The present study investigated the ethical principle of beneficence in nursing care and its related challenges in different studies. This integrated review identified four main categories (nature, applicability, relevant and influential factors, and challenges) and twenty-seven sub-categories. It is obvious that the ethical principle of beneficence is an integral part of the nursing code, also called the "moral heart of the nursing profession," so a nurse should provide nursing care only with the goal of providing benefit to the client[16]. It is on this basis that the code of ethics for nurses of the American Nurses Association begins with the understanding that attention to the health and well-being of patients and vulnerable persons forms the basis of the nursing profession[43]. In nursing ethics, beneficence is considered a moral commitment that is worthy and generous[44]. Despite the role of this ethical principle in nursing care, the Lack of acquaintance with the definition of beneficence concept is considered an important challenge[36]. What is observed in the reviewed studies; "doing good" is considered beneficial [12, 20, 22, 26, 34–37]. The difficulty of implementing this ethical principle; requires a clear definition of "what is good for a patient"[20]. This definition has been expressed in different forms in different studies, including doing good[12, 20, 22, 26, 34 − 3], maximum positive benefits for patients[16, 20, 22, 24, 34, 36–38], best care[16, 23, 34, 35, 37], the core of care[20], and ethical commitment to the benefit for patients[39].
The patient’s best interest must be the center of ethical decision-making at all times[45]. It is on this basis that in every context or every part of society, people should be encouraged to do good acts and benevolence, and their work and actions, both professional and personal, should benefit the people of the whole society[46]. The outcome of this good action will be providing maximum positive benefits for the patients and achieving the best care for them[34, 35, 47], which will ultimately improve the health and general well-being[46, 47].
In most cases, the principle of beneficence and nonmaleficence mean together[12, 16, 22, 26, 34–38, 40, 45], because non-maleficence prevents harming the patient but rather seeks to improve people's well-being and health[20]. In fact, avoiding any useless intervention and any action that may lead to irreparable harm (such as death) to the patient; is interpreted as nonmaleficences. As mentioned, beneficence and nonmaleficence are often two sides of the same coin and are discussed together, as the former involves doing good acts that benefit others, and the latter involves avoiding actions that harm oneself or others. Having these two principles together, conflicts between the care team and the patients' families are inevitable[48]. Although both of these principles are important, the duty of nonmaleficence is considered a stronger commitment in health care[49], in fact, the principle of beneficence requires that "good" be done, and "harmful” actions for patients be avoided[10]. It may be said that the distinction between these two important ethical principles lies in the fact that beneficence is an ethical commitment to take positive steps to help patients and not merely to prevent harm[50].
Recent research shows that health care institutions and organizations that have a benevolent ethical atmosphere may achieve better clinical results, improve patient and family satisfaction, and reduce patient mortality[51]. The importance of these two principles, as the main values of nursing, always influences their behavior to direct their actions for the benefit of patients[36]. Nevertheless, nurses should understand that benevolent actions may not always be a benefit to patients[43] and sometimes conflict with preserving the ethical principle of autonomy[16, 22, 25, 26, 34, 37–39].
Since the professional duty to respect the rights of patients and their autonomy decision-making is considered a universally accepted norm[43], it may be said that nowhere in the ethical decision-making situations; the contradiction is not as obvious as when the principles of beneficence and autonomy collide[47]. However, in all clinical decision-making situations, novice and experienced nurses must consider the patient's right to autonomy and consider their nursing care beneficial for the patient's health outcomes[52]. To achieve this level of care, nurses should expand the scope of ethical principles of beneficence, autonomy and patient Advocacy in patient care[22].
The principle of beneficence makes it necessary to provide equitable care based on need and equally without discrimination for all patients[48], so when nurses are required to make decisions that negate the patient's autonomy, these decisions should be considered as complying with the principle of benefit for them[52]. It should be noted that ignoring the principle of patient autonomy is considered a very serious issue, but it can be considered when there are real reasons to maximize beneficence and as long as it is consistent with the patient's values[47, 53]. Therefore, a nurse can only prioritize beneficence over the principle of client autonomy when there is a good reason that the client's respect will be preserved and she/he will really benefit from this approach[16, 39]. Nevertheless, sometimes nurses report that they experience ethical dilemmas in ethical principles; in these cases, it is recommended that nurses decide on the best care option for patients; consider their needs and preferences[25]. The beneficence can include patient autonomy because "the best interests of patients are closely related to their preferences," which is one of the main duties of the health team towards all patients[54]. On the other hand; respecting the needs, values, and preferences of the patient and their family are at the core of nursing care, and nurses should be aware of these needs by documenting the life history of the patients because the needs and interests of patients are formed based on religious, cultural and social issues[16, 26, 41, 55]. This attention to values in care protects and defends the client and ensures that the best decisions are made in the best way[55].
By the way, health care balances the ethical principles of beneficence and justice, and the best possible care for patients with equitable care is presented for the entire population using limited resources in the most efficient way[35]. It should also be considered that the principle of justice provides a key link between the importance of health for individuals and the responsibilities of promoting the health of society[56]. However, any choices for the patient may sometimes create a conflict between justice and the beneficence[34]. Some researchers consider the attention to beneficence before justice, although the principle based on justice is based on profit, which is reflected in the health system[56]. However, the priorities of health care should be focused on distributive justice, which means that decisions should be made in such a way that, according to the amount of cost; will provide the care to patients that is beneficial for a large number of patients and focus on achieving the greatest benefit for a large number of them[35]. According to the studies, most ethical theories have accepted various aspects of beneficence and consider it as a basis for creating the most benefit for all patients[19].
The attention and focus of the principle of beneficence in nursing management is also on providing safe, effective, timely, efficient, fair, and patient-centered care combined with accuracy, kindness and staff collaboration[37]. In such ethical climates, nursing staff are supported by managers in decisions- making For the benefit of patients[57]. With this point of view, the ethical principle of beneficence will undoubtedly be an integral part of the mission of the nursing profession to reduce the pain and suffering of patients[58]. Achieving this requires nurses to be equipped with ethical knowledge and insight[16], and the responsibility of nurses as an ethical commitment for increasing patient’s trust and their family, so that the beneficence applicability will reduce their pain and suffering, especially in end-of-life and palliative care[41].
Truth-telling to the patient as an issue of communication and trust is considered as the applicability of beneficence, which nurses should combine it with the patient’s autonomy and balance it in their care. As a result, the goal of Truth-telling in health care will be achieving treatment that is effective and based on the patient’s interest[26, 45, 47].
In general, it should be noted that the main guideline in ethical judgment about different choices, especially in case of conflict and dilemmas, is to refer to beneficence, which includes a kind of rational profit in terms of cost-effectiveness regarding the results of the intervention and outcomes for the patient[48].
Studies show that although nurses have good knowledge about nursing ethics, most are not familiar with the principle of beneficence in nursing care and what is good for the patient and for her/his benefit[34, 42]. However, the health promotion programs, policies, research, and access to health care have the principle of beneficence at their core[20]. Therefore, considering the importance of the principle of beneficence in nursing care; it is necessary to carry out appropriate studies with the approach of the beneficence concept and different aspects of this important ethical principle.