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Nursing Ethics
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Nurses’ tension-based ethical ª The Author(s) 2020
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decision making in rural acute 10.1177/0969733020906594
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care settings

Manal M Alzghoul and Kristen Jones-Bonofiglio

Lakehead University, School of Nursing, Canada

Abstract
Background: Nurses in acute care are frequently involved in ethical decision making and experience a
higher prevalence of ethical conflicts and dilemmas. Nurses in underresourced rural acute care settings also
are likely to face unique ethical challenges. However, rarely have the particular contexts of these
experiences in rural acute care settings been researched. A culture of silence and fear in small towns has
made exploring these issues difficult.
Objectives: To explore registered nurses’ experiences of ethical issues and ethical decision making in rural
acute care hospitals in northern Ontario, Canada.
Research design: Guided by an interpretive descriptive approach, data were collected by two nurse
researchers using in-depth, individual, and semistructured telephone interviews. Data were managed with
NVivo v.11 and analyzed using inductive, comparative, thematic analyses.
Participants and research context: The participants were eight registered nurses working in two acute
care hospitals in northern Ontario.
Ethical considerations: Ethical protocols were followed in accordance with ethics approval from the
researchers’ university and the hospitals.
Findings: Results identified four themes that culminated in the development of a quadruple helix ethical
decision-making framework of power, trust, care, and fear.
Discussion and conclusion: The participants described complex ethical conflicts and dilemmas in acute
care settings that were influenced by the context of working and living in small rural communities in
northern Ontario. Nurses described navigating ethics in practice using a tension-based approach to
ethical decision making, needing to carry these issues silently and often having no resolution to ethical
challenges. These findings have important implications for nursing education, research, and practice. Nurses
need safe spaces, formal ethics support, and improved access to resources. Additional ethics education and
training specific to the unique contexts of rural settings are needed.

Keywords
Acute care, ethical decision making, nurses, qualitative, rural

Corresponding author: Manal M Alzghoul, School of Nursing, Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1,
Canada.
Email: malzghou@lakeheadu.ca
2 Nursing Ethics XX(X)

Introduction
Nursing is an ethically intense profession, and the ability of registered nurses (RNs) to make good decisions
in practice is key to providing high-quality and ethically competent nursing care.1 Struggling with ethical
decision making can be an added burden on RNs while they attempt to address patients’ needs and support
patients and families in their own decision-making processes.2 RNs are expected to use ethical principles
and professional nursing values to guide their work and have a working knowledge of the codes of conduct
and standards of nursing practice.3 However, real-life ethical issues cannot always be resolved by following
general ethical principles, professional ethics guidelines, or personal moral values and beliefs. Sometimes,
there are no definitive answers regarding what should or could be the right decision for a particular situation.
Ethical decision making can be complex and involve a degree of risk taking.
A variety of factors may influence the ability of RNs to make good ethical decisions. Age, gender,
education, knowledge of ethics, and nursing experience may correlate with the ability to recognize and
address ethical issues in practice.4 However, the complexity of patients’ clinical situations, the high demand
for quality outcomes, and time constraints on decisions increase the high-pressure and sometimes high-
stakes circumstances of ethical decision making in daily nursing practice. An “in-the-moment” myopic
view of issues may be adopted out of necessity. Unfortunately, short-range perspectives can blur the holistic
views of patients, ethical issues, and ethical decision making.5
The nursing workplace also can influence experiences of ethical issues and ethical decision making in
practice. When compared to nurses working in other healthcare sectors, nurses working in acute care
settings and emergency departments, where often they work with the sickest patients and the most acute
phase of their illnesses, have demonstrated higher frequencies of ethical conflicts and dilemmas.5–7 Simi-
larly, working with people from rural communities, along with practicing in small communities, can
contribute to unique ethical challenges.8,9 For example, living in the shared culture of a small community
can result in an overlap in relationships between healthcare personnel and patients. It may seem as though
everyone in the community knows everyone else’s business. Nurses must be cautious and mindful of the
boundaries between their personal and professional lives.10 This situation is not something that nurses in
small towns can escape; they are recognized as nurses wherever they go. Although nursing ethics has been
studied for decades, literature has been scarce on how the unique context of living and working in small
rural communities impact the kinds of ethical issues that RNs experience and how RNs navigate complex
ethical decision making in these settings.

Methods
This study followed a qualitative design using an interpretive descriptive approach to explore the experi-
ences of eight RNs.11 This approach facilitates the development of knowledge through data collection in the
field and incorporates prior understanding and theorization.11–13

Research settings and participants

This study was conducted in rural communities in northern Ontario, Canada. Northern Ontario comprises
approximately 800,000 square km and has a population of approximately 800,000 people, with only 6% of
Ontario’s population living on 88% of the land.14 According to the Health Quality Ontario, people living in
northern Ontario have higher rates of injury, chronic disease, and mental illness; less access to healthcare
services; and overall poor health outcomes. They also are more likely to die earlier than people in other parts
of the province. These population health disparities are the result of geographic, economic, and climatic
Alzghoul and Jones-Bonofiglio 3

Table 1. Study participants.

Variable Range Why this might matter?

Age 27–59 Median participant age of 36 years

Level of education Undergraduate degree or Similar level of education for all participants
master’s degree
Gender All female Nursing as gendered work. No male RNs were represented in
this study
Other hospital All had some exposure to other Perspective outside of just working in the present small
experience hospital environments community hospital
Current unit Medical, ICU, mental health, Input from different specialty areas of acute care settings
surgical, maternity, or
pediatrics
Work status Casual to full-time status Frequency of exposure to everyday ethical issues. Full-time
status may indicate more job security to be able to speak up
Years of 1–39a Nurses in early and late careers were represented in this study
experience
ICU ¼ intensive care unit.
a
1, 5.5, 6.5, 7, 7, 20, 39.5, 30.

factors that contribute to inequities in access to healthcare providers and services.4 This situation in rural
healthcare is mirrored by other developed countries such as the United States and Australia.9–15
The settings for this study were two acute care hospitals. Robust descriptions of the hospitals were
redacted to ensure the anonymity of the hospitals and the participants. These hospitals serve communities
that meet all the criteria to be considered rural (<400 people/square km) according to the 2016 Canadian
Census. 16 The two hospitals continue to serve a combined population of approximately 10,000
individuals.
The target population comprised RNs currently working in acute care hospitals in rural and northern
Ontario. Nurses were recruited using purposive, nonprobability sampling, meaning that the participants
were selected based on their characteristics and the objectives of the study. Recruitment information (i.e.
posters, information letter) was shared with the hospitals that agreed to participate and was then shared
with all RNs employed by those hospitals using internal institutional communication methods. Therefore,
all potential participants were informed about the research project via the hospitals’ internal communi-
cations first.
Recruitment of participants was challenging and more complex than anticipated. Despite institutional
support and multiple recruitment strategies (i.e. e-mailed information, posters, in-person visits), it took
18 months to recruit the eight RNs. In-person recruitment was not in the original research plan, but it was
included after many months of zero interest from the RNs. The researchers identified a need to build trust
with potential participants before any RNs would seek further information or volunteer to be in the study.
Therefore, in-person recruitment was added to the study protocol. This strategy was successful. For the in-
person recruitment visits, the researchers toured the hospitals and the acute care units, and provided verbal
information about the study to the RNs. It was an opportunity to answer questions about the study and for the
RNs to meet the RN researchers. If they expressed an interest in participating, the nurses were asked to
contact the researchers directly via e-mail or by phone. The RNs were invited to participate as individuals
who could share their own experiences rather than as representatives of their units or institutions. Table 1
provides brief demographic descriptions of the participants. Written informed consent was obtained from
all the RNs before they were interviewed.
4 Nursing Ethics XX(X)

Table 2. Ethics in rural acute care nursing practice.

Themes Examples Summary quotes

Theme 1: Power Physicians “Big fish, little pond”

Theme 2: Trust Being in a small community “Everyone knows everyone”
Theme 3: Care Patient/family “Beating your head against the wall”
Theme 4: Fear Taking risks “You can handle it till morning”

Data collection
This study was approved by the research ethics boards of the researchers’ academic institution and the two
hospitals. In-depth, individual, and semistructured telephone cointerviews by both RN researchers were
conducted using open-ended exploratory questions from a preset interview schedule. Three questions
guided each interview:
1. Please describe your experience with an ethical issue that you have recognized in your practice in
acute care in this hospital.
2. Please describe your experience of addressing ethical issues.
3. Please describe your experience of making ethical decisions in everyday nursing practice.
The interviews lasted 30 to 90 min, were audio recorded, transcribed verbatim, and returned to the
individual participants for review to ensure accuracy or make revisions. The researchers perceived fear and
uncertainty among the participants, many of whom asked the researchers to confirm that their interviews
would not be shared with their employers or include any identifying information. Many participants chose
to receive the transcriptions through their personal e-mail addresses, not their work e-mail addresses.

Analysis
Data analyses were conducted by both researchers using NVivo v.1117 and guided by an interpretive
descriptive approach.11–13 Analyses occurred by reading the transcriptions many times to understand the
RNs’ experiences. Data were coded to identify relationships between and among different variables and to
describe patterns. Finally, once the codes were combined, four themes emerged from the analysis.

Ethical considerations
All participants were provided with information about the study, such as what their participation would
entail, confidentiality, freedom to withdraw, potential risks, and benefits. Interviews were audio-recorded
with participants’ permission. All audio-recordings and identifying information were anonymized using
numeric identifiers. Data were kept confidential, with only the researchers having access via storage on a
dedicated, password-protected computer drive.

Findings: four themes

The RNs shared their experiences of challenging ethical issues and explained how they made decisions in
difficult circumstances. From these experiences, the researchers identified complex examples of ethical issues
in the context of acute care in small community settings in rural locations. The four themes (see Table 2)
describe the RNs’ experiences and reflect the complexity of ethical decision making in practice.
Alzghoul and Jones-Bonofiglio 5

Theme 1: power
The RNs often identified nurse–physician relationships as a key factor in ethical conflicts. In this study, the
RNs voiced many challenges when dealing with physicians in terms of not having consistently collaborative
ethical priorities. The following are examples of how this theme (in the context of the power of physicians)
contributed to ethical dilemmas and was a tension impacting ethical decision making.
Ethical conflicts occurred when physicians and nurses had different ideas about plans of care or when
physicians set different care priorities from that of the RNs, patients, and/or family members. The RNs
became concerned when continuity of care was lacking or when physicians appeared to be reluctant to
provide care to the patients (because new physicians would be taking over care as part of a locum visiting
physician rotation). Locum physicians tended not to know the patients, the community, or the distinct
cultures of the rural north very well. They often were not familiar with the specific needs of the northern
population and the limitations of rural practice. Furthermore, input from RNs was not always sought or
taken seriously when provided. These power dynamics had the potential to put the quality of care of patients
at high risk and resulted in uncertainty for RNs, patients, and their families.
One participant described this theme:

I find it kind of frustrating because I feel like every XX morning we change over to the new doc of the week sort
of thing to these patients; so they’re not getting that continuity of care . . . It’s not a lot of fun because a lot of times
you sort of start a plan of care or whatever with the patients and that and then XX morning you’re sort of starting
all over again. So, it gets to be a little bit—or I find that they’ll push stuff off because you know it’s going to be
done on XX night, so I’ll just leave that for the next person—and I find that kind of frustrating if people are
staying longer or not staying long enough, kind of thing, to finish up treatments or regular, everyday kind of thing.
So, I’m finding that a little frustrating. (Interview 8)

At times, the RNs could not work within the bounds of strained power dynamics with particular
physicians, so they simply waited until a new physician’s rotation began.
One participant explained,

As bad as that sounds—sometimes it really does benefit us because we know that even though this doctor this
week’s being difficult and does not want to order what we think the patient needs, then at least we know that, next
week we’ll be able to have somebody that is more approachable and orders things that we think that the patient
needs. (Interview 7)

Theme 2: trust
Trust in small communities takes many forms. Living in small communities means that almost everyone
knows everyone else, be it as a friend, a family member, or in some other relationship. The RNs talked about
living in, working in, and being part of rural and northern communities. The RNs highlighted the challenge
of not disclosing who might be in hospital. Community members might ask them why someone was in
hospital and how that person was doing. In addition, in-patient units in small hospitals have a limited
number of beds and little privacy for patients. These circumstances can blur the boundaries between the
RNs’ personal and professional relationships.
One participant said,

If you want to find out what’s going on in the hospital, you go to Safeway (grocery store).

The RNs mentioned knowing patients from their own social circles and/or from family and friend con-
nections. When patients were admitted to hospital, the RNs found it difficult to separate what they knew about
6 Nursing Ethics XX(X)

the patients from information in the community and what the patients reported to the healthcare team. The
responsibility to protect patients’ private information could result in conflict with RNs’ sense of responsibility
to share such information with the medical team to ensure proper decision making and good outcomes.
Trust was not only about the RNs knowing people in their communities. Most people in the small
communities knew the nurses, their families, and where they worked. This broad community knowledge
created ethical pressure on the RNs in ways that nonrural RNs may never encounter. Therefore, trust had
both pros and cons and resulted in unique ethical tensions.
The trust that the RNs often felt from other community members was not always there when Indigenous
patients arrived from more northern communities. The RNs understood that trust needed to be built and
earned.
One participant remarked,

Like, our hospital gets so many people that have been flown in from these tiny little northern reserve commu-
nities; and so they are maybe without any support or without a family member and they’re very far away from
home and what they know and they’re thrown into this hospital centre where all of the staff aren’t part of their
community or part of their cultural group. (Interview 2)

Sometimes, differences in culture and language lead to the RNs not being trusted to provide quality care
for Indigenous patients and their families. The RNs expressed the ethical dilemma of trying to respond
appropriately to accusations of racism. Some patients and families believed that they would be discrimi-
nated against and subsequently demanded more services. The RNs reported being worried that if they could
not deliver what the patients or families wanted, the result would be complaints to the media or senior
leadership at the hospitals.

Theme 3: care
Theme 3 reflected the ethical issues that often resulted in decisions that caused or contributed to the
unnecessary pain and suffering of patients, families, and the RNs themselves. One example of unnecessary
suffering was the decision to transfer seriously unwell patients to larger urban hospitals for invasive care
(e.g. advanced diagnostic procedures, treatments, etc.) when palliative and end-of-life care was the better
option, as seen by nurses. The RNs mentioned that they often disagreed with care decisions to send very sick
patients to tertiary care. Nurses considered this unnecessary suffering for patients, families, and the nurses
themselves. For the RNs, the unrelieved suffering of patients and their families was a difficult and unethical
circumstance to endure.

Theme 4: fear
Theme 4 was described by the RNs as a driving force in their ethical decision making. Working in small and
isolated communities with little support meant that the RNs had to assume more responsibilities. The RNs
highlighted the fact that practicing in rural and northern settings forced them to sometimes bend the rules
and take risks in an attempt to navigate ethical dilemmas in practice and provide quality patient care.
One participant noted,

So being in a small hospital there’s only one doctor in the hospital at night time and that’s the Emergency
physician, so one doctor for the entire hospital; and there’s doctors that are on call, but they’re not physically in
the XX. So a lot of times at night we find as nurses that we have to make decisions sometimes that aren’t always in
our scope . . . So a lot of times, like if we are worried about a patient or we think that the patient needs to be
assessed by a doctor, we’re sometimes stuck between a rock and a hard place because a lot of the doctors at night
Alzghoul and Jones-Bonofiglio 7

just say—you can handle it till morning—and they just won’t come in. So, we’re by ourselves. So I would say one
of the big things is just resources and having people available if we need them, is not always the case being in
here. (Interview 1)

The RNs also described the need to plan ahead and err on the side of caution in the acute care
setting in rural and northern communities because acute care personnel and resources were hundreds
of miles away.

One participant explained,

I would say yeah, it’s definitely different because there’s more we have to decide, I guess. Even with this
hospital—like the first hospital I worked at was really small and there’s only two RNs on at any time, especially
like after-hours and then during the day there was some management, but after hours or on the weekends, if I was
a new nurse and like I was only in my second year of nursing, I would’ve been in charge of the hospital. Those
type of decisions would have fallen to me there potentially, so that’s a lot of things I need to figure out without
support in a small setting. (Interview 4)

The participants expressed the need for a timely way to talk about and work through ethical concerns
without fear of reprisals. Often, the RNs were unaware of the availability of ethics resources at their
hospitals. They also feared that any conversations about ethical issues might breach patients’ confidenti-
ality, preventing the RNs from seeking support with ethical decisions and talking about situations to
colleagues.
One RN commented that even speaking to her counselor was a challenge. The counselor was from the
same community and might have recognized the story or the patients that the RN was talking about.

One participant explained, “I guess sometimes maybe you don’t talk about things with people. You don’t get
things off your chest because you don’t want to break confidentiality or anything like that.” (Interview 3)

Another participant stated,

I just find that there isn’t that much support when it comes to making ethical decisions . . . I’m just talking about
who to go to and who to talk to about it and you kind of feel like maybe you’re the only one that thinks this way, so
maybe you shouldn’t even bring it forward to your manager or to the doctor. But if you do want to bring it to
somebody, it’s just hard to know who to talk to about it. (Interview 7)

Additional findings: barriers and facilitators

Dealing regularly with ethical issues without any formal support only added to the RNs’ struggles to provide
quality care. The RNs identified other factors (i.e. barriers and facilitators) that influenced their experiences
regarding ethical issues in practice and the process of making ethical decisions. In this study, barriers were
illustrated in an example of organizational factors, and facilitators were illustrated in an example of personal
factors.

Organizational factors
The lack of resources in rural and northern communities is a major barrier to quality care. Hospitals in rural
areas are not very well equipped. At times, equipment might not even be available, might not be functioning
properly, or might not have qualified personnel to operate it. Some small communities have only one
ambulance, with no other ambulances available for life-threatening emergencies. The RNs also mentioned
8 Nursing Ethics XX(X)

the lack of organizational support for ethics in practice in general. Some of the participants did not know if
their hospitals even had ethics committees. They were not aware of how such a committee functioned or
how they could access it. They also did not feel safe asking for help from these committees.

Personal factors
The RNs also mentioned personal factors that acted as facilitators of ethical decisions. Examples of personal
factors that were key to quality care were having more years of experience, engaging in good communi-
cation and interpersonal relations with other healthcare providers, understanding the culture of the north,
and having previous education that focused on ethics.
One participant stated,

I feel very comfortable talking about it, but as a brand new nurse, I probably wouldn’t have been. Like, if this was
7 years ago, I probably wouldn’t because I would’ve felt maybe that I didn’t know enough or that I wasn’t smart
enough or that I hadn’t learned enough. But now, since I’ve had the experience, I do feel very comfortable talking
about it because it’s frustrating sometimes and you feel like you want to make change and you want things to
happen and you want your voice to be heard. So at this point in my career I definitely feel like I would rather talk
about it than hold it inside and just hope that something changes. (Interview 7)

The RNs also shared strategies to manage and deal with these experiences. For example, they described
creating their own informal support systems, which usually involved talking to other RNs and unit
managers. Relationships with and communication between themselves and others (e.g. unit managers,
physicians, locums, police officers, family, patients, nurses) were important factors in the ethical
decision-making process.
One participant shared,

I know at this point—I know all the staff, so you have that. It’s not like trying to figure out who is the
Physiotherapist. You know because there’s only one, so you know; so you have that relationship to just go and
say—hey, this is what—just give them a quick call and they—so yeah, I consult with all of those people as
well . . . So in that sense it’s good, but then there’s the personality clashes and all that kind of stuff that can get in
the way of patient care and getting what needs to be done. . . . things would get done faster, but then other times
things would be slowing down because of personal conflicts. (Interview 6)

Seeking the advice and/or support of other RNs or managers was a personal factor that helped the RNs to
deal with various situations. They described the value in supporting each other in an attempt to deal with
situations as team members in their own ways.
One participant said,

I think especially as a new nurse I’m constantly asking my nurse colleagues for help, not necessarily to do my
work or whatever, but just to—for guidance and—what would you do in this situation and what has been done in
the past—and then kind of taking that and deciding what I want to do with it, I guess. (Interview 3)

Discussion
The focus of the study was to learn about the ways that nurses living and working in rural communities made
decisions when encountering ethical issues and conflicts. For the eight RNs in this study, their experiences
relevant to ethics and ethical decision making in practice were shaped by living and working in small rural
and northern communities. The RNs explained why these situations were considered ethically problematic
Alzghoul and Jones-Bonofiglio 9

•Physicians •Community

Power Trust

Barriers Facilitators

Fear Care
•Risk Taking •Paents &
Families

Figure 1. Quadruple helix model of tension-based ethical decision making.

and what interventions they used to overcome these conflicts. They also discussed facilitators and barriers
that influenced their decisions. The RNs shared their attempts to balance their professional duties, com-
munity responsibilities and expectations, and personal relationships with other healthcare providers. They
navigated the ethical tensions of power, trust, care, and fear in the best ways that they could with limited
resources.
Results presented in figure 1 showed how these eight RNs used a tension-based decision-making process.
They described having to balance the power of physicians over their nursing practice in small and isolated
communities. They felt the familiar weight of trust from patients and families, and they were unsettled when
trust was absent. They expressed the need to sometimes bend the rules (and put themselves or their jobs at
risk) to provide quality patient care. This type of decision-making process by the RNs (i.e. focusing on the
needs of patients) was supported by similar findings such as those in Barlow et al.18

Registered nurses
The RNs were able to recognize the issue and consider their options when making decisions. The RNs
recognized their lack of ethics education and wanted more hands-on training to resolve ethical issues.2–4
Most of them felt that as nursing students, they received little or no ethics education, especially in regard to
rural nursing practice. Most nurses and other healthcare providers in rural areas are trained in the urban
model of care, which gives patients wide access to diverse health services and specialties.19 More teaching
is needed to prepare nurses to practice in rural areas, where current ethical guidelines and principles may not
be as relevant.19
The RNs shared some of the difficult ethical issues and conflicts that they had experienced. Ethical
conflicts had the potential to occur when the nurses were working with locum physicians,20 working with
limited resources to care for patients and families,21,22 dealing with dual or professional–personal relation-
ships,23,24 and maintaining patient confidentiality.25 Some ethical issues were very similar to ethical issues
reported in the nursing literature.2,18 These issues also were similar to those of other healthcare providers in
rural communities.8,24
Nurse–physician relationships and interactions have been identified as a factor in creating ethical con-
flicts and tensions when nurses make decisions. Research has shown that physicians and nurses have similar
ethical issues and dilemmas.26,27 The RNs in this study had many common and ongoing challenges with
physicians.2,10,18,27 The RNs said that conflicts occurred when physician and nurses had different ideas
about plans of care or physicians ignored input from RNs about particular patients. The RNs expressed
concern when there was no continuity of care or physicians appeared to not be committed to the care of
10 Nursing Ethics XX(X)

patients. These challenges with physicians could have been explained by the perceived power imbalance
and strained interpersonal–professional relationships. Nurse–physician relationships have been acknowl-
edged as a significant predictor of job satisfaction in rural communities, where these tensions have a strong
connection to the retention or attrition rates among nurses.28 One possible solution is to have an open
discussion about shared goals and values to benefit patients and their relationships.26 Another possible
solution is interdisciplinary education; knowing how to respect and collaborate with each other to decrease
the likelihood of issues developing into ethical conflicts in the workforce.2
Another ethical issue for the RNs in this study involved dual relationships.9 Warner et al. found that dual
relationships were not a big concern for rural nurses in Alaska and New Mexico; however, patients
struggled with the potential stigma, embarrassment, and risks to confidentiality of overlapping personal–
professional relationships. Regardless if the concern is relevant to RNs or patients, this ethical issue in rural
settings requires attention. Nurses’ ethics education and training stresses that dual or personal relationships
must be avoided and that personal and professional lives must remain separate.3 This requirement seems
difficult, if not unreasonable, in small communities. Many of the RNs mentioned the roles that their
communities, families, and patients expected them to uphold. The RNs recognized that dual relationships
could impact the trust relationship necessary to obtain the best outcomes for patients and their families. Dual
relationships need to be addressed by the education system and in policies about practicing in rural settings.
Connected to dual relationships is the issue of confidentiality. Living and working in small communities
present the risk of breaching confidentiality unintentionally. In one study, RNs noted that concerns
about confidentiality prevented patients from sharing potentially important information with healthcare
providers.9 However, this concern was not mentioned by the nurses in this study.
Dealing with ethical issues on a daily basis, along with no formal support and no ethics committees (or
resistance to use them), adds to RNs’ overall burden.2 The RNs talked about the strategies that they used to
deal with their emotions when experiencing ethical issues or making ethical decisions. The RNs had to make
their own support systems by talking to other nurses or unit managers, or by internalizing their experi-
ences.7,18 Based on Jameton’s analysis of moral problems, the feelings and emotions that the RNs expe-
rienced (e.g. anger, guilt, anxiety, depression, frustration, and powerlessness) were associated with moral
distress.29 According to Park et al.,2 these types of emotions can lead to job dissatisfaction and burnout
syndrome.

Recommendations
Most healthcare providers in small community settings were trained in an urban model of care that gives
patients wide access to different health services, specialty resources, and support. The RNs in this study
expressed the desire to have learned more in their undergraduate education about the complex real-life
ethical issues in everyday practice that they would eventually face. Undergraduate curriculum content
specific to the challenges of rural settings should be a focus. In addition, nurses in practice would benefit
from additional ethics education, training, and support.

Limitation
One limitation of this study was the use of a small purposive sample, which relates to a lack of general-
izability for the results. However, generalizability as such is not an expectation of qualitative research.
Although this was a small sample, the findings may provide insight into understanding nurses’ moral
distress, ethical dilemmas, and ethical decision-making experiences in similar settings.
The ultimate test of transferability of these findings will be whether they resonate with other RNs’
experiences. This research provides an opportunity for RNs and nurse educators to reflect on their own
Alzghoul and Jones-Bonofiglio 11

ethically challenging experiences in practice. The results also might be useful to decision makers who wish
to better support nurses to feel satisfied that their practice meets high-quality ethical standards.

Conclusion
The exploration of RNs’ experiences regarding ethical conflicts and dilemmas revealed a tension-based
approach to ethical decision making, that is, trying to find an ethical balance. Unique contexts such as
working with locum physicians, managing dual relationships, maintaining patient confidentiality, working
with limited resources, and accepting risk were identified. A consistent focus of the RNs was their moral
obligation to their patients. They expressed considerable moral distress in regard to the need to ensure that
patients received the best possible care.
The RNs had a high sense of ethical responsibility toward patients, families, healthcare team members,
communities, and hospitals. They recognized that making the most appropriate ethical decisions was an
integral part of their role and that they were accountable for their decisions as providers of quality patient
care. Most nursing personnel in all of their different roles work very hard to meet their ethical obligations.
The researchers hope that this study will add to the legacy of commitment to high-quality professional
nursing practice and contribute necessary context to the advancement of nursing ethics, especially for
nurses who live and work in rural settings.

Acknowledgements
We are grateful to all participants for sharing their experiences with us. We would like to thank Professor
Alison Thompson for providing insightful comments to improve the final version of this article. We also
would like to thank Lakehead University for providing partial funding for this study.

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 study was partially funded by the Regional Research Fund, Lakehead
University (grant number 1466398). No support was received for the authorship or publication of this
research.

ORCID iDs
Manal M Alzghoul https://orcid.org/0000-0003-3280-783X
Kristen Jones-Bonofiglio https://orcid.org/0000-0003-3483-9333

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