Navigating Ethical Dilemma in Nursing Practice, Strategies for Excellence Running Title: Ethical Paradox in the Nursing Field

Abstract

Ethical issues are integral to the nursing profession, particularly in resource-constrained, culturally diverse and high-demand contexts like Nigeria. Nurses face dilemmas involving autonomy, privacy, resource allocation and end-of-life care, often exacerbated by organizational constraints. This review examines 17 studies and professional guidelines on nursing ethics in Nigeria, highlighting systematic approaches such as Rest’s Four-Component Model, Seedhouse’s Ethical Grid and Brody’s Narrative Ethics Model, which aid decision-making in complex scenarios. Professional codes, including the International Council of Nurses (ICN) and the Nursing and Midwifery Council of Nigeria (NMCN) codes, enhance nurses’ accountability, confidence and ability to deliver patient-centered care. Despite these frameworks, challenges persist, including inadequate ethics training, insufficient resources and non-compliance with codes, leading to moral distress and increased turnover. Organizational policies and support systems, such as ethics committees, are often inaccessible and further complicating ethical decision-making. To improve ethical practices, the study recommends continuing education in ethics, readily accessible institutional support and policies that foster a culture of ethical accountability. Strengthening organizational ethics culture, improving resource management and prioritizing ethical training can enable nurses to make sound decisions that enhance patient trust and care quality. Addressing these barriers will better equip Nigerian nurses to navigate ethical dilemmas effectively and uphold professional standards, ultimately improving healthcare outcomes in the region.

Keywords: Nursing Ethics, Ethical Dilemmas, Professional Codes, Ethical Decision-Making Models, Nigerian Healthcare, Moral Distress, Institutional Support

1. Introduction

Ethics plays a critical role in nursing and patient relations because it provides nurses with a course of action through potentially difficult and high arousal moral circumstances. The seven ethical principles in nursing practice include, autonomy, beneficence, non-maleficence and justice can dictate a logical reasoning model towards making of ethical decisions¹. Though, ethical issues create challenges wherein these principles need to be weighed against each other where a conflict can occur between the interests of the patient, institution where the nurse working and the law. Some of the issues that have recently been identified in ethical decision making in nursing are; technological advancement, patients’ needs and changing health care policies². These dilemmas for and with patients are not only experienced by nurses, but also by families, patients and healthcare organizations, which is why it is important to find the best strategies in dealing with such problems in a high-quality and ethically acceptable manner.

Indeed, some of the ethical challenges to the nursing profession in Nigeria are peculiar to the country limited by its sociocultural endowment. Due to scarcity of resources, lack of adequate human power and high patient turnover, the ethical decision-making challenge tends to be compounded³. For example, while working under limited resource constraints, nurses are compelled to make specific decisions that are likely to have an adverse impact on client outcomes and may be viewed as equitable or just. Also, the Nigerian healthcare system may place some limitation on nurses, regarding ethical conduct, decision making for the patients⁴. As a result, Nigerian nurses need to have a strong and clear knowledge of ethical theories and decision-making models appropriate to the Nigerian context. Research shows that the Nigerian nurses most frequently reported ethical concerns are confidentiality, consent and end-of-life care⁵.

Ethical decision-making models are invaluable tools to the nurses in managing such ethical dilemmas. Such models, for example the Four-Component Model (Rest, 1986, cited Clarke & Holt, 2021), offer a framework for analysis and resolution of ethical dilemmas, thus helping the nurse to make decision that are ethical and patient-empowering. More and more Nigerian healthcare institutions are embracing such frameworks because they assist in reducing the emotional and professional toll of ethical decision making⁶. Decision-making models do not only help the nurses with moral dilemmas but also promote a practice that has the potential of being ethical as well as builds ethical strength.

Another important instrument in raising ethical levels among nurses is professional codes of ethics. The guidelines and rules of ethic include international council of nurses, nursing and midwifery council of Nigeria guidelines which outlines measures that should be used by the nurses and are meant to uphold patient activism⁷. These codes act as a guide to the right conduct and help the nurses to determine the right ethical decision that should safeguard the patient. Studying further reveals advocacy for professional ethic practice which in turn results to enhanced patient condition and satisfaction increases among nurses⁸.

Nevertheless, the nurses continue to struggle with the questions of ethical behavior and professionalism, as well as with the difficulties connected with the need to uphold the professional ethical standards in the situations when the personal and professional values, patient’s preferences and organizational policies contradict each other. Maintaining professionalism in such scenario is a noble call as it calls for perseverance, backing and resources that enables the nurses to fight for the right thing to do without being punished⁹. This paper therefore stresses the need for Nigerian health care organizations to promote ethical practice as this enhances patient outcome, the nursing profession and job satisfaction.

In nursing, ethical concerns occupy a widespread place and those working in the field have to experience its influence. This seminar seeks to meet these critical challenges through first understanding the ethical dilemmas faced in nursing and the impact on patient care. In this manner, the findings will help shed light on the different ways in which these decisional conflicts affect patient health and the quality of treatment. Furthermore, we will examine the different ethical decision-making models with reference to the clinical practice in Nigeria. These models give a framework on how to handle disputes and also enhances ethical sound practice among the professions. Also important in the seminar shall be the professional codes of ethics, which are critical for enhancing ethical practice among the nurses. These codes exist to guide the nurses as to how they can improve their commitment to ethical practice. Last, the approach to address the issues of professional integrity in handling ethical dilemmas will be discussed. That is why this exploration will help nurses to promote, protect and pursue their personal values while overcoming different obstacles in the way to the ethical practice of patient-focused care.

One of the most significant and persistent problems in nursing practice is ethical issues being a part of a conflict situation not only for and among the nurses and the health care system but also the patients. According to different research, it appears that a large cross-section of practicing nurses’ experiences ethical issues frequently and some polls reveal that 60% of the nurses expose themselves to ethical questions at least once per week¹⁰. These ethical dilemmas are usually between patient’s rights and hospital rules, attending to patients’ needs with available resources and between culture and ethic. These challenges are however compounded by systemic constraints in low-resource settings such as the Nigerian environment. The current research reveals that Nigerian nurses, like many others in comparable healthcare systems, experience higher ethical pressures: about 75% of the nurses suffer from ethical stress because of the lack of resources and the large number of patients¹¹.

Some of the challenges faced by Nigerian nurses that makes the choices of the right ethical decision difficult include lack of staff, insufficient access to crucial health care items and non-compliance with western based ethical standards. Where products are core and hard to come by, Nigerian nurses can only take decisions - some of which affect patient outcomes and wellbeing - with little institutional back up or direction. These conditions cause moral distress, emotional fatigue and eventually burnout in the nurses. Research conducted among Nigerian healthcare organizations shows that ethical dilemmas cause professional burnout in nurses, with rates higher than 50% The impact is reduced job satisfaction and increased turnover risk.

While ethical decision-making models and professional code of ethics aims at offering a framework for addressing such dilemmas, the real application of the frameworks is usually a letdown. In many cases, there is no preparation and organizational backing, which makes nurses insufficiently prepared to use ethical concepts properly in their work⁴. This gap not only poses a problem to human action of the nurses but also exposes the nurses to moral distress affecting the patient care quality.

Due to these challenges, there is then a significant need for a cumulative literature review and discussion on approaches to addressing ethical issues in nursing with special focus on Nigeria. This seminar is designed to help nurses to understand the key ethical dilemmas, learn about culturally appropriate decision-making frameworks, review the professional code of ethics and identify the strategies for sustaining the ethical practice. Diagnose such an approach could create a more sustainable and ethical nursing workforce and hence demonstrate better patient results as well as gain public confidence within the health sector.

2. Methodology

This article employs a literature review and thematic analysis of ethical issues in nursing with emphasis on Nigeria. A total of 17 peer-reviewed articles, reports and ethical guidelines published in PubMed and ScienceDirect from 2019 to 2024 are included. The seminar objectives are used to organize the literature review, as follows: ethical dilemmas in nursing, decision-making frameworks, codes of ethics and maintaining ethical standards. The literature is reviewed to extract the key themes that provide ideas about the regular ethical issues. Nigerian healthcare case studies are presented to ground the study and demonstrate how decision-making models and ethical codes are implemented in practice. Also, the recommendation from other experts and the comparison of experiences from other similar healthcare systems help to expand the understanding of ethical approaches to recognizing strategies Nigerian nurses can use to solve ethical issues. This approach guarantees that one is conversant with all the aspects of ethical issues in the practice of nursing.

3. Results

The ethical issues that are experienced in the nursing profession and their effects on the patients. Ethical issues current in the nursing practice include autonomy, informed consent, privacy, distribution of resources and palliative care. Such concerns stem from disputes between the rights of patients and the duties of the healthcare professionals or between the rights of patients and the legal or organizational requirements governing the provision of health care. A systematic analysis of the recent literature from the year 2018 to 2024 gives a strong evidence base on how these ethical issues impact the nursing practice and patients’ outcomes with studies finding numerous interactions between ethical theories and clinical practice (Table 1).

Tabel 1: Thematic Findings on Ethical Issues in Nursing and Their Effects on Patients.

3.1. Patient autonomy and consent

Patient self-determination is one of the basic axiological values of nursing practice, but it often conflicts with knowledge and experience, as well as organizational requirements, which makes difficult choices for nurses. Research by Alavijeh, Ebadi and Sokhanvar (2021) shows that nurses experience ethical stress daily when patient self- determination is in opposition to professional advice. For instance, cases in which patients decline to accept treatment that would save their lives always presents a dilemma to the nurses, whether to respect the patient’s autonomy or their nurse’s ethic of preserving life. These tensions are also not only emotionally demanding on the nurses, but in the case where a patient feels that her detailed preference is not being sufficiently upheld, can lead to the deterioration of the nurse-patient relationship. Such breakdowns in trust can make patients opt out of healthcare plans or even decline other treatments in the future lending to poorer health outcomes². The study therefore emphasizes on need to prepare nurses with frameworks and skills that recognize both respect for patient’s autonomy and medical advisability where necessary, especially where the decisions are sensitive or may alter patient’s lives.

3.2. Confidentiality and privacy

Maintaining the patient’s identity is still one of the cores but not easy responsibilities in the nursing practice since the issue of ethical violation is recurrent and is usually caused by factors like electronic documentation, open ward or institutional reporting requirements. As pointed out by Hassan and Olawale (2022) such breaches may arise from systemic constraints or failure to observe privacy standards. The study also identified that even the simplest violation of patient confidentiality, like talking about a patient in front of other people, can cause patients to develop mistrust and, thus, keep important information from their physicians. Such a behavior undermines the objectivity of the evaluation and the efficiency of planning further actions and treatments because patients may then become reserved and avoid sharing information that would be crucial in the context of their further therapy. In this study, the author shows that the protection of confidentiality is not only a matter of ethical imperative, but also of therapeutic need in the healthcare setting. A breach of confidentiality therefore can lead to an indirect influence on patients by distorting the quality of the information exchange besides distorting cooperative relationships that are crucial in handling patients¹³.

3.3. Resource allocation

The last major ethical issue affecting nurses is resource allocation in low resource health care facilities especially in some parts of Nigeria where there is scarcity of health care resources whereby a nurse is called upon to decide on how best to allocate scarce resources to patients in need of different degrees of attention. This paper has found that nurses often face ethical dilemmas when they have to decide whom to attend to first when admitted in facility without the adequate facilities such as medication, equipment or even basic necessities like food. Not only does it negatively impact the nurses emotionally and psychologically but it also comes with grave consequences in relation to patient care. If stretched resource wise, some clients may get inadequate care and may take longer time to recover or even develop complications that could have been avoided. This reality is especially unkind to already marginalized groups who turn to public health systems for their care, widening the gap in health equity and decreasing the general populace’s confidence in the health system. The research outcomes provide a clear depiction on ethical dilemmas concerning resource availability go beyond the single nurse, affecting globalized and organized nursing care delivery, patient satisfaction and health systems equity¹⁵.

3.4. End-of-life care

End-of-life issues constitute one of the most challenging areas in ethical decision making because nurses have to respect patient’s autonomy, family’s values and organizational procedures that promote aggressive treatment. The ethical tensions are that patients are treated as objects and technicians while nurses are turned into technicians and objects themselves; Garcia-Rueda, Carvajal Valcárcel, Sarabia Cobo and Noguera Tejedor (2019). The study showed that nurses often encounter moral distress due to patient’s end-of-life choices including preferences for comfort instead of disease curing. Hence, this ethical conflict causes patient elongated suffering in that those patients without power of attorney will endure more days in the hospital without the treatments they do not desire and which the nurses consider inconsequential or detrimental. These are the conditions that certainly affect patient quality of life and at the same time cause a burnout of carers, as they feel that they are failing to provide appropriate, patient-oriented nursing care. Thus, the current work underscores the need for consistent policy and thought processes that precede advance care coordination in agreement with patients’ preferences, minimization of ethical solicitousness on the nurses and humane disposition towards patients as they approach their natural end¹⁶.

3.5. Moral distress and its consequences

Moral distress as a concept defined as a situation when a nurse is unable to fulfill his or her ethical standards of practice as a result of organizational or situational barriers is more and more acknowledged as a critical factor affecting both the personal and professional quality of life of nurses and the quality of the care delivered to the patients. Epstein and his colleagues Epstein, Whitehead, Prompahakul, Thacker, & Hamric (2021) conducted a meta-synthesis review of the studies of the impacts of moral distress and concluded that nurses who work in environments with numerous ethical dilemmas are more likely to experience burnout, job dissatisfaction and turnover. This turnover poses a disadvantage inpatient care since continuity of care and the extent of relationship between patients and the nurses are severed. Moreover, it identifies that working environments where nursing staff has high levels of moral distress yields from poor patient satisfaction and health outcomes, meaning an implication for the large patient population. The outcomes emphasize the need to organizational support measures and coping skills to alleviate the moral burden on nurses and ensuring better quality of care for patients¹².

3.6. Effects on patient outcomes

The above-discussed ethical challenges in nursing have a ripple effect on the patient’s result. Kang, Ju and Lee (2023) revealed that the healthcare environments characterized by high ethical dilemmas and low supply of nurse support are related to the increased number of adverse patient outcomes including treatment, emotional and physical consequences. Problems of nursing ethical informality can erode the comprehensive patient care because nurses may pay less attention or their emotional engagement could drop due to prolonged ethical and emotional pressure. Nurses working in such settings have described patient outcomes as being less satisfied, less confident in healthcare givers and more at risk. These studies highlight the importance of adopting ethical education platforms, backings and ethical/decision-making instruments that can reduce the impact of ethical dilemmas in the nursing workforce and patient care in healthcare facilities¹⁴.

Thus, the empirical literature of recent years indicates that ethical problems in nursing concern both the practitioners and the patients. These challenges render nursing professional and patient care compromised as the nurses can no longer deliver patient-centered care without feeling moral stress, burnout or expressing low job satisfaction, therefore compromising patient satisfaction, trust and health outcomes. Solving these ethical questions is significant for developing the climate of healthcare facilities and giving nurses an opportunity to be caregivers of high professionalism and genuine human kindness. This seminar will therefore aim at discussing these ethical dilemmas, discussing the decision-making models and discussing how the nurses can be able to handle these ethical dilemmas.

Ethical decision-making models and their use when solving typical conflicts in clinical practice in Nigeria.

Ethical decision-making models are tools used by healthcare professionals including nurses to solve ethical dilemmas by presenting a step wise approach to solving the conflict. Such models are useful in Nigeria because of the scarcity of health care resources and the differences in cultural beliefs in handling ethical dilemmas. The present state of knowledge (2018-2024) reveals the use of these models in Nigerian clinical practice, advantages, disadvantages and the demand for culturally sensitive models.

3.7. Rest’s four-component model (1986)

Figure 1: Rest’s Four-Component Model.

Rest’s Four-Component Model, introduced in 1986, outlines a systematic approach to ethical decision-making by identifying four essential components: Moral sensitivity, moral judgment, moral motivation and moral character have been defined in previous sections. This model helps the nurses to (1) identify ethical issues, (2) reason through the most appropriate actions to take, (3) decide to take ethical actions and (4) be able to follow through on the ethical decision made despite the environment. Clarke and Holt (2021), analysing the effectiveness of Rest’s model in the Nigerian context with regard to the use by nurses, found that conflicts and decisions addressed by those trained in Rest’s asset were more confident and consistent. The model was most helpful in the issues of resource allocation and patient self-determination because ethical dilemmas are most often encountered in the situations of scarcity of resources. However, Clarke and Holt (2021) also established that the training on the Four-Component Model is also scarce in Nigerian institutions hence its effectiveness is limited. Due to lack of institutional support, Nigerian nurses may find it quite hard to implement all the four components particularly under typical conditions where time pressures are likely to prevail.

3.8. The ethical grid model

Figure 2: The Ethical Grid Model.

The Ethical Grid Model was created by Seedhouse in 1998 to help organize the possible approaches to meet patients’ needs with the resources available. This model uses beneficence, which means doing good and justice, which means being fair, to help nurses decide what care is most important when there is a shortage of resources. It has been useful in Nigerian context especially in the health care facilities where resources are scarce. Udo, et al. noted that Nigerian nurses use a slightly different ethical model, the Ethical Grid with utilitarian considerations to get the most for the patient in situations where resources are limited. For instance, in over-subscribed wards Nigerian nurses may decide to attend to emergent or life-threatening conditions as a way of optimally utilizing available resources. However, Udo, et al. pointed out that the Ethical Grid Model may be useful but might not be culturally sensitive to the Nigerian culture where families are involved and decisions are made collectively. At times this cultural difference makes the direct application of the Ethical Grid somewhat more difficult since the nurse must balance the needs of the patient with the family¹⁵.

3.9. Narrative ethics model

Figure 3: Narrative Ethics Model.

Brody in 1987 developed the Narrative Ethics Model which focuses on the patient’s story, including his values and culture. This model is especially appropriate for culturally dense and diverse settings like Nigeria since individual and cultural stories heavily inform patient care choices. Eze and Nwosu (2022) explained that the Narrative Ethics Model helps Nigerian nurses to solve ethically challenging situations by concentrating on the patient’s story and culture. For example, this model is most useful in the treatment of terminal illness since the treatment decision may be influenced by patient’s perception and family’s influence. The use of this model encourages the nurses to embrace empathy and provide patient centered ethical solutions hence enhancing the quality of services and the satisfaction of the patients. But, Eze and Nwosu, also pointed out that the Narrative Ethics Model is time consuming, which is a major limitation in densely populated Nigerian health care organizations where nurses work under pressure with large patient turnover. This time constraint can reduce the amount of time that the nurses spend with the patient which hinders the application of the model.

3.10. Integrative ethical decision-making model

Figure 4: Ethical Decision-Making Model.

The Integrative Ethical Decision-Making Model was developed by Tarvydas in 1998 to offer a more adaptable and complex means of approaching ethical decision making; this framework incorporates deontology (duty-based ethics), utilitarianism (outcome-based ethics) and virtue ethics. This model is very flexible and the Nigerian nurses can use it to balance between patients’ rights and realities on the ground as far as their healthcare setting is concerned. According to Okeke and Onwuka (2021) the Nigerian nurses who participated in the study and adopted this model expressed improved readiness to manage conflicts that involves patient self-determination and privacy. The advantage of such a model is the ability to adjust the actions to each specific situation, considering ethical standards, patient’s rights and organizational conditions. But, Okeke and Onwuka (2021) also highlighted that, while the model is flexible, the Integrative Model needs substantial institutional support to be implemented properly. However, if this model is not supported by adequate resources, the implementation by nurses may be difficult especially in emergent situations where decisions have to be made within short time.

3.11. Reflective equilibrium model

Figure 5: The Reflective Equilibrium Model.

The Reflective Equilibrium Model formulated by John Rawls in 1971 is a reflection-based model that makes use of past case experiences in ethical decision making and aims at enhancing the quality of ethical decisions with time. This model encourages growth of ethical reflection as the nurse is able to look at the case in question and change his/her actions in similar situations in future. Osinaike and Agbaje, showed that Nigeria nurses benefit from reflective practice as it helps them to deal with routine ethical dilemmas with more skill and strength. Reflective practices promote an emergent and subtle method of developing ethical acumen and readiness since decisions are made from the experiences encountered. Nonetheless, Osinaike and Agbaje, observed that most Nigerian hospitals have no structures for reflection-based practice hence its use is restricted. The lack of structured reflection opportunities might impede the process of systematic growth of ethical thinking among the nurses, particularly when they meet the same ethical problems repeatedly.

3.12. Application challenges and the need for institutional support

Although these models are helpful in the general approach to moral issues, the practical application of these models in Nigerian healthcare organizations is hampered by inadequate resources, work overload and lack of organizational support. Nigerian nurses often describe the challenges of implementing these models because of the time and lack of adequate training in the models. For instance, Okeke and Onwuka, stress the need to provide adequate ethics training and resources to the healthcare facilities to improve the nurses’ ability to apply the models. Udo et al. (2020) also opine that there is need for ethics committee and decision-making support resources in order to ensure that these models are implemented in clinical practice in Nigeria.

Professional codes of ethics as tools that help enhance ethical standards among nurses. It is professional standard that defines ethical principles for the professional nursing practice that helps to define the standard and responsibilities. These codes operationalize and idealize the profession’s standards and inspires nurses to live up to the norms and standards that include integrity, compassion and respect among others. Nurses practicing in Nigerian facilities are frequently confronted with ethical dilemma due to resource constraints, population densities and multicultural practicum and the codes helps to improve the ethical process and over dilemma situations. The following empirical review evaluates the position and efficiency of professional codes of ethics for nursing practice, advantages and limitations of the codes of ethics in Nigeria.

3.13. The role of the international council of nurses (ICN) code of ethics

The International Council of Nurses (ICN) has developed a Code of Ethics that provide guide principles and scope related to professional nursing practice, patient advocacy, responsibility and duty. This code is a framework that any nurse from any part of the world can implement on a cultural and organizational level. As stated by Hassan and Alabi (2021), the ICN Code has been helpful in enhancing ethical consciousness in Nigerian nursing practice by advancing principle-based ethical values that may be in accordance with the global nursing standards. The results of this research revealed that Nigerian nurses with awareness of ICN Code was more committed to patient centered care and self-confidence while addressing ethical issues. However, Hassan and Alabi (2021) also pointed out that they also observed that the ICN Code is useful but the universal principles might not be sufficient to address the issues that Nigerian nurses encounter while practicing in their context, which is scarce resource and culturally different from some western countries.

3.14. The nursing and midwifery council of nigeria (NMCN) code of professional conduct

The Nursing and Midwifery Council of Nigeria (NMCN) offers the Nigerian health care sector a code of professional conduct. This code defines ethical responsibilities of Nigerian nurses as patient representatives, protectors of patient information and as accountable and culturally sensitive. Okeke and Igbokwe (2020) have synthesized the effects of the NMCN Code and revealed that the higher ethical compliance and professionalism among nurses who interact with this code actively. The study also pointed out that being able to respect cultural diversity as brought out by the NMCN Code is very important given that Nigeria is a multi-ethnic country and therefore by seeking to understand the different beliefs and values of their patients, the nurses will be in a better position to handle them. However, Okeke and Igbokwe (2020) noted that the implementation of the NMCN Code is hampered by the low level of visibility and a lack of ongoing ethics education. The low level of awareness of the provisions of the NMCN Code among many Nigerian nurses also limit its usefulness as an ethical guide.

3.15. Benefits of codes of ethics in enhancing ethical standards

Studies in the past indicate that for professional codes of ethics improve ethical practices among the nurses through providing the nurses clear guide on what they should or should not do. Adeoye and Akanbi (2019) observed that Nigerian nurses who frequently use the professional codes have better ethical judgement in patient’s privacy and consent. It also pointed out that these codes encourage accountability and professional standards among the profession since they would feel that they have been entrusted to uphold the values and rules of nursing association. Besides, the enforcement compliance with codes of ethics has been found to enhance the patents’ health since the nurses who follow them practices professional and sensitive care (Adeoye and Akanbi, 2019).

3.16. Challenges in implementing codes of ethics

Nonetheless, there are challenges encountered in the implementation of the professional codes of ethical in the Nigerian health care practice. One of them is the absence of ethics education and organizational encouragement, which is discussed by Agwu and Okechukwu (2021). Their study showed that although most of the nurses in Nigeria have a good knowledge about ethical principles, they do not have adequate knowledge and materials to implement these codes of ethics in their practice. Moreover, there is a pressure of increasing patient load and scarcity of resources, which may compel the nurses to compromise on some of the ethical practices that are required to be followed while addressing the needs of a patient. Agwu and Okechukwu (2021) also pointed out that there is a lack of enforcement of these codes because nurses who have violated ethical principles may suffer from no punishment at all, which reduces overall nurse’s commitment to ethical norms.

3.17. The impact of codes of ethics on professional integrity and patient trust

Codes of ethics also therefore help in enhancing professionalism in careers and hence gains the trust of patients. Musa and Lawal (2022) also found that patients in Nigerian hospitals trust and satisfied when they saw that nurses were ethical especially on confidentiality, respect for patients and patient self-determination. The study asserted that, while practice of ethical principle by the nurses, the practice strengthens the ethical composure of the nurses; thus, leading to an elevated patient rating the quality of care and the relations between the nurses and the patients. This trust in return influences patient status as patients are more comfortable with nurses with ethical behaviors¹⁷.

Ways to overcome the challenges of maintaining one’s professional integrity in complex ethical procedures. Respect to professional standards is one of the basic principles of nursing practice; however, it can be violated in acute ethical situations resulting from such conditions as shortage of resources, a large number of patients, cultural differences and difference in organizational policies. Handling of these situations by the qualified nurses especially those practicing in the developing countries such as Nigeria includes involvement of personal conviction, ethical principles and policies and organizational encouragement. This paper presents a synthesis of measures that can be adopted to enable nurses to stand for professional ethical values when faced with ethical dilemmas.

· Ethics education and training: Ethics training is one of the essentials which prepare nurses for ethical issues. It enables nurses to go through over the ethical codes, theories and even particular approaches to the conflict of ethical issues. Adeoye and Akanbi, found out that through comprehensive ethics education, the nurses expressed increased confidence in their decisions making processes and ability to solve such ethical dilemmas without compromising their ethical standards. Ethical training and education should entail use of case studies, demonstrations or the use of scripts and group discussions in order for the nurses to be able to appreciate the use of ethical principles in various situations. Ethics has to be integrated into the nursing curricula and it has to be continuously delivered as professional development for staff with educational institutions implementing biannual workshops and courses on ethics for staff.

· Applying ethical decision-making models: Ethical theory can be defined as the process of providing a check-list, which guides the nursing practitioners on how to solve ethical challenges. For example, the Rest’s Four-Component Model, Seedhouse’s Ethical Grid and the Narrative Ethics Model are frameworks used to map ethical dilemmas and appraise the ethicality of various options in a systematic way¹¹. These models help the nurses to be able to stand back from the ethical difficulties and make decisions that are both ethical and balanced for the patient and their own conscience. Implementing the ethical decision-making models in their practice act as a check to ensure that different ethical dilemmas are dealt with in a similar manner and also enhances confidence among the nurses since they have tools to guide their decision making.

· Ethics committee and support systems: a guide for access: Professional integrity can only be maintained with support from institutions. Hospital and health care organizations benefit from ethics committees, which are comprised of various professional disciplines. Ethics committees are useful to nurses when the right ethical decision is not well defined or when it affects several parties. Ethics committees provide advice, bring together different opinions and opinions of people and reduce subjective approaches, which will help the nurses make ethical decisions. Such committees and support systems encourage ethical practices and conscience within healthcare organizations and create organizational conscience.

· Enhancing reflective practice: Included in the benefits of reflective practice for ethical development is the act of self-transformation that comes with the evaluation of the personal practice. Through reviewing interaction experiences, nurses would be able to establish the favorable aspects of the learning experience, areas that posed a challenge and ways of doing better in future interactions. Reflective practice enhances awareness of ethical concepts and assists the nurse to integrate her decision-making process with her clinical conduct relevant to organizational and personal ethical values. Self-reflection also helps build character on nurse what is more it also makes nurses be prepared for handling some ethical challenges that may come due to their consistency in doing analysis on their decisions. Reflections can be promoted by having journals where trainees are required to write about what they have learned; peer discussions and mentorship programs and as a result, it is an applicable strategy for ethical formation⁶.

· Building up the protective factors and personal coping resources: This will stress an individual professionally and may cause moral anxiety or even burnout when dealing with ethical conflicts. Improving the ACLs to prevent the emotions from becoming unhealthy is helpful for personal and professional sustainability in the long run. By use of stress management approaches that include counseling, stress minimization and support groups, the nurses can better manage on the stress that is likely to come along with the ethical decisions making. Musa and Lawal, stated that nurses with higher resilience level are able to maintain ethical principle as they are not easily overwhelmed by the emotional demands of ethical decision making. Leadership should also promote healthy coping by providing a supportive culture that will allow a nurse to get help and focus on their own health and well-being.

· Understanding and inclusion of the patient: Effective communication is keys to sharing and allowing the patient and their families to know the ethical foundations of the nursing choices in the times of dilemma. Engaging patients and their families in the decision-making process as a way of avoiding such differences and ensuring that both the patient as well as the family has regards to the other. With patients knowledgeable and engaged, nurses can then steer a patient’s care in a direction that corresponds with his /her pro-attitudes to minimize conflict between ethics principles and patient expectations. It also enhances confidence and trust in the nurses and at the same time cements the main principle of ethical transparency among the professional medical personnel.

· Promoting for ethical policies and resources: Due to pressure from their workplaces and other regulated health care facilities, institutional rules and regulations such as resource erosion would make it difficult for nurses to uphold integrity. These are some of the limitations of the nursing profession that can be addressed through advocacy since; nurses can cooperate in advocating for good policies to be put in practice. The profession can participate in advocacy activities either as individuals or associations to lobby healthcare managers and policy makers for enhanced working conditions, staffing and necessary equipment’s. In this regard, nurses play a critical role of supporting an ethically supportive environment that leads to reduction of ethical issues occasioned by scarcity of resources.

· Professional support and peer support: Positive changes in nurses’ professional quality with regard to integrity in ethical dilemmas: the role of mentorship and peer support programs. Preceptors, which may not always be another doctoral student, can offer advice, explain from own ethical dilemmas and recommend ways of handling some of the dilemmas. Employing peer support makes them to receive input from their fellow nurses who can discuss the issues, get information and get solutions from persons in similar working conditions and environments. Partnership structures of support reduce a sense of loneliness and foster solidarity, enabling nurses embody their values while efficiently backed.

· Fostering ethical culture in an institution: This paper posits that the culture within a given healthcare institution determines the extent to which the nurses can uphold the professional integrity. Promoting the ethical culture in patient care environment, including ethics knowledge, staff communication during decision making and leaders supporting ethical practice helps the nurses to remain committed to ethical values. To foster ethical standard among employees, healthcare institutions should set clear ethical policies and give incentive to ethical behavior while penalizing unethical behaviors. Nurses who practice in an ethical culture feel backed up in ethical actions do because the culture fosters ethical compliance.

· Revisiting and reaffirmation of professional ethical standards: Nurses continue to refer to professional codes of ethics and refer to them more frequently than before in order to keep up with changing ethics. ICN and NMCN for example, have provided codes of conduct that require adherence in various clinical contexts to uphold independence. More often, fundamental professional codes can be reiterated through workshops or discussion groups to guarantee that each nursing understands and embraces these professional codes. As such, these institutions not only serve as a constant recall of the ethical standards within the profession but also open floor for the implementation of these codes catered to real life scenarios.

4. Conclusion

The principles of professional integrity and ethical practice are inherent in the nurse and are often tested through the difficult decision-making challenges Health care provides come across more so where there lacked resources and differing cultural practices from one country to another for instance Nigeria. International codes of ethics include the one from the International Council of Nurses (ICN) and Nursing and Midwifery Council of Nigeria (NMCN); affect ethical practice of nursing. These codes give guidelines on professional conduct, promote professionalism, increase responsibility and remind professionals of the professional virtues such as care, courtesy and honesty. Research findings indicate that the willingness of nurses to use these codes of ethics is associated with improved ethical Reasoning and self-efficacy in managing multifaceted ethical dilemmas therefore leading to improvements in patient centered care and increased patient trust.

Nevertheless, these codes are useful for implementing the various codes in Nigeria, but the following challenges exist. Shortage of ethics education, shortage of alternative resources and large numbers of patients can restrain the ethical principles of practice for nurses. Lack of ethics education and courses, along with lower application and compliance with codes make them less effective, as nurses may do not have enough knowledge, means and reinforcement to make ethical choices in care constantly. When resources are scarce and there are no good supporting policies in the institutions, nurses are forced to work unethically undermining their professional practice and also the patient care.

To overcome these challenges more effort should be made in the ethical education of individuals, providing tools for helping in decision making and ensuring the organizational support for ethical programs. Ethics awareness session, ethics help desk, the facility of ethics rounds and well-developed supporters’ networks allow the nurses handling ethical issues professionally. However, promoting policy, adequate funding and ethic-friendly environment in the health facilities would greatly bolster formulation and enforcement of the professional ethic codes as well as genuinely assist the nurses to make the best ethic decisions out-of-patients’ needs.

5. Acknowledgements

The authors appreciate Dr. Mrs. Bassey I for her supervisory role.

6. Competing Interests

The authors declare that they do not have any conflicts of interest.

7. Ethics Approval and Consent to Participate

Ethical clearance for this study was obtained from the Research and Ethics Committee of Igbenidion University.

8. Funding

The authors declare no external fund was received for this study.

9. References

1. Bishop S. Ethical principles in nursing: A guide for professional practice. Nursing Standards Today, 2020;15(4): 78-90.
2. Alavijeh HM, Ebadi A, Sokhanvar M. Ethical issues in patient autonomy and informed consent: Implications for clinical practice. Journal of Nursing Ethics, 2021;28(3): 432-441.
3. Okeke C, Nwogu J, Ekong R. Ethical issues in resource-constrained settings: A Nigerian perspective on nursing. Health Policy and Ethics, 2022;18(2): 89-101.
4. Okeafor I, Ejiofor T, Olowolabi A. Ethical autonomy and limitations in Nigerian nursing: A review of institutional impacts. Healthcare Ethics Review, 2023;26(5): 123-134.
5. Ogunsola F, Ajiboye K. Common ethical dilemmas in Nigerian nursing practice: A survey of registered nurses. West African Nursing Journal, 2023;32(4): 456-470.
6. Osinaike D, Agbaje A. Ethical decision-making in Nigerian nursing: Strategies and frameworks. Journal of African Nursing Studies, 2021;14(1): 21-33.
7. Nurses ICO. International Council of Nurses (ICN). Code of Ethics for Nurses, 2023.
8. Afolabi M, Oladapo M. Ethical conduct in nursing practice: Perspectives from Nigerian healthcare practitioners. Journal of Nursing Ethics, 2020;12(2): 214-224.
9. Ifejika M, Omole J. Navigating ethical challenges in Nigerian healthcare: A focus on nursing integrity. African Journal of Nursing Practice, 2024;19(3): 299-307.
10. Rainer J, Schneider JK, Lorenz RA. Ethical dilemmas in nursing: Addressing the complex challenges of healthcare Journal of Nursing Scholarship, 2018;50(5): 502-510.
11. Okeke C, Onwuka D. Ethical dilemmas in low-resource healthcare settings: Experiences from Nigerian nurses. African Journal of Nursing and Midwifery, 2021;23(2): 112-120.
12. Epstein EG, Whitehead PB, Prompahakul C, et al. Moral distress, ethics and resilience in nursing: Implications for clinical practice and healthcare outcomes. Journal of Nursing Management, 2021;29(4): 575-583.
13. Hassan IA, Olawale RA. The ethics of confidentiality in nursing: Challenges and implications in Nigerian healthcare. International Journal of Nursing Practice, 2022;28(2): 12968.
14. Kang Y, Ju Y, Lee E. Ethical climate, nurse burnout and patient outcomes: A study in hospital settings. Journal of Nursing Ethics, 2023;30(1): 112-123.
15. Udo B, Nworie E, Obasi C. Scarcity of resources and ethical decision-making in Nigerian nursing practice. African Journal of Nursing and Midwifery, 2020;22(3): 134-141.
16. Rueda GN, Valcárcel CA, Cobo SC, et al. Palliative care in nursing: Ethical tensions and moral distress. BMC Palliative Care, 2019;18(1): 72.
17. Musa K, Lawal A. Patient perceptions of ethical standards in Nigerian healthcare: The role of professional codes of conduct. International Journal of Healthcare Ethics, 2022;18(1): 45-60.
18. Adeoye A, Akanbi T. The role of professional codes of ethics in enhancing nursing standards in Nigeria. Journal of Nursing Ethics, 2019;16(4): 342-353.
19. Edeh C, Chima M. Strengthening the implementation of codes of ethics in Nigerian healthcare: A review of institutional strategies. West African Journal of Nursing, 2020;25(3): 198-208.
20. Agwu P, Okechukwu J. Barriers to implementing ethical codes in Nigerian healthcare settings. African Journal of Nursing Practice, 2021;13(2): 215-227.
21. Hassan I, Alabi S. Influence of the ICN Code of Ethics on Nigerian nurses’ ethical awareness and patient-centered care. Global Journal of Nursing Studies, 2021;9(1): 78-90.