Research involving older adults who have experienced elder abuse and neglect often attracts scrutiny from institutional review boards (IRBs) because of concerns relating to distress, disclosure, coercion, dependency, capacity and participant safety. However, experiencing elder abuse and neglect does not in itself make an older adult vulnerable as a research participant; vulnerability arises from personal, relational and contextual circumstances. Although ethical oversight is essential, increasing bureaucratisation, described as ethics creep, may obstruct research involving marginalised populations. This is especially important for nurses, who hold important roles as researchers, clinicians, advocates, gatekeepers and as recipients of safeguarding disclosures. Drawing on ethics creep, vulnerability, critical gerontology, human rights and epistemic injustice, this paper examines how disproportionate ethical regulation may restrict older adults' participation in elder abuse and neglect research. Rather than calling for reduced oversight, we argue for proportionate, relational and human rights-based IRB governance that protects participants while enabling older adults to share their lived experiences.

Surrogacy remains an important option for some individuals and couples hoping to build a family, especially people with reproductive health issues, including those unable to carry a pregnancy, and some same-sex couples. However, advances in reproductive technology have raised complex ethical concerns, particularly around commercial surrogacy arrangements, where financial incentives, power imbalances, and conflicting interests may complicate the ethical landscape. This paper critically examines ethical dilemmas faced by nurses and midwives in surrogacy care, focussing on their role in safeguarding the autonomy, well-being, and rights of surrogates, intended parents, and the future child. The paper further explores care ethics as a complementary framework that emphasises relational and context-sensitive decision-making in surrogacy care.

BackgroundPatient safety is fundamental to universal health coverage and the health-related Sustainable Development Goals. Safety behavior among nurses, especially those in the operating room, effectively supports the achievement of patient safety objectives. However, evidence on their safety behavior levels and associated factors remains limited.AimTo investigate the mediating role of moral efficacy in the relationship between patient safety culture and safety behavior among operating room nurses.Research designA cross-sectional study.Participants and research contextFrom October to November 2025, 427 operating room nurses were recruited by convenience sampling from seven provincial-level regions in China. Data were collected using a general information questionnaire, the Nurse Safety Behavior Scale, the Hospital Survey on Patient Safety Culture, and the Moral Potency Questionnaire. Pearson's correlation, multiple linear regression, and PROCESS v4.1 Model 4 with 5000 bootstrap resamples were used for data analysis.Ethical considerationsThis study was approved by the Ethics Committee of Sichuan Provincial People's Hospital. Before accessing the questionnaire, participants reviewed an online information and informed consent page explaining the study purpose and procedures, voluntary participation, anonymity, confidentiality, and the right to withdraw before submission. Only participants who provided electronic consent were allowed to proceed. No identifiable personal data were collected, and results were reported in aggregate form.ResultsThe results revealed positive correlations between patient safety culture, moral efficacy, and nurse safety behavior (both p < 0.01). Patient safety culture is positively associated with nurse safety behavior (β = 0.426, p < 0.001). Moral efficacy plays a mediating role between patient safety culture and nurse safety behavior (β = 0.125, p < 0.001).ConclusionsNursing managers should pay close attention to patient safety culture and consider targeted and feasible strategies to strengthen nurse moral efficacy and safety-related practices, which may be beneficial for patient safety in operating rooms.

BackgroundNurse managers play a pivotal role in fostering organizational justice. Empirical understanding of their lived experiences when enacting this role amid organizational injustice affecting bedside nurses remains scarce.Research aimTo analyze the ethical trajectories of nurse managers navigating organizational injustice.Research designA secondary data analysis was conducted on nurse managers' narratives drawn from a primary dataset that explored healthcare managers' perspectives on, and experiences with, managing whistleblowing disclosures undertaken by care providers in healthcare settings.Participants and research contextThe study involved the secondary analysis of 18 narratives from nurse managers working within the Canadian healthcare system.Ethical considerationsThe study obtained ethical approval from the University of Ottawa Research Ethics Board.FindingsWhen navigating organizational injustice, nurse managers experience ethical trajectories marked by managerial courage, systemic moral erosion, and self-preservation agency. These trajectories highlight the complexities and tensions embedded in performing their role to promote organizational justice.ConclusionsNurse managers cannot sustain organizational justice through individual moral endurance alone; systemic structural transformations are imperative. Advancing toward an organizational ethics framework is essential to safeguard nurse managers' moral agency and render nursing leadership ethically sustainable.

BackgroundWorkplace violence is common in intensive care units and is often regarded as an inevitable aspect of the job. This normalisation may obscure the emotional impact of violence on healthcare professionals and the ethical tensions that arise when altruistic caregiving values conflict with personal safety. Therefore, this study was conducted to explore healthcare professionals' emotional experiences of workplace violence within the context of intensive care.Research designThis study constitutes a secondary, inductive analysis of data originally collected in 37 semi-structured interviews. The interviews were conducted between November 2024 and March 2025 in intensive care units across five hospitals in Sweden. Data were interpreted using Reflexive thematic analysis.Ethical considerationsEthical aspects were carefully considered throughout the study in line with established ethical principles. Participation was voluntary, and informed consent was obtained from all individuals before the interview. Data confidentiality was ensured, and all direct quotes were anonymised.FindingsParticipants' descriptions of their emotional experiences generated three themes. A conflict between professional obligation and human vulnerability captured how participants experienced a tension between the expectation to remain composed in their professional roles and their human vulnerability. Balancing core values of caregiving with safety illustrated the professional and moral dilemmas that emerged when violence or escalating aggression forced healthcare professionals to reconcile their commitment to compassionate care. Organisational conditions influencing emotional responses reflected the conditions that either support or undermine ICU healthcare professionals' emotional resilience when they encounter violence.ConclusionsWorkplace violence in intensive care was experienced as more than a threat to personal safety; participants described how it challenged their professional identity and caring values. Organisational conditions influenced how healthcare professionals experienced and managed these challenges.

Pediatric palliative care is increasingly recognized as an established practice yet less than ten percent of children who need it access it worldwide. Contributing to this gap is an absence of pediatric-specific bioethics frameworks to guide the care of dying children. Because philosophies influence cohesive care provision, the purpose of this review was to critically examine the international, scholarly literature on the ethical content of pediatric end-of-life care guidelines to ascertain what pediatric ethics approaches are used to guide the care of dying children. A Rapid Review of the international, scholarly literature was undertaken from September 2024 to April 2025. Of the 12,215 reviewed documents, 19 were retained for inclusion. Documents were mapped for the presence of pediatric-specific bioethics frameworks, care guidelines, ethical approaches, principles and values. Records were identified according to country, population, holistic care, child-centricity and pediatric, family, and ethicist involvement in ethical decision-making. Nineteen documents were included. Findings were synthesized through tabulation and narrative analysis. No pediatric-specific bioethics framework explicitly originating in pediatric theory and research was identified. Although most ethical approaches focused on children, they relied on prevailing adapted adult frameworks or adultist iterations of principlism, care and relational ethics and single or matrix-based principal accounts. Care for dying children needs to be consistently grounded in child philosophies. Recommendation: Expanding access to pediatric palliative care requires ethics education research toward pediatric-specific pedagogies and bioethics frameworks to support consistent, ethically robust, holistic, and child-centered care to improve access across clinical, international and interdisciplinary settings.

BackgroundMoral distress is an increasingly recognized ethical concern in healthcare, particularly in older adult care, where it is associated with negative consequences for nurses, patients, and healthcare organizations. Although widely studied, its emotional dimensions, particularly the role of shame, remain insufficiently understood.AimTo explore nurses' experiences of moral distress, shame, and professional identity in older adult care, as well as their perspectives on support and development opportunities that can alleviate moral distress and its consequences.Research designQualitative exploratory design. In-depth semi-structured interviews.Participants and research contextFifteen nurses in an older adult care context. Years of professional experience ranged from 4 to 46. Ethical considerationsEthical approval was obtained from the Committee on Research Ethics at Åbo Akademi University, Finland, and permission was granted by the participating Wellbeing Services County. Written and oral informed consent was obtained from all participants. The study adhered to the Finnish National Board on Research Integrity (TENK, 2023) guidelines on good scientific practice.FindingsThree main themes were identified: Moral distress as a pervasive threat to professional identity, Shame and moral conflict in the experience of moral distress, and Organizational conditions and strategies for managing moral distress. DiscussionMoral distress was perceived as closely linked to shame and professional identity. The findings underscore the need to address emotional and organizational dimensions of moral distress in care for older adults.ConclusionsMoral distress in older adult care is a pervasive, multidimensional, and sustained phenomenon shaped by individual factors and organizational conditions. Efforts to reduce moral distress should move beyond individual coping strategies and include structural and cultural changes that support nurses' professional and ethical values and encourage open dialogue. Addressing moral distress is important not only for supporting nurses but also for safeguarding the quality and sustainability of care in older adult settings.

Moral distress is recognized as a major contributor to burnout and attrition among nurses. While the sequelae of moral distress are profound, the antecedents of moral distress are multi-factorial and therefore the phenomenon is challenging to address. Many interventions target individual-level factors such as moral resilience; however, moral distress is a system-level problem. As such, there is a growing focus on developing upstream, system-level interventions to mitigate or prevent moral distress in the healthcare setting. Moral community is a system-level dynamic that reflects ethical climate and perceived organizational support, metrics that are often associated with moral distress. However, the connection between moral distress and moral community in nursing remains under-examined. Therefore, the purpose of this narrative review was to explore the relationship between moral distress and the concept of moral community in the context of nursing practice. Three categories emerged from this analysis: organizational constraints that instigate moral distress, moral community as a concept, and the role of moral community in an organization. Based on these categories, a revised definition of moral community was developed and used to synthesize a novel theoretical framework relating moral community to moral distress. Further research may apply the proposed definition of moral community and theoretical framework to (1) evaluate existing organizational ethical frameworks and (2) formulate novel interventions to address moral distress.

BackgroundHealthcare resource cutbacks create organizational conditions that may constrain moral agency and contribute to moral distress, yet little is known about how leaders and healthcare professionals experience these ethical challenges.AimThe aim of this study was to explore how leaders and healthcare professionals experience moral distress associated with healthcare resource cutbacks. The research question was: How do leaders and healthcare professionals experience moral distress associated with healthcare resource cutbacks?Research designQualitative exploratory design. In-depth semi-structured interviews. Participants and research contextTwelve participants, six leaders and six health professionals. Among leaders, leadership experience ranged from 1 to 30 years. Among healthcare professionals, healthcare experience ranged from 7 to 41 years.Ethical considerationsThe study adhered to the Finnish National Board on Research Integrity (TENK) guidelines on good scientific practice. Ethical approval was obtained from an ethics committee at a university in Finland (verdict 11/2024) and research permissions were granted by the two healthcare organizations included in the study. Participants received written information about the study and provided informed consent before interviews.FindingsFive themes were generated: Organizational transformation as a source of moral constraint; Structural limitations create conflicts between professional values and organizational realities; Moral distress as emotional suffering and erosion of professional identity and well-being; Relational and organizational support as protection against moral distress; Professional commitment as both a source of resilience and vulnerability. ConclusionsMoral distress associated with healthcare resource cutbacks is an ethical and organizational phenomenon arising from tension between caring responsibility and restricted possibilities for ethical action experienced by both leaders and healthcare professionals. Ethically sustainable healthcare requires individual commitment and organizational structures that enable caring responsibility. Addressing moral distress requires attention to resource allocation, decision-making, leadership, and organizational conditions that strengthen moral agency and support care grounded in human dignity.

BackgroundPatient safety is commonly conceptualized through ethical reductionism, risk management, and technical performance indicators. However, such approaches may insufficiently address the ethical, relational, spiritual, and culturally embedded dimensions of nursing care. Within Islamic ethical thought, the principle of Hifz al-Nafs (protection of life) offers a holistic moral framework for understanding patient protection beyond biomedical risk prevention.AimThis study aimed to explore Indonesian nurses' ethical understandings and lived experiences of patient safety and caring and to examine how Hifz al-Nafs can serve as a culturally grounded ethical lens for interpreting these experiences.Research designA qualitative descriptive design was employed using semi-structured face-to-face interviews and thematic analysis following Braun and Clarke's six-step framework.Participants and research contextTwelve registered nurses from two tertiary hospitals in Indonesia participated in the study. Participants were purposively recruited to ensure variation in clinical experience and practice settings.Ethical considerationsThis study was approved by the relevant institutional ethics committees. A written informed consent was obtained from all participants, and participation was voluntary and de-identified.ResultsThree interrelated thematic clusters were identified: Institutional Gaps, Binary Framings, and Community Solidarity. Participants described patient safety as an ethically grounded practice integrating technical competence, relational ethical care, spiritual sensitivity, and communal responsibility. Hifz al-Nafs was used retrospectively as an interpretive ethical lens; participants did not explicitly use the term during the interviews.ConclusionsThe findings reconceptualize patient safety as an ethical and culturally situated nursing practice rather than solely a technical process. The study contributes a culturally grounded Caring-Safety synthesis that links procedural safety, relational care, and moral responsibility without claiming a universally transferable model.

BackgroundMedical assistance in dying (MAID) raises complex ethical and professional questions for nurses, whose attitudes may vary across legal, sociocultural, and clinical contexts. Although nurses' experiences and attitudes toward assisted dying have been extensively examined, the prevalence and contextual variation of nurses' support for MAID across the international evidence remain unclear.Research aimTo estimate the prevalence of nurses' support for MAID and examine whether support varies across geographic, legal, clinical, and country-income contexts.Research designA systematic review and meta-analysis of studies reporting quantitative data on nurses' support for MAID or related assisted-dying practices.Search and quality appraisal10 electronic databases were searched from inception to 10 May 2025. Methodological quality was appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Random-effects models were used to pool prevalence estimates, with subgroup analyses and univariable meta-regression used to examine contextual variation.Results26 studies involving 12,529 nurses from 19 countries were included. The pooled prevalence of support for MAID was 42.5% (95% confidence interval 34.6%-50.4%), with very high between-study heterogeneity (I[2] = 99.6%). Support varied by geographic region (p = .004), with pooled estimates of 51.0% in Europe, North America, and Oceania, 30.1% in Asia, and 23.1% in Africa. Support was also higher where an eligible form of assisted dying was legally authorized than where it was not (58.4% vs 37.6%; p = .038). Neither clinical setting nor country income level was significantly associated with support.ConclusionsNurses' support for MAID varies substantially across the available international evidence and should not be interpreted as a uniform global professional position. Geographic region and legal status were associated with this variation, supporting the need for context-sensitive ethical preparedness, role clarity, and organizational support rather than assumptions of professional consensus.

BackgroundMoral courage helps nursing students respond to ethically difficult situations, yet little is known about how its dimensions relate to ethical sensitivity, professional identity, and emotional intelligence at the dimension level.Research objectiveThis study examined the dimension-level network structure of moral courage, ethical sensitivity, professional identity, and emotional intelligence among undergraduate nursing students.Research designA cross-sectional online survey was conducted. Dimension scores were standardized and analyzed with an EBICglasso Gaussian graphical model. Strength and bridge centrality were estimated, and network accuracy and stability were assessed using bootstrap procedures.Participants and research contextParticipants were 494 full-time third-year undergraduate nursing students from one university who were approaching a mandatory clinical internship.Ethical considerationsThis study was approved by the ethics committee of North China University of Science and Technology(approval no. 2024185). Informed consent was obtained from all participants.ResultsThe network included 16 nodes and 51 non-zero edges. Within moral courage, moral integrity showed two of the largest conditional associations, with compassion and true presence with the patient (0.383) and moral responsibility (0.369). Cross-community associations were generally smaller. Compassion and true presence with the patient had the highest bridge expected influence point estimate (0.180), whereas social comparison and self-reflection had the highest bridge strength (0.207). The leading bridge expected influence estimates were close. Correlation stability coefficients were 0.749 for strength, 0.516 for bridge expected influence, and 0.439 for bridge strength, warranting cautious interpretation.ConclusionAmong nursing students approaching clinical internship, moral courage showed relatively strong within-community associations and smaller cross-community associations with related constructs. Different bridge rankings indicated that cross-community connectivity was not concentrated in a single consistently highest-ranked dimension. These findings support longitudinal and educational research during the transition to clinical practice.

BackgroundCompassionate care is a core ethical obligation in nursing, yet the processes through which nurses enact and sustain it remain insufficiently theorized. Existing grounded theory models have not examined an East Asian care context in which nursing staff may assume both clinical and daily living care.Research question/aim/objectivesHow do clinical nurses experience, construct, and sustain compassionate care, and what ethical challenges shape this process?Research designA grounded theory design following Strauss and Corbin was employed. Semi-structured interviews were analysed using open, axial, and selective coding with constant comparison. Ethics of care and moral distress served as sensitizing concepts, while categories were generated inductively. Trustworthiness followed Lincoln and Guba's criteria.Participants and research contextParticipants were thirteen female nurses from tertiary and secondary hospitals in South Korea, working across intensive care, hospice and palliative care, general and haematology wards, and emergency settings (mean clinical experience 14.9 years). Interviews were conducted from July 2020 to February 2021 during the COVID-19 pandemic.Ethical considerationsInstitutional Review Board approval was obtained, and all participants provided written informed consent.Findings/resultsThe core category-comprehensive care grounded in an understanding of the illness trajectory-described compassionate nursing as a practice in which anticipating where a patient stands in the illness course shaped responses to present and emerging needs. Workload and time pressure constrained compassionate engagement, while collegial support helped nurses sustain it. Professional fulfilment and emotional depletion appeared as consequences that could influence subsequent care.ConclusionsCompassionate care was shaped by the integration of clinical understanding, relational engagement, and organizational conditions. Sustaining this practice may require workload governance and structured collegial support rather than reliance on individual resilience alone.

BackgroundWhen transplant clinicians encounter ethical challenges and are constrained by their institution from acting in a manner within their professional ethical obligations, they may experience moral distress. Moral distress has been associated with negative effects such as burnout and turnover. Conversely, high grit has been positively correlated with job satisfaction, job performance, and organizational commitment.Research questionsWhat is the level of grit and moral distress among transplant clinicians? What correlations between demographics, grit, moral distress, and intent to leave exist among transplant clinicians?Research designThis cross-sectional study was conducted from October 2024 through March 2025. Three instruments, an investigator-developed demographic survey, the 12-Item Grit Scale, and the Measure of Moral Distress for Healthcare Professionals, were used to capture transplant clinician's grit and level of moral distress. Data were analyzed using descriptive statistics, Pearson correlation, and generalized structural equation modeling.Participants and research contextThe target population for this study consisted of organ transplant clinicians (e.g., surgeons, physicians, coordinators, advanced practice providers, nurses, and allied health team members) in the United States.Ethical considerationsEthics review and approval was obtained prior to subject recruitment.ResultsAmong 101 transplant clinicians, higher moral distress was observed in those with advanced education, frequent ethical challenges, and specific transplant roles (e.g., advanced practice providers, physicians, multi-organ), while grit remained consistent across demographic and clinical factors. Generalized structural equation modeling suggests a potential mediating role between clinician characteristics (education), workforce factors (frequent ethical issues and specific transplant roles), and turnover intentions.ConclusionTransplant clinicians who experience moral distress frequently and at high intensity may express an intent to leave their role regardless of their level of grit. Healthcare organizations must create targeted interventions and resources to mitigate moral distress and support transplant clinicians who experience moral distressing events.