BackgroundAt a time marked by ongoing global instability and health emergencies, the ethical and operational burdens on healthcare systems derived from the COVID-19 crisis, remain urgently relevant. Positioned between frontline staff and senior management, nurse middle managers (NMMs) were tasked during the pandemic with implementing institutional policies while simultaneously supporting teams facing rapid clinical and emotional challenges. Despite the pivotal role of NMMs, there exists a significant gap in understanding the ethical challenges and the strategies they employed during time of crisis.Research design and populationThis qualitative study used Interpretative Phenomenological Analysis approach to examine the lived ethical experiences and coping strategies of 16 Israeli NMMs from diverse healthcare sectors during COVID-19, and their implications for future crises.Ethical considerationsThe study received ethical approval from the University Research Ethics Committee. All participants gave informed verbal consent after a detailed briefing.FindingsMoral distress emerged as an ongoing, cumulative condition shaped by structural exclusion, constrained moral agency, and institutional inequities Three main themes emerged (1) the dual role of NMMs and its ethical ramifications, (2) ethical tensions and frustration in the relationship with senior leadership, and (3) confronting ethical dilemmas emerging from the unique challenges of the pandemic. Participants reported distress when required to implement policies conflicting with professional values, while being excluded from decision-making yet expected to justify top-down directives. Many served as emotional anchors for their teams without reciprocal support.ConclusionsThe study illuminates the distinctive moral position of NMMs in time of crisis, revealing sustained ethical conflicts rooted in systemic constraints. By reframing moral distress as structurally embedded, it underscores the need for organizational reforms to strengthen ethical preparedness, support NMMs, and enhance healthcare system resilience in future crises.

BackgroundIn Turkey, dementia care is largely provided by family members due to limited formal services and strong cultural expectations regarding familial responsibility. This situation places caregivers under considerable burden and exposes them to complex ethical dilemmas, particularly when balancing patient autonomy and safety.Research aimThis study aimed to explore the ethical challenges and dilemmas faced by family caregivers providing dementia care in Turkey.Research designA descriptive qualitative design using interpretative phenomenological analysis (IPA) was employed to explore caregivers' lived experiences. Data were collected through semi-structured interviews (June-July 2024), audio-recorded, and transcribed verbatim. Methodological rigor was ensured using COREQ guidelines.ParticipantsParticipants comprised 12 family caregivers of individuals with dementia receiving home-based care coordinated by a state hospital in Turkey. Purposive sampling was used. Eligible participants were Turkish-speaking adults who had provided unpaid care for at least 6months.Ethical considerationsEthical approval was obtained from the Koç University Social Sciences Ethics Committee (Approval No: 2024.022.IRB3.005). Written informed consent was obtained, confidentiality was ensured using pseudonyms, and participants could withdraw at any time without consequences.FindingsThree themes emerged: dissatisfaction with formal dementia care services; caregiving shaped by cultural values, moral responsibility, and emotional burden; and ethical dilemmas related to dignity, autonomy, informed consent, daily care practices, and medical decision-making. Caregivers frequently described tensions between protecting their relatives and respecting autonomy, often in the absence of professional ethical guidance.Discussion and conclusionsThe findings highlight how ethical dilemmas in dementia care are not solely individual but are shaped by cultural norms and systemic limitations. The lack of accessible formal services and ethical support structures intensifies caregivers' moral distress and decision-making burden. Culturally sensitive, ethically informed, and family-centred support systems are essential to strengthen caregivers' decision-making and well-being.

BackgroundEthical issues in nursing care for older adults in community setting are becoming more visible as population aging accelerates. However, existing studies are fragmented and lack a comprehensive synthesis to inform ethical practice and governance.AimsTo identify major ethical issues, their impacts, and related strategies in nursing care for older adults in community setting, providing evidence for ethical practice, education, and policy development.MethodsA scoping review was conducted following JBI methodology. PubMed, Web of Science, Scopus, CINAHL, Ovid-Embase, PhilPapers, and PsycINFO were searched up to 8 February 2026. Two reviewers independently screened, extracted, and synthesized data.ResultsFourteen studies were included in this review. Evidence was synthesized at three levels including nursing staff, older adults, and the care system, and categorized into three domains: ethical challenges, ethical impacts, and improvement strategies. Ethical challenges mainly arise from three aspects: role ambiguity and competence limitations among nursing staff under contextual constraints, restrictions on older adults' autonomy and opportunities to participate in decision-making, and structural conditions related to resource allocation and governance mechanisms. These ethical issues manifested as increased moral distress and emotional strain among nurses, diminished trust in nurses and reduced care adherence among older adults, and systemic pressures on the quality, equity, and sustainability of community nursing services. To address these challenges, the literature proposed strategies including strengthening ethics education and reflective practice, promoting supportive communication and shared decision-making, and improving governance structures and resource support.ConclusionsEthical issues in community nursing for older adults demonstrate multilevel characteristics embedded within practice contexts and institutional conditions. Strengthening ethical competence, promoting supportive communication and participatory decision-making, and advancing institutionalized ethical governance are essential for fostering more equitable and sustainable community nursing practice. Future research should expand geographical representation and further strengthen the evidence base for ethical governance in community nursing through high-quality empirical studies.

BackgroundNurses in China's public hospitals face high-pressure environments and emotional labor, leading to professional fatigue, identity conflicts, and reduced work efficacy. These challenges impact job satisfaction and engagement. Despite these issues, job crafting mechanisms, which could help nurses reshape their work roles to improve job satisfaction and efficacy, and managerial interventions remain underexplored. This study investigates the key factors that influence how nurses proactively adjust their tasks, relationships, and work environments, aiming to enhance engagement, performance, and workforce retention.AimThis study explores key factors influencing nurses' job crafting in China through a multi-level qualitative approach.MethodsFrom 2023 to 2024, semi-structured interviews were conducted with 18 registered nurses at a tertiary public hospital in China. Data collection included literature review and research group discussions, while data analysis was conducted using grounded theory.Ethical considerationsThe study was approved by the Ethics Committee of Gansu Provincial Hospital (No. 2025-267). Informed consent was obtained from all participants, and confidentiality was strictly maintained throughout the research process.FindingsThree themes emerged: adaptability (including knowledge-action gaps, task preferences, and learned helplessness), organizational support (leadership styles, incentives, and resource access), and interpersonal relationships (team effectiveness and contextual dependence). These themes reflect multilevel factors influencing nurses' job crafting behaviors within clinical and organizational contexts.ConclusionNurses' job crafting is shaped by individual adaptability, value-driven decision-making, and organizational support, with leadership playing a mediating role. Aligning with Maslow's hierarchy, job crafting requires a localized framework integrating management innovation and Chinese strategic wisdom to enhance adaptability and job satisfaction.

This theoretical-reflective essay addresses ethics in nursing care for transgender people, emphasizing the tension between the care provided and the institutional invisibilities that perpetuate the exclusion of this population in the healthcare system. Based on universal principles of human rights and contemporary philosophical concepts, such as Axel Honneth's ethics of recognition and Judith Butler's performative theory of gender, the text problematizes professional practice in the face of the specific demands and vulnerabilities of transgender people. Structural invisibility, sustained and reinforced by cisnormativity norms and the absence of specific content in professional training, represents an ethical barrier to ensuring humanized and inclusive care. The study highlights that the denial of gender identity, the incorrect use of the chosen name, and the perpetuation of prejudices constitute ethical and human rights violations, aggravating suffering and health inequalities. The proposed reflection also emphasizes the responsibility of nursing professionals to transcend technique and take a critical, ethical, and political stance that recognizes others in their uniqueness and promotes care practices that respect diversity. The essay advocates the adoption of an ethic of recognition as the foundation for transforming care into a space of welcome, justice, and redress for structural inequalities. Finally, the text reaffirms the importance of transforming invisibilities into visibilities, and that nursing should position itself as an active agent in promoting equity and the rights of the transgender population, ensuring care that legitimizes, values, and respects their identities and histories.

BackgroundThe COVID-19 pandemic has posed unprecedented challenges for nurses, including resource shortages, heavier workloads, and ethical decision-making pressures, putting them at high risk for moral injury. This threatens their physical and mental health, job stability, and the quality of care.AimThe aim was to systematically assess the level of moral injury among nurses during the COVID-19 pandemic.MethodsA comprehensive search was conducted on 12 databases (PubMed, Web of Science, MEDLINE, ProQuest, Embase, CINAHL, Scopus, PsycINFO, CBM, CNKI, VIP, WanFang Data) for cross-sectional studies published up to 20 July 2025, that reported the level of moral injury among nurses using the Moral Injury Symptoms Scale-Health Professionals Version. A systematic review and meta-analysis were conducted. Two researchers independently screened the literature, extracted data, and assessed methodological quality. The pooled mean score was calculated using random-effects or fixed-effects models, with subgroup analysis to explore heterogeneity.Ethical considerationsEthical approval was not required as the review synthesized publicly available data.ResultsThis study included 16 articles, involving 5824 participants. The meta-analysis showed that the pooled mean total MISS-HP score for nurses was 42.12 (95% CI: 40.70-43.53). Among the dimensions, the pooled mean score for Loss of religion/spiritual faith was the highest at 5.68 (95% CI: 4.61-6.74), while the pooled mean score for religious struggles was the lowest at 2.26 (95% CI: 1.13-3.40). Subgroup analysis results indicated significant differences in moral injury levels among nurses based on Survey year and department (p < .001).ConclusionsUnder the context of the COVID-19 pandemic, nurses experienced moderate to high levels of moral injury, particularly during the early stages of the pandemic in 2020, with emergency department nurses being most affected. To support nurses' well-being and mental health, healthcare institutions should strengthen ethical support systems, improve management, and consider the role of religion/spiritual faith in alleviating moral injury.

BackgroundNurses' innovative behaviors play an irreplaceable role in advancing nursing practice, improving healthcare service quality, and driving transformation in the nursing profession. However, existing studies on the factors influencing nurses' innovative behaviors and their underlying mechanisms remain limited, necessitating further investigation.ObjectiveThis study investigated the impact of ethical leadership on nurses' innovative behaviors, examining the mediating roles of innovative climate and self-efficacy.Research designThis is a multicenter longitudinal study with three-wave data collection (February-August 2024) following STROBE guidelines. Structural equation modeling was employed to examine mediation effects.Participants and research contextA total of 1,522 nurses from 16 tertiary hospitals in China completed baseline assessments (T1), with 1,409 (T2) and 1,298 (T3) completing follow-ups. Participants were registered nurses with ≥1 year of experience, sampled through stratified cluster sampling across clinical departments.Ethical considerationsapproved by the Henan University Biomedical Research Ethics Committee (HUSOM2023-478). Participants provided informed consent, data were collected anonymously, and confidentiality was maintained throughout.ResultsEthical leadership significantly predicted innovative behavior (β = 0.334, 95% CI [0.284,0.386]). Both innovative climate (β = 0.059 [0.046, 0.072]) and self-efficacy (β = 0.017 [0.011, 0.023]) served as partial mediators, with a significant chain mediation effect (β = 0.021 [0.015, 0.027]) accounting for 4.87% of total effect.ConclusionEthical leadership not only directly promotes nurses' innovative behaviors but also strengthens this effect indirectly through the chain-mediated roles of innovative climate and self-efficacy. Enhancing ethical leadership can optimize the innovative climate in nursing departments and improve nurses' self-efficacy, thereby effectively fostering their innovative behaviors.

BackgroundDigitalization is a widespread global phenomenon that is increasingly integrated into healthcare delivery. Nursing, as the largest group of healthcare professionals, relies heavily on Hospital Information Systems (HIS) to record and access patient data. This reliance raises important concerns regarding privacy, security, and the ethical standards of care.AimThis qualitative study sought to investigate the ethical experiences of nurses utilizing HIS in patient care delivery.Research DesignA qualitative exploratory design was employed, utilizing semi-structured interviews in line with COREQ guidelines. The data were analyzed using conventional content analysis.Participants and Research ContextThe study included 17 nurses involved in patient care within a healthcare setting.Ethical ConsiderationsThe research received ethical approval from the relevant ethics committee. All participants provided informed consent and were guaranteed confidentiality and anonymity.ResultsThree themes emerged from the data: patient privacy, ethical behavior, and ethical challenges.ConclusionAddressing the ethical experiences of nurses using HIS is crucial to enhancing care quality. However, issues like unauthorized access and lack of training highlight the need for ongoing education and privacy awareness initiatives to support ethical nursing practice in the digital era.

BackgroundShared decision-making (SDM) requires bidirectional communication between medical staff and patients (or their surrogates) to ensure treatment aligns with patients' values and preferences. In the intensive care unit (ICU), critically ill patients often lose decision-making capacity, placing surrogate decision-making responsibilities on family members. However, surrogates face significant challenges due to restricted information access, communication barriers, and decision-making delays. The impact of ICU spatial isolation, restricted visitation policies (RVP), and information flow on the decision-making process remain underexplored. This study examines how these factors shape surrogate decision-making and affect its effectiveness.MethodsA focused ethnographic study was conducted in the ICU of a tertiary hospital in China over 6months. Data were collected through participant observation and semi-structured interviews with 9 ICU physicians, 6 nurses, and 10 family surrogates. Thematic content analysis was used to systematically code and synthesize data, identifying key challenges within the ICU decision-making ecosystem.ResultsICU spatial isolation and RVP placed surrogates at the periphery of the information network, where they receive only fragmented and unidirectional updates. Medical staff predominantly relied on one-way, ad-hoc communication, preventing surrogates from fully understanding patient conditions. Additionally, discussions often neglected patients' values, impeding substituted judgment. The resulting information deficit led surrogates to seek external sources, exacerbating trust issues with medical staff. This dual-layered isolation-spatial and informational-and distrust increased the influence of non-medical factors such as financial constraints, emotional distress, and sociocultural pressures, potentially leading to decisions misaligned with patient interests. The study proposes a staged visitation and structured communication model to address these challenges and enhance surrogate decision-making quality.ConclusionsFuture research should assess the effectiveness of this model and explore strategies to balance ICU staff workload with surrogate informational needs in high-stress environments.Ethical considerationsThe study was approved by the Institutional Review Board of Dalian Medical University (Approval No. BECDMU 2024-008). Written informed consent was obtained from all formal interview participants, while oral informed consent was secured for ethnographic observations. Confidentiality and anonymity were strictly maintained.