Ethical Dilemmas and Clinical Decision-Making Processes Faced by Nurses Working in High-Stakes Critical and Emergency Care Environments

Abstract

Nurses working in critical and emergency care environments frequently encounter ethical dilemmas due to the urgency, complexity, and life-threatening nature of patient conditions. These high-stakes settings demand rapid clinical decision-making that must balance ethical principles, patient needs, institutional policies, and resource limitations. This study aimed to explore the ethical challenges faced by nurses in such environments and understand how they navigate clinical decisions under pressure. A qualitative exploratory design was employed, using in-depth semi-structured interviews with 15 registered nurses working in critical and emergency care units across major hospitals in [City/Country, e.g., Lahore, Pakistan]. Participants were selected through purposive sampling to capture a range of experiences. Data were analyzed thematically using Braun and Clarke’s method to identify recurring patterns and insights. The study revealed five major themes: (1) Conflicting values between patient autonomy and medical necessity, (2) Emotional burden of end-of-life decisions, (3) Pressure from families and physicians, (4) Inadequate institutional support in ethical decision-making, and (5) Reliance on peer consultation and personal moral frameworks. Nurses expressed moral distress when unable to advocate effectively for patients, especially in resource-limited or policy-restricted situations. Ethical dilemmas are pervasive in emergency and critical care settings, profoundly influencing nurses' clinical decision-making and emotional well-being. Institutional ethics training, supportive leadership, and access to ethics consultation services are essential to empower nurses and promote ethically sound care under pressure.