Navigating Ethical Tensions in Primary Healthcare Nursing: Frequency, Impact, and Management Strategies in Ethical Dilemmas

Abstract

Background: Ethical decision-making is central to nursing practice, yet the frequency and nature of ethical dilemmas in primary healthcare settings remain underexplored. Nurses often operate autonomously in resource-limited environments, where institutional support and formal ethics infrastructures are scarce.

This study aimed to investigate the frequency, perceived impact, and management strategies of ethical dilemmas among primary healthcare nurses in Greece, as well as the demographic and professional predictors of ethical attitudes and knowledge.

Material and Methods: A cross-sectional descriptive-analytical study was conducted among 492 registered nurses working in public primary healthcare units under the 2nd Regional Health Authority of Piraeus and the Aegean. Data were collected using a structured questionnaire including demographic variables and the Nurses’ Ethics Questionnaire (NEQ–Gr). Descriptive statistics, bivariate analyses, and multiple linear regressions were performed using IBM SPSS Statistics 28.0.

Results: Ethical dilemmas were frequent, with 73% of nurses encountering them at least monthly. Moral distress—acting against personal ethical values—was reported by 47% at least occasionally. The overall ethical attitude score was high (mean 3.8 ± 0.4), reflecting positive orientations toward truth-telling, informed consent, and patient autonomy. Higher education (b = 0.03, p = 0.048) and employment in areas with refugee reception facilities (b = 0.18, p < 0.001) predicted stronger ethical attitudes. Educational level was the only significant predictor of ethical knowledge (b = 0.10, p = 0.014).

Conclusions: Greek primary healthcare nurses frequently face ethically challenging situations with limited institutional support. Education and work context significantly influence ethical competence. Establishing ethics committees, integrating applied ethics into nursing curricula, and fostering moral resilience are essential to strengthen ethical decision-making and the moral integrity of care.

Keywords:

Nursing ethics; Ethical dilemmas; Primary healthcare; Moral distress; Ethical knowledge; Ethical attitudes; Ethics committees;