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Texto & Contexto - Enfermagem

Print version ISSN 0104-0707On-line version ISSN 1980-265X

Texto contexto - enferm. vol.25 no.2 Florianópolis  2016  Epub July 07, 2016 

Literature Reviewrs



Carlise Rigon Dalla Nora 1  

Sérgio Deodato 2  

Margarida Maria da Silva Vieira 3  

Elma Lourdes Campos Pavone Zoboli 4  

1Doctoral student in Nursing at the Universidade Católica Portuguesa (UCP). Researcher of the Centro de Investigação Interdisciplinar em Saúde (CIIS). Porto, Portugal. E-mail:

2Ph.D. in Nursing. Professor, UCP. Researcher, CIIS. Lisboa, Portugal. E-mail:

3Ph.D. in Philosophy. Professor, UCP. Researcher, CIIS. Porto, Portugal. E-mail:

4Ph.D. in Public Health. Professor, Departamento de Enfermagem em Saúde Coletiva, Universidade de São Paulo. São Paulo, Brazil. E-mail:


This study aimed to identify the elements and strategies that facilitate the ethical decision-making of nurses faced with ethical problems, from publications on the theme. An integrative literature review was carried out. Data collection was performed between the months of April and May 2014, in the databases: SciELO, CINAHL, LILACS and MEDLINE. Original, theoretical and case study articles, with a health team that included nurses, published in Portuguese, English and Spanish were included. A total of 19 studies were selected, the analysis of which resulted in three categories: external factors of ethical decision-making in nursing, individual factors of ethical decision-making in nursing and facilitating strategies of ethical decision-making in nursing. It was concluded that nurses need to use strategies that develop sensitivity, ability and ethical competence, in order to make prudent ethical decisions, contributing to the quality of health care.

DESCRIPTORS: Ethics; Ethics in nursing; Nursing; Decision making; Review.


Este estudio tiene como objetivo identificar los elementos y estrategias que faciliten la toma de decisión ética de las enfermeras frente a los problemas éticos, a partir de las publicaciones sobre el tema. Se realizó una revisión integradora de literatura. La recolección de datos se llevó a cabo entre abril y mayo de 2014, en las bases de datos: SciELO, CINAHL, LILACS y MEDLINE. Se incluyeron artículos originales de investigación, estudios teóricos y estudio de caso, publicadas en inglés, español y portugués, con el equipo de salud que incluye enfermeras. Se seleccionaron 19 estudios, el análisis resultó en tres categorías: factores externos de la toma de decisiones éticas en enfermería, factores individuales de la toma de decisiones éticas en enfermería y estrategias facilitadoras de la toma de decisiones éticas en la enfermería. Se concluye que los enfermeros han de utilizar estrategias que desarrollan la sensibilidad, habilidades y competencia ética, para así, tomar decisiones éticas prudentes, lo que contribuye a la calidad de la atención a la salud.

DESCRIPTORES: Ética; Ética en enfermería; Enfermería; Toma de decisiones; Revisión.


Nurses are constantly faced with the need to make ethical decisions. The current health care environment, with the rapid advances in science and technology, has created numerous ethical problems for the practice of nurses as well as an increase in these problems.1-3 It is essential to develop decision-making skills for the excellence of the professional practice and quality of the health services.4

Ethical problems in health are situations that unsettle and disturb the conscience of the nurses. This is because, for such problems, there is not only one solution, but several courses able to lead these professionals to a solution, which requires the exercise of ethical deliberation.5 Solving these problems requires permanent creativity, as the answer has to be far-reaching, in order to obtain an increasingly better health practice.4 Conversely, ethical dilemmas are understood as situations in which the solution is reduced to two extreme and opposed options, two conflicting situations.6

Thus, the ethical problem differs from the ethical dilemma, because in the dilemma the nurse faces an extreme situation, which requires the challenge of having to choose between two, and only two, incompatible courses of action.6 In this context, the development of the theoretical framework of this study is derived from the concept of ethical problems, as it is understood that this is a complex phenomenon which involves specific and defined questions of care practice, perceived as a cause of conflict within the context of ethical values ​​and duties.4

Nurses must solve the ethical problems of their practice, assuming their professional duty to act. For this, they need to seek suitable alternatives to resolve the problem identified, constructing an ethically prudent decision. Prudence is expressed as the ability to value the principles and duties involved in the ethical problem, reaching reasonable decisions.7

Ethical nursing problems are constituted by the existence of uncertainty regarding the decision to act. This uncertainty is caused when the dignity, rights and will of the user need to be considered. Such situations can generate doubts or conflicts in the choice of nursing interventions.8 To make ethical decisions nurses have a wide range of elements that influence and determine their actions. Resources are multidimensional, with ethical, scientific, professional, behavioral, cultural, social and legal elements, which lead to great complexity and uncertainty at the time of ethical decision-making.8

This study addresses the theme of ethical decision-making, a key requirement for professional excellence. The ability to make decisions is interrelated with the ethical competence and autonomy of the nurse.9 The well-being and safety of the user depend largely on the ethical decisions that nurses take, with these decisions often being complex. In this context, the guiding questions used in this study were, what are the key elements for ethical decision-making in nursing and which strategies facilitate the ethical decision-making of nurses?

The taking of a decision by the nurse needs to be done carefully and thoughtfully, considering all the elements involved in the ethical problem. Based on these reflections, this study aimed to identify the elements and strategies that facilitate the ethical decision-making of nurses faced with ethical problems, from publications on the subject.

The article is structured in accordance with the integrative literature review methodology, in which the guiding questions are described, databases verified, the keywords used, the criteria for inclusion, exclusion and analysis applied, and the interpretation and presentation of the data performed.


An integrative literature review was developed.10 This method enables a broad comprehension of a particular subject, while highlighting the gaps in knowledge that need to be explored in new studies. To increase the rigor of the review, the study followed the following steps: identification of the problem, literature search, evaluation of the studies included, analysis and presentation of the data.10

The guiding questions of this review were: What are the main elements for ethical decision-making in nursing? What are the strategies that facilitate ethical decision-making in nursing? To answer them, an online bibliographical study was performed, in the databases: Scientific Electronic Library Online (SciELO), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Center on Health Sciences Information (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE). These databases were accessed through the VHL (Virtual Health Library) search engine and EBSCO.

The descriptors/MeSH and subject keywords used were: ethical decision-making, decision-making, problem solving, nurs*, ethics, nursing ethics, bioethics, ethical dilemma, ethical challenge. The following associations were created with the Boolean operator "and": ethical decision-making and nurs*, ethical decision-making and nursing ethics, problem solving and ethical dilemma and nurs*; ethical challenges and ethical dilemma, ethical challenges and bioethics and nurs*, ethical decision-making and ethical challenges, ethical decision-making and ethical dilemma. These descriptors were searched in English, Portuguese and Spanish. The bibliographic references of the studies included were reviewed in order to find any more material of interest to this study.

The inclusion criteria used were: original research articles, theoretical studies and case studies - in English, Spanish and Portuguese - with a health team that included nurses. No time limit was set in the search, as ethics was considered a theme that has permeated science since its inception.

The exclusion criteria used were: investigations with health teams without nurses, students and users as study subjects, experience reports, studies with poorly defined or little explained designs or aims, journalistic and editorial material.

The collection and analysis of data were carried out between the months of April and May 2014, separately by two researchers. The results were compared and disagreements resolved by consensus. That is: the researchers compared the results of the searches carried out independently in the databases, checking the differences in the findings, always aiming to include the largest possible number of studies. For the selection of the publications included in the study, the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)11 were used, as shown in Figure 1. The use of PRISMA was chosen as it facilitates the presentation of the study selection process and is considered useful for other types of reviews (in addition to the systematic review and meta-analysis), having wide applicability.11

For the analysis and interpretation of the data, the integrative literature review procedures were used, which included: observing the standards of the studies, the plausibility, the comparisons, searching for common and unusual patterns, summary of the data in general and the construction of a logical chain of evidence.10 For this, a structured instrument was used, which allowed the identification of the essential elements of the studies. This instrument allowed the synthesis and interpretation of the data and the basic numerical analysis of the extent, nature and distribution of the studies included in the review. Finally, the compilation and communication of the results was performed with the intention of presenting a general overview of the entire material, through a thematic construction according to the elements and strategies of ethical decision-making in nursing.

Figure 1 Selection of the studies in the databases 


The final sample included 19 studies, nine were empirical articles12-20 (when data collection of the study is from people), eight theoretical1,4,21-26 (when the study discusses a topic or a theoretical question, with no intervention at the level of experience) and two case studies27-28 (when the study has an empirical intervention, which allows the phenomena to be studied in depth in real contexts). The majority of the studies (95%) were published in English.1,12-28

Six studies were published in Nursing Ethics (impact factor 1.093, evaluation year 2013), three in the Journal of Advanced Nursing (impact factor 1.685, evaluation year 2013) and two in the Journal of Community Health Nursing (impact factor 0.65, evaluation year 2013). Considering the classification that has seven levels of quality of evidence,29 the results of this integrative review present a level of evidence of six, as they were derived from a single descriptive or qualitative study.

The studies included in this review were distributed between the years 198928 and 2013, with three articles published in the 1990s.20,22-23 Five studies were performed in the United States,1,14,22-23,28 three in the UK,20,25-26 two in Australia,15,19 Sweden,12-13 Norway17,24 and Canada16,18 and one in Israel,27 Brazil4 and Chile.21

Six studies were conducted in the hospital context,12-13,15,19-20,24 one with nurses of primary healthcare, pediatrics, adult health and obstetrics14 and one only with nurses of primary healthcare.17 The study participants were supervisors nurses,1-2,15 nurses,3,5,9 nurses and students,15,18 healthcare professionals17,19 and nursing managers.27 The majority of the authors (95%) were university professors.1,4,12-26,28 In one study27 the author was the president of a nursing association.

Seventeen studies were qualitative1,4,12-13,15-18,20-28 and two quantitative.14,19 The data collection methods used were questionnaires,15,19 interviews12,20 focus groups13,18 and combined methods: focus group and questionnaire,17 observation and interviews16 and questionnaire and interview.14 Seven studies carried out content analysis,13,15-18,20-21 two statistical analysis14,19 and two hermeneutic analysis.12,24

After the analysis, three categories were revealed: external factors of the ethical decision-making in nursing; individual factors of the ethical decision-making in nursing; and facilitating strategies of the ethical decision-making in nursing.

External factors of the ethical decision-making in nursing

This category highlights the issues related to external factors of the ethical decision, which contribute to the ethical decision-making in nursing. These factors can affect the perception of the existence of ethical problems, the solution alternatives and their consequences.

The factors that refer to the organizational characteristics are described in studies14,23,27 and indicate that the nurses experience tensions between the values ​​of the organization (the establishment of productivity, effectiveness and efficiency) and the professional nursing values ​​(quality of care, respect for the person and respect for autonomy, among others) that cause nurses to face conflicting demands.

Also, in the organizational context, one study,16 performed in a home care context, evidenced budgetary constraints and difficulties in establishing working relationships with other professionals. Nurses refer to working with technological limitations and failures in communication with other professionals,16 which ultimately hinder the work process.4,16,24

Regarding the social factors, the results indicate that the nurse needs to reflect with the family members about the care for the user and take the necessary decisions together with those responsible in order to favor the relationship of trust between professional, user and family members.15-16 The results show that, to comprehend the social context and values ​​of the people, the nurses find a comfortable way to participate in the decision-making of the users, and even in the construction of their own ethical decisions.4

Studies15,20-21 also reported that nurses must comprehend the characteristics involved in the case, that is, the perspective of the family, the user and the institution. Another study22 describes how the culture of the user and nurses influence the ethical decision, which results from the interaction between these subjects.

The legal issues that stood out in the results refer to the laws, the regulations, the code of conduct and "the code of ethics of the profession".13,15,21-22,25,27 The ethical principles and values ​​of nursing, are the main elements that influence ethical decision-making.18,21-22,25,27-28 The results show that the values, principles and responsibilities are important for decision-making in nursing.18,21-22,25,28 The ethical principles of autonomy, charity, not causing harm and justice were described in studies13,21,27 as the main guides of ethical decision-making in nursing.

Individual factors of the ethical decision-making in nursing

In this category, individual experiences, knowledge and communication were emphasized as elements that influence the ethical decision-making in nursing. The first step in the decision-making process is to identify the ethical problem, because without knowing the circumstances and facts involved in the problem it is impossible to make an appropriate ethical decision.26

Regarding the individual or personal factors, the studies show that professionals who work closer to the user experience ethical problems more often than professionals that work at more distance. That is, these nurses tend to experience ethical problems more often.17 The studies report that nurses need to develop critical thinking,18 confidence, courage and ethical sensitivity16,24-25 to make prudent judgments regarding the problems experienced.

Nurses, in the construction of their response to the ethical problem, seek a basis of scientific knowledge,1,16-18,22,24-25,28 with the central focus of their action being to satisfy the needs of the user. Elements were highlighted that assist in the comprehension of ethical problems, such as ethical competence1,17,22 and moral conscience.25

With respect to the ability to communicate, studies show that nurses need to convey information in a clear, objective and simple way, informing the users about their health, so that they can make their decisions, that is, the users are considered in their entirety as the focus of respect.4,15-16,24 One study15 states that the nurse assumes the responsibility for taking the decision together with the users, family members and team members, promoting ethically responsible decisions. The user-centered therapeutic relationship allows a relationship based on mutual trust and respect to be created.16

The set of individual factors that emerge from the findings demonstrates the breadth and complexity of the elements involved in ethical decision-making.

Strategies that facilitate the ethical decision-making in nursing

In this category, the strategies described in the literature that support the professional in ethical decision-making are presented, strengthening the analysis, reflection and discussion of the ethical problems experienced in the services.

One element in the decision-making is the ethical discussion among members of the health team.15,17,25,27 One study4 states that the moments of discussion and reflection function as an environment of sharing in the construction of the decision to be made, thus ensuring a prudent ethical decision. Ethical discussions do not relieve the responsibility of the nurse to decide; the duty of the decision is always with the person that experienced the ethical problem.

The moments of discussion and debate among the team appear to be essential, as, with the reflections that occur in the interdisciplinary spaces, new and better solutions are perceive for every ethical case.15,17,25,27 Another study17 also highlighted the importance of ethical reflection groups as spaces for nurses to reflect on their ethical problems.

Regarding the moments of discussions, the literature shows the deliberation process as a systematic and contextualized itinerary of analysis of the ethical problems, seeking practical solutions among the prudent alternatives.4 The deliberation enables nurses to consider the gaps in comprehension of an ethical problem and perceive the differences in values ​​and duties among the participants in order to find the "optimal solution". When this is not possible, it is necessary to find the least harmful solution that seeks the most appropriate way to solve the ethical problems in a reasonable and prudent manner.4

Studies13-14 describe that ethics education helps nurses to rethink other perspectives and learn new things that can lead professionals to change their beliefs and/or values ​​and increase their autonomy. Thus, participation in training increases the ability of nurses to provide quality care.15

Studies4,16-17,25 describe the need for the support of experts for health staff, in order to collaborate in the ethical decision-making of the nurses. The results show that clinical supervision contributes to the self-confidence, development of skills and knowledge and provides greater capacity for nurses to take responsibility and support the user.12-13,15,25 The exposure to other ideas and opinions can increase tolerance and the ability to comprehend the ethical problem, which may cause a change in values.4

From the review of the results, it is clear that personal elements, such as knowledge and communication, are the elements that exert greater influence on ethical decision-making. The intermediate elements refer to issues related to the organization of the services and social issues with regard to the team, users, family and managers. In the outermost level of decision-making, are the issues related to the law, as they appear in smaller numbers in the review.


This review highlighted the main characteristics, principles, values, duties and rights that nurses ponder, question and alternatively place in the construction of their ethical decision-making. This deliberation process results in the final choice, which must be a prudent and responsible decision. The multidimensional nature of the factors that influence the ethical decision demonstrates the complexity of the decision-making of the nurse faced with an ethical problem.8

The results show that nurses are confronted daily with the need to make ethical decisions. This decision cannot be understood as a banal choice, which requires little knowledge, skills or attention. On the contrary, dealing with ethical problems requires pronounced moral sensitivity from the nurse, as well as ethical knowledge, life experience, virtue, information and a great personal commitment to do what is "right".30

Ethical problems cannot be solved simply by nurses following pre-established standards or guidance. They require permanent creativity, as the answer has to be far-reaching, going beyond the solution of a particular case, in the sense of ethical excellence in the practice of health care.31 The ethical problems evidenced by nurses can be complex and the solution may often be ambiguous. Studies30,32 validate the findings of this review, when stating that the way nurses face and respond to ethical problems can vary according to personal elements, such as the values, experiences, autonomy and skill of each professional.

The results of this study indicate that individual factors influence ethical decision-making. A study33 conducted in England shows that nurses prefer to rely on their own experience or on the experience of colleagues to respond to the ethical problems, and that these professionals do not usually look for solutions in the scientific literature when faced with situations of clinical uncertainty.

To reach a prudent decision, i.e., correct and rational decisions, experience is needed. It is therefore essential that professionals develop skills and ethical competence, to help manage the uncertainty and reduce the distress that the ethical decision-making process causes. To make prudent decisions involves questioning the uncertainty, knowing the context and specific circumstances of the ethical problem and predicting the possible consequences.6

The results also indicate that nurses experience more ethical problems than other professionals. The higher the moral sensitivity of the nurses, the better their ethical decision-making faced with the problems. According to one study,34 it is the moral sensitivity of nurses that allows them to be aware of the ethical problems of their profession and find creative solutions to each situation. Recognition of the problems allows the interpretation of the needs of the user, generating responses appropriate to these needs and promoting quality care.

The review highlighted that to construct ethical decision the nurse evaluates the ethical problem in all its complexity and includes the user in the construction of the decision. A study35 corroborates this statement by suggesting that human dignity and respect for the person were described as values identified by nurses in the decision-making. To respect the principle of human dignity, all other values will also be considered, i.e., the beliefs of the user will be respected, there will be privacy during the care, effective communication and the needs of the user will be met.

The review showed that external factors also directly or indirectly influence the decision-making and therefore need to be carefully evaluated and considered. The literature explains this finding stating that the difficulties experienced by professionals due to organizational constraints, such as the decrease in the number of personnel in the team or overburdened workloads, end up having negative effects on the quality of care. Adversity in the workplace can lead to moral distress, burnout, increased staff turnover and the decrease in the quality of care.36

In this context, due to budgetary constraints in the health services, it is possible for work overload, technical failures and ethical problems in nursing care to occur. In some cases, the practice becomes mechanized and there is lack of professional development policies.32 A study30 states that nurses who are not prepared to deal with the ethical dimension of the practice or have no skill to manage the ethical problems increase the occurrence of ethical problems in the services, causing stress for the health team and for themselves.

Another study32 corroborates the results of this review by stating that the organizational structure of the institution, the human resources policy and the objectives of the institution in providing care influence the practices of the nurses and hence their ethical decision-making. Nurses need to take into account the culture and the organizational system of the service in which they work, as it is mainly in this context that they experience ethical problems.37

The construction of the ethical decision in nursing also involves the participation of other team members, allowing other professionals, in addition to being responsible for the decision, to be invited to enrich, with their knowledge and experience, the construction of the best course of action for the resolution of the ethical issue.38 The more prospects and elements the professionals integrate, the more likely it is that the ethical decision will be prudent and reasonable. One study30 states that dialogue within the team is a good option for resolving ethical problems. Dialog encourages the participation and responsibility of nurses in the shared management of decision-making, acting as a protective factor, avoiding and minimizing situations of ethical conflict.30

The elements related to legislation, regulations and rules evidenced in this review also influence ethical decision-making. The standards, procedures and guidelines existing in the services are useful and relevant to nursing, as they provide structure for the daily practice; however, these rules cannot obstruct the application of ethical decisions. One study30 stresses the need to shift the ethical reflection from the simple consultation of the professional code of ethics, which is often based on obligations and obedience, to the perception of a sense of commitment to the right to health and the provision of effective and quality care. Conversely, the code of conduct is vital for the profession, as it provides a necessary means of self-control for the nurses, ensuring that they do not constitute a threat or risk to users or to the credibility of the profession in the exercise of their functions.27

The facilitator strategies of decision-making evidenced in this review refer to the discussions and debates among the staff, ethics education, the support of experts and clinical supervision. These strategies are essential to promote the ethical reasoning that the decision-making requires.9 One study39 states that, similar to clinical skills, ethical skills can also be acquired through experience and can improve over time through an adequate approach, with the use of different support strategies.

This review shows that to develop intellectual and cognitive skills for ethical decision-making, it is essential that continuing education initiatives and training programs are able to awaken professionals to reflect on their work process and the ethical problems present in this context, aiming for the extension of their ethical horizons. A study40 corroborates this finding, noting that nurses need support for the resolution of ethical problems and, therefore, proposes training and ethical education as a strategy.

Accordingly, ethical decision-making can be improved through integral training. This training needs to cover key concepts and explain how to apply the theoretical approach of ethics in the practice. Studies describe how ethics education has a positive influence on the ability of nursing students to make ethical decisions.30,41-42 Vocational training and the construction of knowledge develop from multiple dimensions, multiple perspectives and knowledge that enable support for the transition from the role of student to the role of nurse, emphasizing how to deal with ethical problems.35

Ongoing ethics education is of the utmost importance to help nurses properly manage ethical problems, providing tools and skills necessary for ethical decision-making.30 However, it is essential to prioritize the training of nurses who have practical skills, competence and ethical sensitivity to lead to reflection, discussion and responsible resolution of the ethical problems experienced in the health services.

This study aimed to evaluate most of the existing literature, however, some limitations to this process may have occurred, as there are studies published in other languages, as well as a wide variety of studies that probably exist in other indexing bases that may not have been included. The integrative literature review is only one of many methods that can be used to analyze the elements of ethical decision-making and other methods could possibly produce different results. Therefore, to explore the ethical decision-making of nurses through other methods and in other contexts is recommended.


As conclusive ideas of this study, it can be noted that the elements for ethical decision-making in nursing appear related to elements of the external context, comprising the characteristics related to organizational, social and legal factors. There are also the elements of the personal context, which include personal characteristics, communication and knowledge of the professional. Nurses analyze and compare the courses of action based on these multi-dimensional elements, which implies wide complexity in the ethical decision-making in nursing.

The results of this review are useful for nurses, because they need to develop habits, abilities, sensitivity and ethical competence to address the ethical problems of the practice, taking ethical decisions directed toward the development of effective and quality care for users and family members. Accordingly, ethics training needs to be ongoing in health services in order to enable nurses to fulfill their roles and responsibilities competently when faced with ethical decision-making.

This study found a variety of strategies that provide a way for the construction, analysis, reflection and discussion of the ethical problems of the practice; this allows the areas of uncertainty and ambiguity in ethical decision-making to be reduced. When using a support tool for decision-making, professionals promote a comprehensive and thorough approach to the ethical problem and decide correctly.

This review provides a consistent sample of studies in the area of ​​ethics in nursing, published in quality scientific journals with high impact factors. The research demonstrated comprehensive, encompassing studies from different decades. Nevertheless, more studies on this topic are needed in order to understand better the ethical decision-making process of nurses, providing the basis for the development of effective new strategies to address the ethical problems of the professional practice.


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Received: March 03, 2015; Accepted: September 25, 2015

Correspondence: Carlise Rigon Dalla Nora Rua João Pedro Ribeiro, 885, 1D 4000-308, Porto, Portugal E-mail:

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