviews and discussions were translated into English by investigators. Inductive thematic analysis was utilized to analyze these transcripts and case study notes following a six-phase approach outlined by Braun and Clarke [22]. The phases included: (1) familiarizing oneself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the final report. Themes and sub-themes were derived inductively from the coded data, ensuring that they emerged directly from the participants’ narratives. Discrepancies in coding were discussed and resolved to reach consensus, ensuring intercoder reliability and transparency in the analysis process.

The data analysis was led by one investigator, who oversaw the coding and theme development, while the second investigator ensured peer review and validation of the findings. Both investigators had substantial experience in qualitative methods and thematic analysis. Additionally, Open Code qualitative data analysis software were used to assist with organizing and coding the data effectively. Similarly, throughout the analysis, participant quotations were used to illustrate and support the identified themes, ensuring that the findings were firmly grounded in the data. The final themes and sub-themes were presented clearly, with the consistency of the data and findings verified through ongoing discussion between the coders.

To ensure the validity and reliability of this study, several key strategies were employed. Triangulation was utilized by integrating multiple data sources, including interviews, focus groups, and case studies. Moreover, to ensure the accuracy and trustworthiness of the data, the four criteria of credibility, dependability, confirmability, and transferability were applied [23]. Credibility was established through member checking, peer debriefing, and prolonged engagement with the participants. Dependability was assured by employing the code-recode procedure and providing a clear, consistent methodology. Confirmability was strengthened through participant validation, ensuring that the findings accurately reflected the participants’ perspectives. Transferability was achieved by offering a thick description of the data collection, analysis processes, and findings, allowing readers to assess the applicability of the results to their own contexts.

The research team consisted of two nurses with substantial experience in intensive care units (ICUs) and emergency departments (EDs). Each team member had varied roles in the research process, ranging from conducting interviews to data analysis. Two additional nurses, with similar critical care experience, were involved in data collection, conducting interviews under the guidance of the research team. To ensure the quality and consistency of the research, all team members underwent rigorous training in interview techniques, ethical guidelines, and the study’s objectives. Regular team meetings were held to address challenges and refine the research approach.

In terms of reflexivity, the research team recognized that their backgrounds as healthcare professionals in critical care settings could potentially influence how they interacted with participants and interpreted the data. The team members made a conscious effort to remain aware of their professional experiences and biases, acknowledging how these might shape both data collection and analysis. To mitigate these biases, they engaged in reflexive discussions throughout the process, reflecting on their positions and assumptions to ensure the findings were rooted in participants’ experiences.

Peer debriefing was also incorporated into the process, where feedback from colleagues outside the research team helped ensure, the interpretations remained valid and unbiased. The research team also considered their relationship to the participants, ensuring that these dynamics did not unduly affect the data collection or analysis. By embracing a reflexive approach, the team aimed to enhance the trustworthiness of the study and ensure the findings accurately reflected the nurses’ strategies in managing patient acuity.

In this study, 28 nurses working in critical care and emergency settings, including emergency and critical care nurses as well as other trained nurses, participated. Among them, 18(64.3%) were females and 10 (35.7%) were males. The participants’ ages ranged from 25 to 47 years, with a mean age of 32 ± 5.6 years. Besides this, 23 participants held a bachelor’s degree, while 5 had a master’s degree. The mean working experience was 7 years.

Ethical dilemmas and decision-making in emergency and critical care nursing was defined as the main theme which contained the themes of ethical dilemmas in clinical practice, core ethical issues in critical care, emotional and professional impact of ethical challenges, decision-making processes in complex scenarios, support systems and resource availability, team dynamics and collaborative decision-making, and Education, reflection and recommendations for improvement in ethical decision-making (Table 2).

Participants discussed a range of ethical dilemmas commonly encountered in critical care settings. One significant challenge involved making end-of-life decisions, such as whether to initiate aggressive treatment for a terminally ill patient at the insistence of the family, despite the patient’s deteriorating condition. This dilemma often revolves around the tension between continuing or withdrawing life-sustaining measures when the prognosis is poor. Another critical issue is resource allocation during crises, where limited resources must be distributed among numerous patients in need of care. Nurses face the difficult task of prioritizing patients based on the severity of their conditions, weighing potential outcomes, and making decisions that can impact multiple lives. Furthermore, ethical challenges arise in obtaining informed consent, particularly when patients are unable to communicate their wishes. In these instances, nurses are tasked with managing surrogate decision-making, ensuring that the patient’s best interests are prioritized while navigating potential conflicts between the medical team’s recommendations and the desires of the family. Lastly, interpersonal conflicts, including disagreements with patients’ families or coworkers, often complicate decision-making, especially when staffing levels are insufficient to provide adequate care.

Nurse C(IDI): “A terminally ill patient’s family insisted on all treatments, making it difficult to balance their wishes with the reality of the patient’s worsening condition.”

Nurse D(FGD): “During a crisis, we had more patients needing critical care than resources available. Deciding who should receive care was incredibly difficult, with each choice weighing heavily.”

Key ethical issues include balancing patient autonomy with beneficence, particularly when nurses must respect patient preferences while also considering what is in the patient’s best interest. End-of-life decisions, such as whether to continue aggressive treatment or transition to comfort care, often present ethical dilemmas where family wishes conflict with medical realities. Another pressing issue is resource allocation, which requires prioritizing care under conditions of scarcity, balancing fairness and the potential outcomes for patients. Additionally, obtaining informed consent from patients who cannot communicate poses significant challenges for nurses, who must rely on surrogate decision-makers. Conflicts between healthcare professionals’ recommendations and family wishes can further complicate ethical decision-making. Lastly, interpersonal dynamics, including disagreements among team members or with patients’ families, add complexity to the decision-making process, particularly when staffing and resources are limited.

Nurse A(IDI): “Balancing patient autonomy with what I know is best for their health is a constant challenge. Allocating limited resources fairly is also a major issue.”

Nurse B (IDI): “End-of-life decisions are hard, as it’s difficult to balance the family’s hope for recovery with the patient’s true condition. Deciding when to shift from aggressive treatment to palliative care often feels like an internal struggle.”

The ethical dilemmas described by participants often lead to significant emotional distress and moral conflict, contributing to burnout and ethical fatigue among nurses. These challenges, compounded by professional debates and interpersonal stress, have a negative impact on job satisfaction and team cohesion. The emotional toll of navigating complex ethical situations, particularly those involving end-of-life care or difficult resource decisions, can result in nurses feeling drained and conflicted.

Nurse D(FGD): “Dealing with these dilemmas leaves me emotionally drained and conflicted. The stress and constant debates within the team contribute to burnout and job dissatisfaction.”

Nurses typically approach decision-making by integrating a combination of ethical principles, clinical guidelines, and collaborative discussions with colleagues. Many nurses use a blend of utilitarian and deontological approaches, balancing the potential consequences of their actions with adherence to professional obligations. Reflective practice is a crucial tool in this process, allowing nurses to learn from past experiences and apply those lessons to current ethical challenges. Structured ethical frameworks, such as the Four Box Method, also help guide their decision-making by organizing key factors like medical indications, patient preferences, quality of life, and contextual features.

Nurse C(IDI): “I used ethical principles, clinical guidelines, and advice from colleagues to navigate dilemmas. Reflecting on past cases and structured frameworks helped guide my decisions.”

Nurse D(FGD): “I often consult with my colleagues to gain different perspectives, which helps me feel more confident in my choices.”

While ethics committees and peer support are crucial in guiding nurses through ethical decisions, participants noted that these resources are often unavailable in urgent situations, which limits their effectiveness. Nurses highlighted the need for more structured and accessible support systems to manage ethical challenges and prevent burnout. Additionally, regular access to ethics consultations and emotional support services could help nurses navigate complex dilemmas and address ethical fatigue.

Nurse G(IDI): “Access to ethics committees and colleague support is invaluable, but they aren’t always available during critical moments when you need them most.”

Effective teamwork is essential for managing ethical dilemmas, as collaboration fosters shared decision-making and helps distribute emotional burdens. Nurses emphasize the importance of open communication and regular team discussions to address ethical issues and resolve conflicts. When communication is clear and team members are aligned on ethical considerations, nurses are better equipped to make informed decisions that reflect shared values. However, poor communication or interpersonal conflicts can lead to delays, misunderstandings, and heightened tension.

Nurse H(FGD): “Effective teamwork is crucial for navigating ethical dilemmas, as collaborative discussions and shared decision-making enable us to reach consensus and distribute the emotional burdens, just like our multidisciplinary team did when addressing a complex issue about patient consent.”

While nurses have received ethics as courses, many participants feel that the depth and frequency of such training were insufficient. A more comprehensive and structured approach to ethics education is needed, with a focus on integrating ethical principles into all levels of nursing practice. Additionally, incorporating experiential learning strategies, such as simulations, role-playing, and reflective practices, can help nurses build confidence in handling ethical dilemmas. Some participants emphasized the importance of using models like the Four Box Method as a guiding framework for making moral decisions.

Nurse C(IDI): “The training has definitely helped me understand and apply ethical principles better, but there’s still a need for more comprehensive and frequent sessions.”

Participants reflected on their decision-making processes through debriefing sessions and informal discussions with colleagues. These reflective practices help nurses process their experiences and learn from past ethical challenges. Many also recommended using structured frameworks, such as the Four Box Method, to guide their reflections. This model clarifies the ethical dilemma or problem, outlines the relevant facts of the case, identifies the parties involved and their perspectives, and examines the ethical principles and values at stake. It also considers applicable laws, explores possible choices and their justifications, identifies the best overall option, facilitates its implementation, and evaluates the effects of the chosen course of action. In addition, participants suggested improving access to ethics consultations, enhancing mental health services, and establishing clearer institutional policies to address ethical dilemmas. They also emphasized the importance of fostering a supportive work environment with open communication, which can help alleviate stress and moral distress, ultimately improving the quality of care provided.

Nurse G(IDI): “I reflect on my decisions through debriefing sessions and conversations with colleagues. It helps me process and learn from the experiences.”

Nurse F(FGD): “Enhanced support systems, including real-time ethics consultations and mental health services, are needed. Clearer policies and a supportive work environment are also crucial.”

The following case studies highlight key ethical dilemmas faced by ICU teams, including resource allocation, pain management, and patient autonomy in critical care decisions. Case Study 1 examines the challenge of allocating a ventilator between two patients with different prognoses, illustrating the issue of limited resources in terminal illness versus potential recovery (Table 3). Case Study 2 focuses on balancing effective pain relief with the risk of respiratory depression in a terminal cancer patient (Table 4). Case Study 3 explores the conflict between respecting patient autonomy and the healthcare team’s duty to provide life-saving care when a patient refuses treatment (Table 5). These scenarios demonstrate how ICU teams navigate the ethical principles of beneficence, autonomy, justice, and non-maleficence in making complex decisions. The Four Box Method, as proposed by Jonsen, Sigler, and Winslade, provides a structured framework for analyzing and resolving these dilemmas by considering medical indications, patient preferences, quality of life and contextual features [20].

The strengths of the study include the use of a multi-method approach, incorporating in-depth interviews, focus groups, and case studies. Additionally, the study applied the Four Box Method as a structured conceptual framework, ensuring a systematic analysis of ethical cases in the ethical decision-making process. Furthermore, data triangulation and measures to ensure trustworthiness were effectively employed. However, the study has some limitations, including limited generalizability. There is also potential for selection bias, as participants were chosen based on their expertise and experience.

To address these challenges, several recommendations emerge from the study. First, there is a need to strengthen support systems within healthcare settings, including real-time ethics consultations and mental health services, to provide immediate assistance during ethical decision-making. Second, implementing more comprehensive and regular ethics training sessions will better prepare nurses for the ethical complexities of their roles. Third, improving communication and collaboration within multidisciplinary teams can enhance ethical decision-making and reduce the emotional burden on individual nurses. Additionally, developing clear policies for managing ethical dilemmas and providing ongoing education on advance directives and autonomy can further support nurses in navigating these challenging situations.