The main theme emerged from our analysis is moral neutralization. It means that nurses began with ethical practice, but their work environment discourages them. The unethical practice became normal for them. This process makes them give up eventually, and they began to practice unethically. They start to justify their immoral practice. Moral indifference develops in some of the nurses. We named this process, which started with feeling discouraged from becoming morally indifference as moral neutralization. We found five sub-themes regarding moral indifference? including (1) feeling discouraged, (2) normalization, (3) giving up, (4) becoming a justifier and (5) moral indifference. The main theme, sub-themes, and codes are presented in Table 2.
Table 2
Main theme, subthemes, and codes of moral neutralisation
Main Theme | Subthemes | Codes |
Moral neutralisation | Feeling discouraged | Be criticized for ethical performance Being punished for doing work ethically Weak encouragement system False judgment Low job satisfaction |
Normalization | When in Rome, do as the Romans do Following neutral role models Doing the orders Earning positive results from wrong actions |
Giving Up | Disappointment Stop trying Doing the job wrong Closing eyes on others fault |
Becoming a justifier | Using economic aspects as an excuse Having too many responsibilities as an excuse Rationalaising immoral actions with a heavy workload |
Moral indifference | Decreasing sensitivity Not caring about the patient Not feeling guilty Putting the job first |
Feeling discouraged
The first sub-theme of moral neutralization was feeling discouraged. Nurses started their work after graduation with ethical values that they learned at school. However, they were criticized and punished for doing ethical practice. They believed that the weak encouragement system was the main cause of this feeling.
Some nurses mentioned that they were criticized for ethical performance.
In my previous ward, nurses asked the patient’s family to do the endotracheal suctioning. Their excuse was that the family should learn how to do the procedure because they have to do it in the home. But I did the procedure myself. They criticized me because I was disturbing their routine (Nurse 16).
Being punished for doing work ethically was a pattern that we found in the data.
In our ward, preparing the deceased for transfer to the mortuary is done by environmental services and the patient’s family, while it is the responsibility of the nurse. The first time I did it for a patient, the head nurse wanted me and penalized me harshly. She said you do not have the right to change our way of doing work (Nurse 21).
Nurses blamed the weak encouragement system for this feeling.
The election of the ethical nurse of the year is based on work experience. It doesn’t matter how ethical you are; you should wait until your turn comes (Nurse 6) .
Some nurses thought they were falsely judged.
Because I do nursing care very carefully, it takes a lot of time. My work usually lasts long after the shift. My colleagues have accused me of being slow (Nurse 8).
Being criticized or punished for ethical work led to low job satisfaction.
I put the patient’s analgesic on hold because it started to show side effects. He had pain yet, but the side effects were hypotension and bradycardia which are dangerous. He sued me, and no one supported me for that. I did the procedure correctly. A situation like this makes you unhappy (Nurse25).
Normalization
Nurses start to do what they see and learn from the work environment and other nurses, things they order to do. Furthermore, they earn positive feedbacks and result from unethical practices.
Some nurses said that when in Rome, do as the Romans do.
In our ward, it is routine to infuse several drugs together. This makes things run faster. I do it like others, to finish my work more rapidly (Nurse15).
They were following neutral role models who may do unethical works.
When I was new to this ward, one of my colleagues who had 15 years of work experience, was my model. Once, a patient had a cardiac arrest, he did not CPR the patient. Only he shook the leads to have a CPR strip on the monitor. After that, I learned to do the same on patients who need CPR (Nurse12) .
Our participants told us they began to do the orders after a time because they did not have enough authority.
Our head nurse does not believe in administering opioid analgesics to addict patients. She says it is a waste. She forbids us to administer opioids to them. We do the order regardless of the severity of the patient’s pain (Nurse 5).
Some nurses argued that they stopped doing the right thing because they earned positive results from wrong actions.
Before doing the postoperative care, I had it recorded in the report. Supervisor arrived and only read my report without checking the patient. She applauded me for writing such a detailed report without checking the patient. I realized that good care is not important, we should only write it down. I was punished before, for a late recording of the care that I have been done (Nurse 17).
Giving Up
Eventually, some nurses become disappointed, they do not attempt to do the work ethically, and they may start doing immoral actions.
Some nurses express their disappointment from doing ethical practice.
There is no point to do work ethically, nothing will change. I tried it by reporting the faults in the ward, and nothing happened. I am so disappointed with the system (Nurse 10).
One of our participants said she stopped trying to do the right thing.
Previously, I used to report medical errors of my colleagues. However, I stopped it, because the head nurse did not care or handled it, a way that caused a lot of problems in the ward (Nurse 20).
Even some nurses mentioned that they started to do the job wrongly.
We are ordered to record ECG every three hours. I take all three ECGs on one occasion, and I write a three-time stamp on them (Nurse 15).
Closing eyes on other's fault was another example.
I never reported my colleagues' faults, somehow I managed the situations. We are colleagues; we are supposed to have each other's back. I'm a conservative person I don't want to disturb the ward atmosphere (Nurse 11).
Becoming a justifier
Nurses who we were interviewed tried to justify their immoral actions. They used economic problems, having too many responsibilities and a heavy workload as excuses.
The following quote is an example of using economic aspects as an excuse.
Bathing the patient is the duty of the nurse. I used to do it myself. But now I give it to environmental services. How much they pay me to do such hard things (Nurse 6).
Some nurses claimed that they had too many responsibilities, and this forced them to do immoral actions.
I have a lot of paperwork. How do I suppose to provide good care of my patients, talking to them or providing mental health care for them? I have too many responsibilities (Nurse 21).
The following quote is the rationalization of immoral actions with a heavy workload by an interviewed nurse.
When our ward has too many turns over, I administer the antibiotics with intravenous injection, I don’t have time to do the infusion (Nurse 7).
Moral indifference
Some nurses reach a level of moral indifference, which shows itself with a decrease in sensitivity to the moral aspect of care. They even stopped trying to justify their immoral action and put morality away.
Decreasing sensitivity was one of the main aspects of moral indifference which was mentioned.
When I came to this ward when the physician asked me to decrease the ventilator support, it was very hard for me, I couldn’t do that, it was very challenging. Now, I do that without thinking about it. I will do the order (Nurse 2).
One of the nurses mentioned that she was not caring for the patients anymore.
Sometimes you don't’ have the knowledge of something, and you do a procedure incorrectly. But I have enough knowledge. For example, I know that the restrictions shouldn’t be tight, and we have to check them several times during the shift. But I don’t do that. I don’t care (Nurse 12).
Some of them said that they lost their feeling of guilt.
When I was a novice, I used to administer the drugs on time. When I didn’t do that I had a guilt feeling. Now, I administer all drugs at the beginning of the shift without looking at their time of order, and I don’t have any bad feelings about it (Nurse 19).
One of our participants mentioned that she put the job first without considering moral aspects.
While I am at work, most of my attention is on completing the job. I don’t think about patients’ feelings and even their health. For example, when I fix the IV, I use a lot of surgical tapes. I want it to be fixed completely and making no problem for me. It can hurt the patient's skin, but it doesn’t matter. What I care about is only doing the job (Nurse 23).