The main theme that 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 indifferent 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 neutralization
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. When a nurse wants to do things ethically, she/he may be criticized by colleagues and managers, because working this way usually takes more time. For example, while teaching needed cares to the patient's family is the nurse's duty, providing proper care and preventing nosocomial infections takes precedence. Heavy workload and nursing shortage may make some nurses want to lighten their work. They may criticize a nurse who does her/his job in accordance with ethical principles because it is more time-consuming.
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 some hospital wards, doing things immorally has become routine. In these wards, newcomers who want to work with the ethical principles that they have learned are suppressed by the managers. Department managers do not tolerate this kind of work because they will change their routines.
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. When a nurse does her job ethically, she/he expects the system to encourage her/him. Some hospitals do not have a system that encourages ethical performance. Lack of a proper encouragement system along with punishment for ethical work reduces the moral motivation to act.
The election of the most 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. In a context where the unethical practice has become the routine, false judgments were the result of confusion between ethical practice and being slow or a novice. In such a situation, it becomes difficult for the nurse to have moral performance.
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. A patient with poor condition sued a nurse over his pain while the nurse put analgesic on hold because of its side effects. Lack of enough support for working ethically can lead to job dissatisfaction.
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).
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, after entering the profession, tried to be like others to avoid confrontation. They said that when in Rome, do as the Romans do. In this case, the nurse may imitate other immoral actions to be like everyone else.
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).
Role models play an important role in shaping the moral performance of nurses. Many role models affect the nurse after entering the profession. If the nurse follows role models that are morally neutral or negative and have immoral performance, it will have a negative impact.
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).
Many novice nurses follow the ward’s managers and centers of power. The hierarchy of power and work experience that exists in nursing makes junior nurses follow senior nurses. Our participants told us that 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).
Rewarding immoral work can cause people to repeat it. For example, early completion of work or approval by a superior can cause a person to repeat his or her immoral work. 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).
Eventually, some nurses become disappointed, they do not attempt to do the work ethically, and they may start doing immoral actions.
Getting negative results from moral performance and positive results from immoral performance and the lack of an accurate and appropriate encouragement and punishment system caused the nurse to give up. 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).
When nurses did not get a positive result from their ethical work, they did not continue. One of our participants said she stopped trying to do the right thing because she thought it is futile.
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).
The positive consequences of the immoral act prompted the nurses to start doing it. This positive result may have happened to them or they may have seen it in the work of others. 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).
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).
Nurses who still cared about moral performance tried to justify their immoral actions. 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).
Numerous reasons such as high workload, low wages, nursing shortage, high responsibilities, and low working hours were explanations that were used to justify immoral actions. Nurses were trying to calm their conscience in this way. 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).
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).
Levels of moral numbness may occur in the nurse. Because the nurse does not care about moral performance at this stage, she/he may even intentionally do immoral work. One of the nurses mentioned that she was not caring for the patients anymore.
Sometimes you don't’ know 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).
In some cases, nurses who initially tried to engage in ethical practice became so immoral that they deliberately committed immoral acts. Some of them were even proud of committing immoral acts. 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).
Finishing daily work without even paying attention to the ethical aspects had become a priority for some nurses. 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).