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The Relationship Between Ethical Courage and Moral Distress in Nursing Students of Mashhad University of Medical Sciences in 2023
Sepide Ghavidel, Sajedeh Ghaani, Seyedehghodsieh Bahreinitousi, Mohaddeseh Mohsenpour,
Volume 17, Issue 0 (12-2024)
Abstract
Moral distress is a common topic in medical ethics, referring to a state where individuals, despite possessing knowledge and the ability to act ethically, are unable to perform the right ethical actions due to external constraints. Ethical courage is a crucial virtue for conscientious performance by healthcare providers, particularly nurses and nursing students. It facilitates the delivery of nursing care and is especially important in today’s healthcare environment, where factors such as increased patient awareness, evolving health needs, social justice issues, and access to healthcare services have contributed to heightened levels of moral distress among nurses and nursing students. This study aims to investigate the relationship between ethical courage and moral distress in nursing students. This descriptive, cross-sectional study was conducted in 2023 in Mashhad, Iran. The study population consisted of third-semester nursing students at Mashhad University of Medical Sciences. A total of 40 third-semester nursing students, both male and female, participated in the study. Data were collected using two questionnaires: the Moral Distress Scale (Corley) and the Ethical Courage Questionnaire (designed by Sekerka and colleagues). The data were analyzed using SPSS version 25, employing descriptive statistics and Pearson correlation tests. The majority of the students were female (51.2%), while 36.6% were male. The average age of the participants was 21.14 years. Among the students, 75.6% were single, and 4.9% were married. The findings revealed a weak, non-significant negative correlation between moral distress and ethical courage (r = -0.055, p > 0.05). The average moral distress score was 75.34 ± 10.81 (range: 12–16), while the average ethical courage score was 85 ± 9.33 (range: 60–103). The study found a weak, non-significant negative correlation between moral distress and ethical courage among nursing students. Based on these findings, it is recommended to implement workshops focused on ethical motivation and educational programs designed to reduce moral distress and enhance ethical courage among nursing students. Additionally, the non-significant correlation may be attributed to the small sample size. Therefore, future studies with larger sample sizes are suggested to validate these findings.

The Heart of Healing: How Narrative Medicine Deepens Nursing – A Systematic Review of Clinical Trials
Negin Farid, Nazanin Nazari, Narges Jafar Malek,
Volume 17, Issue 0 (12-2024)
Abstract
Narrative medicine has emerged as a transformative model in healthcare, emphasizing the role of patient stories in enhancing the quality of care. By recognizing the individuality of each patient's narrative—shaped by personal experiences and cultural contexts—this approach fosters deeper connections between caregivers and patients. Despite its growing recognition, narrative medicine remains underutilized in nursing, where the psychological and emotional dimensions of care are often overlooked. This systematic review examines clinical trials that investigate the integration of narrative practices into nursing education and care delivery, with the aim of assessing their clinical and educational impact. A comprehensive literature search was conducted across international and national databases including PubMed, Scopus, Web of Science, SID, Noor, Magiran, Irandoc, and Google Scholar, using relevant English and Persian keywords. Eligible studies were clinical trials published in English or Persian. After removing duplicates and applying inclusion criteria, eight studies were included for analysis. Selection and data extraction were conducted independently by two researchers, with discrepancies resolved by a third reviewer. The review adhered to PRISMA guidelines and ethical standards were maintained throughout. The studies, published between 2018 and 2024, involved nursing students (mean age 17.96–21.5 years), patients with lung tumors (mean age 49.31 years), and elderly patients (aged 61–89 years) with complex fractures. Findings were synthesized into three main domains. First, narrative-based education significantly enhanced empathy and academic performance among nursing students. Second, the implementation of narrative approaches led to measurable reductions in anxiety and depression among patients, particularly those with lung tumors. Third, improvements were observed in overall quality of life, pain management, and cognitive function, especially in elderly patients. These findings suggest that narrative education plays a critical role in improving both clinical and psychological outcomes. Narrative-based interventions enhance the empathetic capacity of nurses and contribute to higher standards of patient care. Incorporating narrative approaches into nursing curricula and clinical practice is recommended as a strategy to foster more holistic and human-centered care.

The Importance of Patient Autonomy in Home Care: A Systematic Review
Mohammadreza Jalilfar, Hedayat Jafari, Fatemeh Roudi, Seyed Tohid Hoseini, Soodabeh Eslami, Seyed Mohammad Mirshafiei,
Volume 17, Issue 0 (12-2024)
Abstract
With the increasing need for home nursing care, patient autonomy emerges as a crucial ethical principle in delivering care services. Therefore, this study aimed to investigate the importance of autonomy and individual independence in home-based patient care. In this systematic review, articles from PubMed, Scopus, ScienceDirect, Magiran databases, and Google Scholar search engine, published within the last 10 years, were used to search for articles related to autonomy and independence in home nursing care. The keywords used in the search were: "patient autonomy", "home nursing care", "nursing ethics" and "autonomy in nursing home care".  After reviewing and filtering the articles based on the study's objectives, 20 articles related to autonomy in home nursing care were included in this systematic review. The findings of these studies indicated that various factors can influence patient autonomy at home-care, including: · Individual factors: age, gender, physical and mental health status of the patient; · Family factors: family support, family relationships, family culture; · Social factors: social support, access to social resources; · Organizational factors: care policies, organizational structure, organizational culture.  Considering these findings and their comparisons, it can be concluded that to promote patient autonomy at home, all the mentioned factors should be considered. Some of the suggested solutions to promote patient autonomy are: · Educating the patient and family about patient autonomy; · Strengthening family support for the patient; · Providing social support services to the patient; · Developing care policies that support patient autonomy; · Improving organizational structure and culture.  Patient autonomy is one of the essential ethical principles in home nursing care. Considering the factors affecting patient's autonomy, comprehensive solutions should be considered to promote it. Patient and family education, strengthening family support, providing social support services  and improving organizational structure and culture are among the effective solutions in this field.

Defenders without a Defense: Factors Associated with Ethical Conflict in the Context of Nursing Care
Ebrahim Falahati, Mousa Alavi, Mohsen Shahriari,
Volume 17, Issue 0 (12-2024)
Abstract
While ethical conflict is an internal and individual experience, it is significantly influenced by environmental factors and variables. It describes a situation characterized by a discrepancy or conflict between the ethical values of caregivers, between caregivers and patients, or within the individual caregiver regarding the morally right course of action, often leading to ambiguity regarding duties and obligations. This research aimed to elucidate the factors associated with ethical conflict within the nursing context. This qualitative study employed conventional content analysis. Participants included 27 nurses working in various clinical departments, including emergency, intensive care, internal medicine, and surgery. Data were collected through in-depth semi-structured individual interviews conducted after obtaining written informed consent. Data analysis was performed using MAXQDA version 20 software, adhering to Granheim and Lundman's approach. To enhance the rigor of the study, the criteria of credibility, confirmability, dependability, and transferability proposed by Lincoln and Guba were applied. Decision-making challenges within the context of care emerged as a central theme. Several factors were identified as contributing to ethical conflict in nursing care, including disrupted relationships, inefficient management systems, physician prioritization, conflicts of interest, legal constraints, a negative ethical climate, and insufficient resources. Nurses, as primary patient advocates, are consistently exposed to various ethical conflicts within their practice. This study highlights the critical importance of addressing decision-making challenges within the context of care for policymakers within the healthcare system. Reducing these conflicts is crucial for improving the quality of nursing care.

Ethical Challenges in ICU
Atefe Salimi Akinabadi, Maryam Jahangiri, Mitra Zandi,
Volume 17, Issue 0 (12-2024)
Abstract
The intensive care unit (ICU) is a complex environment where diverse healthcare professionals collaborate to care for critically ill patients. Evidence suggests that ethical issues or conflicts are prevalent and can negatively impact ICU care. This research aimed to investigate the ethical challenges encountered by critical care nurses in clinical practice. Using the PRISMA guideline, relevant studies were identified through searches of the PubMed, Scopus, and Web of Science databases from 2015-2024 using the following MeSH terms: "ethics," "ethical challenges," "nursing," and "intensive care unit." Only English-language manuscripts were included. Ethical challenges in the ICU were categorized as follows:
1. Internal Constraints: Lack of self-confidence, fear, maladaptive coping mechanisms, religious conflicts, and spiritual conflicts.
2. External Constraints: Lack of collegiality, hierarchical structures, poor communication, inadequate staffing, restrictive policies, shortages of full-time critical care physicians and nurses, and working with incompetent staff.
3. Clinical Situations: Futile treatment, inappropriate care, inadequate pain relief, hastening death, providing false hope, end-of-life care decisions, decisions about life-sustaining treatments, and the use of physical restraints.
Recognizing ethical challenges in the ICU is crucial. It enables the implementation of measures to minimize ethical conflict, design effective strategies for preventing ethical dilemmas, and improve the nursing work environment.

Ethical Challenges in Nursing and Midwifery Schools from the Perspective of Faculty Members: A Qualitative Study
Mahrokh Keshvari, Negar Farajzadeh, Mohsen Shahriari, Mohammad Azadmanesh, Aliasghar Jamalinasab,
Volume 17, Issue 0 (12-2024)
Abstract
Nursing and midwifery professors play a crucial role in transmitting societal norms, providing cultural experiences, shaping students' behavior, beliefs, and attitudes, and cultivating moral virtues. As significant influencers on students' moral development during their academic journey, careful attention to this aspect is essential. This study aimed to elucidate the ethical challenges encountered by faculty members within the Faculty of Nursing and Midwifery. This qualitative study employed content analysis. Purposive sampling was utilized to select 23 faculty members from the Faculty of Nursing and Midwifery at Isfahan University of Medical Sciences, with data collection spanning eight months. Data were collected through semi-structured interviews and analyzed using conventional qualitative content analysis. Continuous and comparative data analysis revealed three primary categories of ethical challenges perceived by faculty members: discrimination and injustice, low professional commitment, and unprofessional behavior.
· Discrimination and injustice: This category encompassed three subcategories: disparities in rule implementation across faculties and groups, unfair financial compensation, and inequitable distribution of academic units and points.
· Low professional commitment: This category included two subcategories: educational underselling and non-adherence to established rules by faculty members.
· Unprofessional behavior: This category comprised two subcategories: unhealthy competition among faculty members and inappropriate student evaluations.
The experiences of faculty members in this study highlighted the presence of numerous challenges, with ethical issues significantly impacting their performance and motivation. The identified ethical challenges primarily revolved around discrimination and injustice, low professional commitment, and unprofessional behavior. Given the pivotal role of faculty members in teaching ethical principles and actively addressing ethical challenges, it is imperative for administrators and officials to acknowledge these concerns and implement strategies to mitigate these issues.
Examination of Nursing Students' Moral Sensitivity and Its Relationship with Demographic Characteristics
Maryam Sina, Zahra Keshtkaran, Zinat Mohebbi, Naeimehossadat Asmarian,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses, as the largest healthcare provider group, play a crucial role in patient care and treatment teams. To provide professional and appropriate care, nursing students must possess both clinical and moral competencies. Moral sensitivity, defined as the ability to recognize and understand moral situations, is paramount. It fosters trust and responsiveness to individual patient needs while equipping nurses to navigate ethical challenges within clinical settings. This study aimed to assess the moral sensitivity of nursing students and investigate its relationship with demographic characteristics. This descriptive-cross-sectional study involved 112 third- and fourth-year nursing students. Data were collected using demographic questionnaires and Lutzen's moral sensitivity scale. Data analysis was performed using SPSS version 23, employing descriptive and analytical statistical tests. The highest mean score for moral sensitivity was observed in the area of "honesty in decision-making" (14.71 ± 6.25), while the lowest mean was found in the area of "professional knowledge" (3.70 ± 2.12). The overall mean score for moral sensitivity was 15.87 ± 8.54, indicating a moderate level. Analysis of the relationship between demographic variables, including age, GPA, gender, marital status, living situation, current semester, family financial status, and parental education, revealed a significant positive correlation between moral sensitivity and family economic status only in the area of "experience with moral issues" (P=0.046). The findings of this study underscore the critical need for the development and implementation of structured programs designed to enhance the moral sensitivity of nursing students. Furthermore, this study highlights the importance of considering influential social factors, such as economic conditions, in fostering moral experiences and strengthening ethical sensitivity.

Explaining Nursing Students’ Experiences of Professional Ethics in Relation to Psychiatric Clients: an Analysis Based on Narrative Writing-Reflection
Mina Gaeeni, Hamid Asayesh, Ahmad Parizad, Zahra Abedini,
Volume 17, Issue 0 (12-2024)
Abstract
Clinical education constitutes the cornerstone of nursing education. Enhancing students' theoretical and practical knowledge within the psychiatric department is crucial for improving their attitudes, acceptance, and delivery of care. The outcomes of effective clinical learning encompass the development and refinement of professional competencies, including communication and professional ethics, the cultivation of critical thinking for clinical judgment and decision-making, the enhancement of ethical sensitivity, and the fostering of effective team and group performance. Recognizing the significance of these factors, this study aimed to "explain the experiences of nursing students based on narrative writing-reflection during their first encounter with psychiatric clients." This qualitative study was conducted during the psychiatric nursing internship at the Faculty of Nursing, Qom University of Medical Sciences, over two consecutive semesters. Purposive sampling was employed, and data were collected through 10 semi-structured individual interviews and 2 face-to-face and virtual focus groups (n=5 per group). Data collection continued until data saturation was reached. Data analysis was conducted using a qualitative content analysis approach with the assistance of MAXQDA20 software. The clinical experiences of students during their initial psychiatric nursing training course, as reflected in their narrative writing-reflections, revealed a primary theme: "encouraging ethical and spiritual communication in nursing." This overarching theme encompassed four sub-themes: "enhancing empathetic communication," "enhancing ethical sensitivity," "respecting the dignity of clients," and "listening to the voice of clients' feelings." The experiences gained through the reflective method within the clinical education setting, particularly in specialized clinical environments such as psychiatric wards and during initial encounters with clients in these departments, can provide valuable insights into students' attitudes and perspectives towards these clients and their families. These rich experiences can be effectively utilized to cultivate and strengthen communication and professional ethics among medical science students.

Investigating the Relationship Between Moral Intelligence and Clinical Competence of Nurses and Nursing Students: A Systematic Review
Zahra Abdollahi, Marzieh Barahooei Noori, Mohammad Hossein Khani, Mohammad Hossein Taklif, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Moral intelligence encompasses an individual's ability to discern right from wrong, possess ethical values, and demonstrate ethical behavior in practice. Clinical competence, a crucial aspect of nursing practice, encompasses a combination of knowledge, skills, and attitudes, including adherence to ethical principles. This systematic review aimed to investigate the relationship between moral intelligence and clinical competence among nurses and nursing students. A comprehensive literature search was conducted using keywords related to "moral intelligence," "clinical competence," "nurses," and "nursing students" in major international databases, including Web of Science Core Collection, PubMed/Medline, Scopus, and Google Scholar, as well as national databases such as Irandoc, SID, and Magiran. The search included publications in Persian and English with no time limitations. After removing duplicates and screening the initial 150 identified studies, five studies met the inclusion criteria. Ethical considerations, including minimizing bias in the selection, extraction, and analysis of evidence, were adhered to throughout the review process. The abstract adheres to PRISMA guidelines for reporting systematic reviews. The review revealed a significant positive correlation between moral intelligence and clinical competence across various dimensions. Studies demonstrated that higher levels of moral intelligence were associated with improved clinical competence, including ethical reasoning and clinical self-efficacy. Factors such as age, work experience, educational status, and individual rank were found to influence this relationship. Additionally, some studies indicated that moral intelligence could predict clinical competence scores, while others demonstrated that it could be a significant predictor of clinical competence alongside other factors such as Grade Point Average (GPA). This systematic review provides evidence for a significant positive relationship between moral intelligence and clinical competence among nurses and nursing students. Enhancing moral intelligence through targeted educational interventions can contribute to improved clinical competence and ultimately enhance the quality of patient care. Future research should focus on developing and evaluating educational programs designed to enhance moral intelligence in nursing education and practice.

Investigating the Ethical Challenges of Nurses in End-of-Life Care at Home for Elderly Patients: A Review Study
Nayereh Baghcheghi, Zahra Maddah,
Volume 17, Issue 0 (12-2024)
Abstract
With the increasing elderly population and the growing demand for home healthcare and end-of-life care services, nurses are facing expanded duties and responsibilities. This intensification of responsibilities can expose them to significant ethical challenges. This study aimed to investigate the ethical issues nurses encounter in providing end-of-life care at home for elderly patients. This review study involved a comprehensive search of databases including PubMed (Medline), Google Scholar, ISI Scopus, ProQuest, Science Direct, SID, IranDoc, IranMedex, and Magiran. The keywords used were: nursing ethics, ethical challenges, end-of-life care, and home care, along with their Persian equivalents. The search covered literature published between 2000 and 2024. The review identified several prominent ethical challenges faced by nurses in home-based end-of-life care, including: lack of attention to patients’ rights and independence, disrespect for the dignity of elderly patients, inadequate empathetic care, poor communication, and unsafe home environments for nurses. These challenges may lead to moral distress, as well as psychological and emotional consequences for both the care providers and the elderly patients. Given the serious ethical challenges nurses face in end-of-life home care for the elderly, it is essential for them to be well-versed in ethical principles relevant to this context. Enhancing awareness and competence in ethical practices can help nurses uphold patient rights, promote autonomy, and provide high-quality, compassionate care through effective communication and support.

Strategies for the Promotion and Development of Socio-Cultural Indicators Affecting Professional Commitment in Nursing Students
Mandana Arash, Nadergholi Ghourchian, Parivash Jafari, Akhtar Jamali ,
Volume 17, Issue 0 (12-2024)
Abstract
Professional commitment is a key indicator of success in the nursing profession. Nursing schools play a critical role in fostering this commitment by instilling the values and responsibilities associated with the profession. Developing a culture of commitment and integrating it as a societal value is essential for cultivating professional behavior in students. This study aimed to identify strategies for enhancing and developing socio-cultural factors that influence professional commitment among nursing students. This applied research employed a qualitative approach. Twenty professional experts were selected through purposive sampling in 2021. Data were collected using semi-structured interviews, guided by the principle of theoretical saturation, and analyzed using content analysis. Six major components were identified as influential strategies: 1. Participation of communication media in the cultural and scientific advancement of the profession; 2. Attention to cultural differences between universities and healthcare centers; 3. Promotion of a culture of commitment in universities and clinical settings; 4. Attention to the alignment between individual culture and professional culture; 5. Attention to ensuring the profession benefits from social support; 6. Attention to the promotion of a culture of work and effort in society. These components were reflected in 20 specific indicators, including: raising awareness, instilling a sense of need, fostering concern among academic communities, educating nurses, resolving cultural conflicts, creating conducive educational environments, employing committed faculty, embedding commitment in the culture and as a duty, aligning individual and professional cultures, promoting social prestige and recognition of the profession, addressing local cultural aspects and gender roles, and enhancing flexibility and participation in social interactions.
The development of professional commitment in nursing students can be significantly enhanced through the promotion of ethical and professional principles and the establishment of a supportive socio-cultural environment. Embedding professional commitment within cultural frameworks contributes to students’ sense of responsibility and its sustainability in professional practice.
 

Ethical Challenges of Nurses in Caring for Patients with Chronic Mental Illness
Alireza Zare, Mohammad Hossein Taklif, Alireza Javid, Zahra Amadeh, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses, as key members of the healthcare team, face complex ethical issues when caring for patients with chronic mental illnesses. These challenges include maintaining confidentiality, obtaining informed consent from patients with limited cognitive abilities, managing conflicts between patient rights and safety requirements, and addressing social stigma. Inadequate attention to these challenges may lead to reduced care quality and psychological stress for nurses. A better understanding of these challenges and the provision of appropriate solutions is essential. This study was conducted through a simple review approach. A comprehensive search was first conducted in PubMed, Scopus, PsycINFO, and Google Scholar databases. Combined keywords such as "ethical challenges," "nursing," "chronic mental illness patients," and "ethical care" were used. Inclusion criteria included studies published in English and Persian from 2010 to 2023, including research, review, and qualitative articles related to the topic. A total of 150 articles were identified, and after evaluating their quality and relevance, 30 articles were selected for final analysis. Data were analyzed using thematic and comparative analysis methods. The findings revealed that nurses face multiple challenges, including maintaining confidentiality when interacting with families, obtaining informed consent from patients with cognitive disorders, and managing ethical conflicts between patient safety and individual freedom. Additionally, a lack of specialized ethical training, the absence of clear protocols, and the pressure from the social stigma of patients were identified as key challenges. The ethical challenges faced by nurses in caring for patients with chronic mental illness require special attention from relevant organizations. Providing continuous education, developing ethical guidelines, and creating psychological and legal support can help mitigate these challenges. Further studies on practical, experience-based solutions to address these issues are recommended.

Nursing Ethics in the Care of Elderly Patients: A Review of Challenges and Solutions
Alireza Zare, Mohammad Hossein Taklif, Alireza Javid, Zahra Amadeh, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
As the global elderly population continues to rise, nursing care for this demographic faces increasing ethical challenges. The elderly are particularly vulnerable, requiring specialized care that addresses their physical, psychological, and social needs. However, these needs often present ethical dilemmas, including issues related to autonomy, informed consent, fairness in resource allocation, and managing conflicts between patients and their families. This systematic review aims to identify the ethical challenges nurses face in caring for elderly patients and to propose solutions that enhance the quality of care. A comprehensive search was conducted across several reputable databases, including PubMed, Scopus, CINAHL, and Google Scholar, using keywords such as "nursing ethics", "elderly", "ethical challenges", and "ethical care". Articles published between 2010 and 2023 in English and Persian were considered for inclusion. After an initial screening, 40 eligible articles were selected for final analysis, and thematic analysis was used to interpret the data. The findings reveal several key ethical challenges for nurses in elderly care, including respecting patient autonomy, navigating decision-making processes in cases of cognitive decline, ensuring confidentiality, and managing family pressures. Additional difficulties include resource shortages, high workload, and limited access to ethics training. Proposed solutions to address these challenges include continuous ethics education, the development of comprehensive ethics protocols, and the formation of interdisciplinary teams to facilitate more informed decision-making. Addressing ethical challenges in elderly care requires robust planning and action from health systems. By establishing clear ethical guidelines, promoting ongoing education, and fostering a supportive work environment, the quality of care for elderly patients can be significantly improved. Further research should evaluate the effectiveness of these strategies in mitigating ethical issues within nursing practice.

Nurse's Ethical Challenges During Global Crises: War and Beyond
Fatemeh Roudi, Hedayat Jafari, Mohammadreza Jalilfar, Seyed Mohammad Mirshafiei, Seyed Tohid Hoseini, Soodabeh Eslami,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses are critical healthcare providers during global crises, particularly in situations of armed conflict and war, where they face unique and often overwhelming ethical challenges. These professionals are tasked with making immediate and difficult decisions under extreme conditions. This study aims to thoroughly examine the ethical challenges encountered by nurses during global crises, with a particular focus on armed conflicts and wars. This systematic review analyzed articles sourced from PubMed, Scopus, ScienceDirect, Magiran, and Google Scholar databases, using the following search terms: "nursing ethics," "war," "global crises," "ethical considerations in nursing during war," and "nursing ethics in armed conflicts." Following a thorough review and filtering process based on the study's objectives, seven articles were selected for inclusion. The findings highlight several ethical challenges faced by nurses during wartime. These challenges include: allocating limited resources under dire circumstances, providing care to both combatants and civilians without bias, maintaining patient confidentiality while cooperating with military authorities, and delivering care in hazardous and unpredictable environments. The ethical issues nurses encounter in global crises, particularly in war, include: 1) the tension between professional duty and political or military affiliations, 2) the ethical dilemma of allocating scarce resources in critical conditions, 3) the decision of which patients should be prioritized for treatment, and 4) the significant risks to life involved in providing care in conflict zones. Nursing care during global crises, especially in wartime, presents profound ethical dilemmas that demand rapid and sound decision-making. Adequate training in nursing ethics tailored to wartime conditions, as well as robust support for nurses in these high-pressure environments, are critical to addressing these challenges effectively.

The Strategy of Nursing Managers in Ethical Decision-Making: A Qualitative Content Analysis
Mostafa Roshanzadeh, Ali Taj, Somayeh Mohammadi,
Volume 17, Issue 1 (3-2024)
Abstract
In the current health system conditions, the strategies adopted by nursing managers in their ethical decision-making can lead to different results for patients, nurses, and health systems. Therefore, the present study aimed to explain ethical decision-making strategies implemented by nursing managers. The present study was conducted using qualitative content analysis in 2022 at Shahrekord University of Medical Sciences. A total of 18 nursing managers were selected through purposive sampling and were interviewed using in-depth unstructured individual interviews. Data were analyzed using the method proposed by Graneheim and Lundman. The results revealed one main category (human-centeredness) and three subcategories (customer-centeredness, valuing employees’ dignity, and the conflict between respecting the rights of patients and employees and adhering to organizational policies). Nursing managers attempted to make their ethical decisions based on the principle of humanism by using customer-centeredness strategies, valuing employees’ dignity, and prioritizing the rights of individuals and employees over organizational rules. The results of the present study showed nursing managers make decisions in line with respecting the rights of patients and employees. However, sometimes these decisions conflict with the interests of organizations. In this regard, the existing obstacles that create the conditions for such conflicts should be identified. Increasing organizational commitment in managers can also be effective in decisions that benefit different groups of customers, personnel, and health organizations.

The Relationship Between Organizational Support and Compassion Fatigue in Emergency Department Nurses: A Cross-Sectional Study
Reza Abdollahi, Aynaz Bagherzadi, Mrs Mir Hossein Ahnmadi, Mr Yousef Mohammadpour,
Volume 17, Issue 1 (3-2024)
Abstract
Organizational support is a key factor that may influence and moderate compassion fatigue among nurses. Therefore, this descriptive-analytical study aimed to explore the relationship between organizational support and compassion fatigue in emergency department nurses. The research population consisted of all nurses in the emergency departments of educational hospitals in Urmia, Iran in 2024. A total of 150 nurses were randomly selected based on the inclusion criteria for the study. Data were collected through three questionnaires including a demographic information form, Eisenberger’s Organizational Support Scale, and Figley’s Compassion Fatigue Scale. Data analysis was performed using SPSS software version 15. The results indicated a significant negative relationship between organizational support and compassion fatigue (r=0.45 and p< 0.05). The mean score for organizational support among emergency department nurses was 21.13± 0.54. Moreover, the mean scores for compassion fatigue, compassion satisfaction, and secondary traumatic stress were 27.73 ± 8.54, 38.73 ± 1.81, and 28.45 ± 4.82, respectively. The overall mean score for the nurses' job quality was 31.93 ± 4.32. Given the results of the present study and the role of organizational support in reducing compassion fatigue among nurses, it is crucial for nursing managers and policymakers to take certain measures such as improving working conditions and addressing the needs of nurses to enhance organizational support, consequently helping to reduce and mitigate compassion fatigue among nurses.

Nursing Professional Ethics in Clinical Services: A Review of Studies in Iran
Samira Orujlu, Arezoo Ghavi, Leila Valizadeh, Vahid Zamanzadeh, Sadat Seyed Bagher Maddah, Parvaneh Aghajari,
Volume 18, Issue 1 (3-2025)
Abstract
Improving the quality of nursing services and enhancing ethical decision-making in clinical settings require greater attention to professional ethics. This study aimed to review and synthesize existing research on professional ethics in nursing in Iran, to organize, plan, and establish knowledge- and evidence-based decision-making, and also provide strategies for ethics-centered nursing in Iran. Iranian studies on ethics were reviewed without time limitations until June 22, 2023. Database search was conducted using keywords including "Nurse", "Nursing", "Ethics",  "Professional ethics", "Nursing Care", "Codes of Ethics", "Patient Rights", "Conscience", and "Iran", as well as their Persian equivalents, combined with "AND" or "OR" operators. The included studies were analyzed utilizing the five-stage integrative review method proposed by Whittemore and Knafl. A total of 103 Persian and 59 English articles were reviewed. The results were organized into two main categories: achievements of professional ethics (encompassing knowledge, attitudes, and professional performance of nurses; nurses’ experiences with ethical care; positive outcomes of professional nursing ethics education; and the convergence of spiritual health with adherence to professional ethics and the need for an Islamic approach) and factors influencing ethical performance (including facilitators of ethical performance and barriers to adherence to professional ethics). Based on the findings, it is recommended that nursing care protocols and standards be developed, and various educational programs be conducted, including those on ethical care in emergencies and disasters, emotional and spiritual intelligence, training for clinical nursing managers, and the application of creative strategies for teaching clinical professional ethics.

Comparing the Effectiveness of Professional Ethics Education Via Mobile Application and Webinar on Maintaining Patient Dignity from the Perspective of Nursing Students
Mohsen Shahriari, Maryam Sadat Hashemi, Arash Najimi, Mohammad Zare Reshkoieh,
Volume 18, Issue 1 (3-2025)
Abstract
The fundamental nature of nursing care lies in maintaining patients’ human dignity. Protecting the dignity and high value of humanity is the focus of the nursing profession. This study aimed to compare the effectiveness of mobile application-based and webinar-based professional ethics education on maintaining patient dignity among nursing students. This was a quasi-experimental study with a two-group pretest-posttest design involving 90 undergraduate nursing students. One group received professional ethics education via webinars, while the other received training through a mobile application-based program. Data were collected using a demographic information form and a questionnaire assessing nursing students’ views on maintaining patient dignity. The findings showed that before training, the mean total scores for human dignity were 99.96 ± 17.43 in the webinar group and 99.59 ± 16.28 in the mobile application group, with no statistically significant difference (p=0.62). After training, the mean human dignity score was significantly higher in the mobile application group (111.15±14.69) than in the webinar group (104.34 ± 15.38), and this difference was statistically significant (p=0.02). The findings indicated that professional ethics education delivered via a mobile application was associated with a greater improvement in nursing students’ views on patient dignity compared to webinar-based education. Mobile-based education offers a self-directed, flexible learning method, enabling students to have continuous access to educational content without time or place restrictions. It is recommended that medical universities in Iran consider developing and integrating educational applications into their curricula.

The Effect of An Intervention Based on the Knowledge-to-Action Model on Moral Distress in Critical Care Nurses
Mohammadmahdi Pazhavand, Maasoumeh Barkhordari-Sharifabad, Khadijeh Nasiriani,
Volume 18, Issue 1 (3-2025)
Abstract
Identifying an effective coping strategy for moral distress, as an important and common phenomenon among intensive care unit nurses, seems essential. The knowledge-to-action model aims to identify effective methods for implementing evidence into clinical practice. The present study sought to determine the effect of an intervention based on the knowledge-to-action model on moral distress among nurses working in intensive care units. This was an experimental study, and the statistical population included nurses working in the intensive care units of Namazi Hospital in Shiraz, Iran. A total of 100 eligible nurses were selected through convenience sampling and then randomly assigned to intervention and control groups. For the intervention group, the knowledge-to-action model was implemented. Data were collected using the Hamric Moral Distress Scale before and one month after the intervention. Both groups completed the questionnaire at these time points. Data were analyzed using descriptive and inferential statistics with SPSS version 19. The findings showed that the two groups were similar in terms of demographic characteristics and mean moral distress scores before the intervention. After the intervention, the mean scores of moral distress in the intervention group were significantly reduced in the frequency dimension (2.12±0.34) and severity dimension (2.32±0.46) compared to the control group (frequency: 2.51±0.43; severity: 2.57±0.55) (p<0.001). The results indicated that implementing the knowledge-to-action model reduces moral distress in intensive care unit nurses. Therefore, it is recommended that nursing managers adopt this model to improve the quality of care.

The Relationship Between Moral Injury and Moral Courage in Nurses Working in Intensive Care Units
Samaneh Fallah-Karimi, Zahra Khalilzadeh-Farsangi, Azizollah Arbabisarjou, Fatemeh Etemadinia,
Volume 18, Issue 1 (3-2025)
Abstract
Nurses working in intensive care units are frequently exposed to complex ethical issues and difficult decision-making, placing them at high risk for moral injury. Such injury can negatively affect their professional performance and mental health. Accordingly, this study aimed to explore the relationship between moral injury and moral courage among nurses working in intensive care units. This descriptive cross-sectional study was conducted in 2024. The study population consisted of 150 nurses working in intensive care units. Data were collected through Sekerka’s Moral Courage Questionnaire and the Moral Injury Symptom Scale for Health Professionals. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient, and the independent samples t-test via SPSS software version 22. The findings revealed a significant inverse relationship between moral injury and moral courage (r = -0.64, p < 0.001). Moreover, moral courage levels were higher among registered nurses compared to nurses in the compulsory service program. Besides, a direct relationship was observed between age and moral courage, suggesting that moral courage increases with age. The results of this study highlight the importance of designing and implementing effective educational programs to reduce moral injury and promote moral courage among this group of nurses.

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