Article

Ethical decision-making and

professional behaviour among
nurses: A correlational study

Nursing Ethics
20(2) 200212
The Author(s) 2012
Reprints and permission:
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10.1177/0969733012455562
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Birgul Cerit
Abant Izzet Baysal University, Turkey

Leyla Dinc
Hacettepe University, Turkey

Abstract
This study examined the relationship between nurses ethical decision-making levels and their professional
behaviours. Data were collected from 225 nurses who were recruited from university hospitals in Ankara
using proportionate sampling. Data were analysed using descriptive statistics and Pearson correlations. Most
of the nurses were familiar with ethical dilemmas in nursing practice. The Nursing Principled Thinking level
was above average, while the Practical Consideration level was average. Nurses professionalism level was low.
There was a positive but weak correlation between professional behaviours of the nurses and their ethical
decision-making levels. Increasing nurses professionalism level can provide a positive contribution to the ethical decision-making level.
Keywords
Ethical decision-making, nursing ethics, nursing practice, nursing professionalism

Introduction
Ethics are of utmost importance in health care due to the moral questions raised by the advances in science, medicine and biotechnology.1,2 Life-prolonging treatments and technologies, organ transplantation, genetic testing and stem cell research, for example, raise ethical problems that are confronted
by health-care professionals. Therefore, it is crucial for health-care professionals to be aware of ethical
problems, to have the ability to apply moral reasoning to those problems and to develop ethical decisionmaking skills.3,4
According to the International Council of Nurses,5 nursing includes the promotion of health, prevention
of illness and the care of ill, disabled and dying people. Explicit in this definition is caring for people who
are in need. Caring requires more than theoretical knowledge and technical skills; caring has an affective
component that includes awareness of others vulnerability, attentiveness to caring needs and a moral
response to the needs.
As caring is a continual process, nurses spend more time with patients than any other health-care professionals. The close relationship between nurses and patients enables nurses to witness illness experiences and

Corresponding author: Birgul Cerit, Bolu Health School, Abant Izzet Baysal University, 14280/Bolu, Turkey.
Email: birgulcerit@yahoo.com.tr

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201

suffering of patients, all of which demand that nurses make moral judgements with and for those
patients.6 In the meantime, because of the complex ethical issues raised by developments in medicine
and biotechnology, it is essential for nurses to be involved in ethical decision-making processes.
Ethical decision-making is requisite for being a professional, and it is interrelated with professional
competency and autonomy. Thus, it is important to investigate nurses ethical decision-making levels
and professionalism.
Studies report that nurses increasingly confront ethical problems in nursing practice. The relationship
between nurses ethical decision-making levels and their professional conduct is also well acknowledged.710 However, little is known about the relationship between nurses professional behaviours and
their ethical decision-making levels within a secular country with a diverse culture that is mainly affected
by Islamic religious and Mediterranean patriarchal values. As ethical orientation is strongly related to ones
cultural background and professional behaviours are influenced by various factors, it is of interest to ethicists and nurses across cultures to understand the relationship between nurses ethical decision-making
levels and their professional conduct.

Background
Nurses have been striving for professionalism for over a century. Although there is no consensus as to what
constitutes the proper attributes of a profession, Pavalko11 offered the following criteria: a profession should
involve a specialized theory and intellectual technique, should be relevant to basic social values and
processes, should reflect the nature of preparation in terms of the amount and specialization of training and
should motivate members through their service to society, autonomy of practice, sense of commitment,
sense of professional community and codes of ethics. Other investigators also identified similar characteristics of a profession.1214 While all of these characteristics are interrelated, the code of ethics is essential for
autonomy, which allows professionals to make their own judgements and decisions about the services they
provide.
Decision-making is a rational process and includes sequential phases of problem recognition, problem
identification and evaluation of alternatives and the selection of an alternative. Ethical decision-making
is also a rational process involving cognitive activity; however, it also involves moral judgement and justification of the decision.15
Kollemorten et al.16 argue that a clinical decision has an ethical component if it is based on a value
judgement, either to assess the value of the consequences of a decision or to assess the extent to which the
duties of the decision maker and the rights of others are fulfilled. They point out that a value judgement is
based on non-scientific premises.
Lawrence Kohlberg17 suggests that individuals progress through three levels in the ability to make moral
judgements: (a) the pre-conventional level, when moral decisions are based on rewards and punishments
and obedience to authority; (b) the conventional level, when individuals recognize societal laws and rules
and are concerned regarding collective welfare and (c) the post-conventional level, when moral decisions
are based on internalized moral values and abstract principles. Principled thinking occurs at the postconventional level; Kohlberg argued that few people attain this level, especially as moral reasoning is
stimulated by cognitive conflicts. For Kohlberg, the highest stage of moral development involves a concern
for justice and human rights based on internalized universal principles. Although Kohlberg did not link his
model of moral development to a process of ethical decision-making, his stages are often used as a measure
of moral judgement.15 However, Kohlbergs assumption that moral thinking is equated with a justice perspective has been criticized. For example, Gilligan,18 who studied with Kohlberg, questioned his research
findings because they were focused solely on males. She found that the moral reasoning and development of
women and men differed; women placed more importance on relationships and caring for themselves and
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others than on rules and principles. Gilligan has focused on the consideration of care for particular persons
within the context of particular relationships. Some nurse scholars believe that ethics of care can be used as
the basis of ethical decision-making, while critics argue that caring is too subjective19 and is limited as an
ethical basis.20 Others suggest an integrated approach of ethics of justice and ethics of care as a theoretical
basis to inform ethical decision-making.21,22
Although there is no consensus on which ethical theory or moral perspective decisions should be based,
nurses are confronted with ethical problems and are expected to make ethical decisions. However, the
nature of ethical problems that involves complex situations and moral dilemmas, in which the moral solution is ambiguous, may influence the ethical decision-making process. In addition, how nurses respond to
ethical problems varies by professional experience, autonomy and competency. Social and cultural factors
can influence nurses professionalism and ethical decision-making. Thus, it is important to examine the
relationship between nurses ethical decision-making and their professional behaviours from different
cultural contexts.
There are numerous instruments for measuring the moral reasoning and moral judgement of individuals,
which have been adapted into Turkish, including the short version of the Defining Issue Test, which was
devised by James Rest23 in 1979 and adapted into Turkish by Cesur24 in 1997, and the Moral Judgment
Abilities Test (MJT; MoralischerUrteilTest (MUT)), developed by Lind25 in 1977 and adapted into Turkish by Ciftci in 2001.26 There are also two instruments, which are specific to nurses and can be used in
Turkish context, including the Moral Sensitivity Questionnaire developed by Lutzen et al.27 in 1994 and
adapted into Turkish by Tosun in 2003,28 and the Nurses Ethical Sensitivity Test, developed by Byrd29
in 2006 and adapted into Turkish by Orgun and Khorshid30 in 2009. However, none of these instruments
are specific to nurses ethical decision-making. Validated measures of nurses ethical decision-making in
a different culture could be helpful for nurses to monitor and develop their ethical decision-making skills
and professional conduct.

The study
Aim of the study
Turkey has a collective and paternalistic culture, which emphasizes interdependence, cohesion and loyalty
within social groups, and gives priority to collective interest over individual autonomy.31 As cultural values
are internalized through the process of socializing, culture can influence individuals beliefs, values, ethical
decisions and professionalism. The aim of this study was to investigate the correlation between nurses professional behaviours and their ethical decision-making in a different cultural context by adapting the Nursing Dilemma Test (NDT) into Turkish.

Design
This study was descriptive and correlational in design and was conducted in two phases. Phase I, in 2008,
included the adaptation, content validity and reliability testing of the NDT. Phase II, in 2009, investigated
the correlation between nurses professional behaviours and their ethical decisions.
Study phase I. The first phase of this study included the translationback translation, content validity and
reliability study and preliminary testing of the NDT, which was developed by Patricia Crisham in 1981
at the University of Minnesota. Using interviews with 130 registered nurses who were asked to provide
actual experiences with ethical dilemmas in nursing practice, Crisham32 formulated six scenarios. Each scenario presents a situation that is likely to generate moral confusion for nurses who are caring for the patient
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and family. The ethical dilemmas are as follows: (a) newborn with anomalies, which considers the issue of
defining and promoting the quality of life; (b) forcing medication; (c) adults requests to die; (d) orientation
of a new nurse; (e) medication errors and (f) terminally ill adults. The newborn with anomalies, forcing
medication and adults request to die dilemmas involve issues regarding the clients right to autonomy.
The orientation of a new nurse and medication error dilemmas consider maintaining professional and
institutional standards and the fair distribution of nursing resources in paediatric and surgical nursing. The
terminally ill adult dilemma addresses a clients right to know about his personal health care.
In the NDT test, nurses are asked to respond to three sections of questions after each scenario. Section A of each
dilemma asks what a nurse should do. Nurses are expected to choose one of three items. For example, the dilemma
of forcing medication asks whether the nurse should forcefully give the medication or remain undecided.
In section B, nurses must consider six common items in relation to ethical dilemmas in clinical practice.
Nurses are asked to rank the six items in order of importance. The nurses responses to this section indicate
their Nursing Principled Thinking (NP) and Practical Consideration (PC). NP refers to an individual level
of reasoning and behaviour that reflects the post-conventional level of Kohlbergs theory of moral development. PC refers to environmental factors, including available resources, institutional policies and perceived management support, that affect ethical decision-making.
In the NDT rankings, the item ranked as the most important for each dilemma received 6 points; each
subsequent ranking was given one point less such that the item ranking sixth received 1 point. The NP score
was calculated by adding the scores of the NP items across the six dilemmas. The NP index represents the
sum of weighted item ranks and is interpreted as the relative importance given to principled moral
considerations. The highest possible NP score is 66, and there are two NP items for each dilemma. The relative importance given to PC was indexed in a similar process. The PC index represents the sum of weighted
PC ranks and is interpreted as the relative importance given to PC in making a nursing moral decision. The
highest possible PC score is 36 with one PC item for each dilemma.
Section C requires nurses to indicate familiarity with the ethical dilemma. Similar to the NDT, familiarity refers to nurses previous experiences with the ethical dilemmas. To measure the nurses degree of previous involvement with a similar dilemma, a 5-point Likert-type scale was used with each dilemma: 1
indicated made a decision in a similar dilemma, 2 indicated knew someone else in a similar dilemma,
3 indicated not known anyone in a similar dilemma but dilemma is conceivable, 4 indicated difficult
to imagine the dilemma as it seems remote and 5 indicated difficult to take the dilemma seriously as it
seems unreal. The Familiarity (F) score was calculated by adding the points that indicated the participants
degree of familiarity across the six dilemmas, and the F index represents the sum of the familiarity scores.
The classification of the subject as familiar or unfamiliar with the dilemmas was based on the properties of
the F scale: a score of 617 indicated familiarity with the dilemmas and a score of 1830 indicated a lack of
familiarity with the dilemmas.32,33
In phase I of this study, the NDT was separately translated from English to Turkish by three
English language experts. After the translation, researchers prepared the first Turkish version of the
NDT by comparing and assessing three translations. The Turkish version of the NDT and its original
English version were submitted to three experts in areas of nursing, deontology and history of medicine and Turkish language and literature. These experts checked the first Turkish version of the NDT
to measure its compatibility with Turkish language and its content validity. The test was then revised
by the researchers to address the critiques and suggestions of the experts. The Turkish version was
translated into English by another English language expert to determine whether it corresponded with
the original content.
For the assessment of content validity, the NDT was pilot tested with a purposeful sampling of 50 volunteer nurses who were employed at a public hospital. Nurses stated that they did not have any difficulties
understanding or completing the six dilemma test. Therefore, there was no need for further revision.
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To determine the internal consistency, the data were entered in the Statistical Package for Social
Sciences (SPSS) program. We found Cronbachs as of .59 for the NP level and .50 for the PC level (n 50).
To determine the testretest reliability, the test was administered at a 3-week interval to 25 nurses
working at a university hospital. Previous studies using tools to measure moral judgement or ethical
decision-making of nurses did not provide information on testretest reliability of the instrument,3235
while Corley et al.36 reported an interval of 3 weeks for testretest reliability. Our rationale for the
3-week interval for the retest was to reduce the carry-over effect, which refers to remembering the
answers from last time, and to reduce the likelihood of work-related factors such as changes in clinical
setting and organizational policies that may occur over time and influence nurses ethical decisionmaking. According to the literature, if the Pearson correlation coefficient is within the range .70.89, then
the relationship between the variables is defined as strong.37,38 Our testretest results showed a positive
relationship (p < .01; NP: r .77; PC: r .73).
Study phase II. The second phase of this study was carried out to investigate the correlation between nurses
professional behaviours and their ethical decision-making.

Sample
In phase I of this study, a purposeful sample of 50 volunteer nurses was recruited from a public hospital to
assess the content validity, and 25 nurses were sampled from a university hospital to assess the reliability of
the Turkish version of the NDT. The participants (n 75) and settings in phase I were different from phase
II of the study.
The population in the second phase of this study consisted of 630 nurses with bachelors degrees who
were employed at three university hospitals in Ankara. The sample size was calculated using the formula
n N t2 pq/d2 (N  1) t2 pq, as suggested by Sekaran.37 Based on this formula, we calculated the sample
size as 242 nurses. Sampling was determined by proportionate stratification. Accordingly, we first identified the number of nurses working at each hospital and then calculated their proportion to the size of the total
sample. The participating nurses from each hospital were recruited randomly using a random number table.
As 17 nurses refused to participate, the study was conducted with 225 nurses.

Instruments
In the second phase, data were collected with two instruments: the Turkish version of the NDT to measure
the ethical decision-making levels of nurses and the Behavioural Inventory for Professionalism in Nursing
(BIPN) to measure the professionalism behaviour of the nurses.
The BIPN was developed in 1993 by Barbara Kemp Miller, Dona Adams and Lasca Beck.39 The BIPN
includes 48 questions. Questions 17 involve demographic characteristics of the nurses, and questions 848
cover professional behaviour. The BIPN has nine subgroups: (a) educational preparation, referring to the
highest nursing degree attained; (b) publication, referring to published nursing articles; (c) research, referring to involvement as investigators or participants; (d) participation in a professional organization; (e)
community service participation; (f) competence and continuing education, including reading and subscribing to nursing journals; (g) following a nursing code of ethics; (h) familiarity with nursing theory and (i)
autonomy, referring to participation in peer review, nursing audits, quality assurance, self-evaluation and
ethics committees, as well as budgeting for their areas, hiring and firing or consulting with other agencies.39
Behaviours are weighted within each of the nine categories to equal 3, such that a total scale score of 27
(9  3) is possible. Weightings for specific behaviours within each category range from 0.5 to 3. The BIPN
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was adapted in 2004 into Turkish by Karadag, Hisar and Elbas,40 and its validation and reliability were
confirmed (Cronbachs a .78.87).

Data collection
During the period from 16 March 2009 to 30 June 2009, the two instruments were administered to 225
volunteer nurses through face-to-face interviews (response level 92.97%).

Ethical considerations
The study protocol was officially approved, and ethical clearance was obtained by the Ethical Commission
of Hacettepe University. The medical and nursing directories of three university hospitals provided written
permission for this study. Nurses were informed about the aims and methods of the study. They were told
that their participation must be voluntary and that they could withdraw from the study at any time. Those
who agreed to participate signed the informed consent form. Written permission was granted by Patricia
Crisham in 2008 for the translation and adaptation of the NDT into Turkish. Similarly, written permission
was obtained from Ayis e Karadag et al. on 15 February 2008 for the use of BIPN.

Data analysis
The SPSS, version 15.00 for Windows, was used for data entry with appropriate coding and statistical
analysis. We used descriptive statistics to analyse the demographic data. Mean and standard deviation
(SD) were used to identify the NP and PC scores for ethical decision-making and for scores of professionalism behaviours. Cronbachs as were calculated for NP and PC scores as a measure of internal consistency,
and testretest reliability was tested with a Pearson correlation coefficient. The degree of association
between nurses ethical decision-making and professionalism behaviours was also analysed with a Pearson
correlation coefficient. Statistical significance was set at p < .05.

Results
The age of most participants (86%) ranged from 18 to 30 years. More than half of the participating nurses
were working at clinics, and 73% had 5 years of clinical experience. We identified Cronbachs as of .68 for
the NP level score and .56 (n 225) for the PC level.
Based on the data from section A of each scenario of NDT, approximately 69% of the nurses were in
favour of resuscitation of a newborn with abnormalities, more than half would administer medication
against the will of the patient and for the third scenario, 88% would provide respiratory support despite
a competent adult patients request to die. Almost half of the nurses stated that there is no time allocated
for the orientation of new nurses into the paediatric and surgical nursing clinic, as it would compromise
patient quality of care. The last scenario included a dilemma about a terminally ill adult who wanted to
know his diagnosis in spite of his doctors and family members wishes. Nurses responses to this scenario
were quite different, with 40.5% agreeing with the doctor and family and 33.8% remaining undecided
(see Table 1).
The mean NP score of nurses was 47.89 (SD 8.16), and the mean PC score was 17.34 (SD 4.12; see
Table 2). Nurses responses to section C of the NDT showed that 71.6% (n 161) were familiar with similar
ethical dilemmas in clinical practice.
The nurses mean BIPN scores were quite low (5.97). The highest average score was the theory subdimension, and the lowest average scores were the sub-dimensions publication, autonomy and public
service (see Table 3).
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Table 1. Nurses responses to section A of the Nursing Dilemma Test (n 225).

Dilemmas

What should nurse do?

Newborn with anomalies

Should resuscitate the newborn

Cannot decide
Should not resuscitate the newborn
Should forcefully give the medication
Cannot decide
Should not forcefully give the medication
Should provide assistance for artificial respiration
Cannot decide
Should not provide assistance for artificial respiration
Should allocate time for orientation of the nurse
Cannot decide
Should not allocate time for orientation of the nurse
Should report the medication error now
Cannot decide
Should not report the medication error now
Should answer the patients questions
Cannot decide
Should not answer the patients questions

Forcing medication

Adults request to die

New nurse orientation

Medication error

Terminally ill adults

%a

155
32
38
127
39
59
198
17
10
112
43
70
197
14
14
58
76
91

68.9
14.2
16.9
56.5
17.3
26.2
88.0
7.6
4.4
49.7
19.2
31.1
87.6
6.2
6.2
25.7
33.8
40.5

The table entries represent percentages of rows for each dilemma.

Table 2. Mean scores of nurses in Nursing Dilemma Test (n 225).

Nursing Dilemma Test
Nursing Principled Thinking
Practical Consideration
Familiarity

Minimum

Maximum

M (SD)

33
6
6

64
31
30

47.89 (8.16)
17.34 (4.12)
14.95 (3.98)

An analysis of the relationships between nurses professional behaviours and the levels of ethical
decision-making yielded the following results: there was a positive, weak, but significant correlation
between nurses principled thinking level and their total professionalism level and several subdimensions of BIPN (nurses research activities, participation in a professional organization, competency
and continuing education and autonomy) (r .172.287). There was no significant correlation between
nurses PC level and their professional behaviours (see Table 4).

Discussion
The first limitation of our study is the unacceptably low internal consistency estimates and no reported test
retest reliability for NDT, despite its use in several studies without additional testing.33,41 Compared to the
original NDT, we obtained higher Cronbachs as for NP (.68) and PC (.56) scores, and used testretest reliability, indicating positive correlation coefficients; however, our results also showed low reliability for this
test. In addition, although NDT content validity was approved by experts, we did not assess construct and
concurrent validity.
The second limitation is NDT scenarios representing ethical dilemmas. Although several instruments
were translated into Turkish to measure the moral reasoning of individuals, no instrument in Turkey
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Table 3. Mean scores of nurses obtained from BIPN (n 225).

Subscales of BIPN
Educational preparation
Publication
Research
Participation in a professional organization
Community service
Competence and continuing education
Codes of ethics for nurses
Theory
Autonomy
Total Score

Items

Minimum

Maximum

M (SD)

8
3
4
5
2
9
1
4
9
45

1.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.00

3.00
2.50
3.00
3.00
3.00
3.00
3.00
3.00
2.50
19.50

1.06 (0.34)
0.07 (0.35)
0.45 (0.70)
0.50 (0.71)
0.23 (0.73)
1.00 (0.82)
0.72 (1.28)
1.74 (1.07)
0.16 (0.44)
5.97 (3.80)

BIPN: Behavioural Inventory Form for Professionalism in Nursing.

Table 4. Correlations of nurses professional behaviours and ethical decision-making levels (n 225).
Professional behaviours
Educational preparation
Publication
Research
Participation in a professional organization
Community service
Competence and continuing education
Codes of ethics for nurses
Theory
Autonomy
Total Score of professionalism
*

Nursing Principled Thinking

.078
.080
.287*
.172*
.047
.228*
.127
.042
.232*
.222*

Practical Consideration
.040
.021
.048
.017
.021
.101
.001
.107
.010
.065

p < .01

measured specifically the ethical decision-making level of the nurses. In this study, we also used the NDT
because the scenarios were formulated by Crisham32 after interviews with 130 registered nurses who provided actual experiences with ethical dilemmas. The current study also provides evidence that most of the
nurses in our sample were familiar with similar ethical dilemmas in clinical practice. Thus, the six ethical
scenarios included in the NDT address a variety of client care challenges in nursing practice. In addition,
the NDT measures not only nurses responses to ethical dilemmas, and their level of moral reasoning, but
also the importance given to PCs that may affect moral reasoning. Therefore, we considered the NDT
more applicable to nursing practice. However, some of the ethical dilemmas presented in the NDT might
be regarded as scenarios involving moral distress, rather than really ethical dilemmas. Corley42 suggests
that when nurses cannot do what they think is right, they experience moral distress. According to
Jameton,43 moral distress refers to a negative state of painful psychological imbalance experienced when
nurses make a moral decision but cannot act accordingly because of real or perceived institutional constraints. Indeed, nurses are required to make decisions that take into account many factors, including the
institutional policies, organizational ethical climate and the expectations of the organizational authorities
as well as their professional, ethical and legal responsibilities. In the study of Pauly et al.,44 moral distress
intensity and frequency were found to be inversely correlated with perceptions of ethical climate, which is
described by Olson45 as the presence of organizational conditions that allow employees to engage in
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ethical reflection, and that provides the context for ethical decision-making in the clinical setting.
Although the sixth item of section B in the NDT measures the importance of PCs for each scenario, most
of the ethical dilemmas require nurses to make decisions by considering the orders of physicians for
patient care. For example, whether to resuscitate a newborn with abnormalities or not depends upon the
physicians resuscitation order. Similarly, answering a terminally ill patients questions about his medical
diagnosis or condition is beyond the nurses legal authority in Turkey. Except any condition that poses
risk for a patient, nurses have a legal obligation to carry out physicians written order, but they are also
legally obliged to respect patient rights, which require nurses to inform patients about their medical condition. Thus, due to the medical context of the ethical dilemmas of NDT, it is possible for nurses in our
sample to perceive their professional autonomy as under siege and feel unable to make their own ethical
decisions due to external restraints or their professional and legal obligations.
The third limitation relates to representativeness of 225 nurses working at three university hospitals
in Ankara. Although university hospitals differ from public hospitals by combining the health-care
services with education and research activities, regardless of hospital or work setting, nurses are
legally authorized to provide care for the individual, family and community, and to administer treatment and medications ordered by a physician. However, according to Turkish Ministry of Health 2010
data, Ankara has 72 hospitals, 9 (12%) of which are university hospitals.46 This limits the generalizability of our sample. Further research with a larger sample is required to assess the psychometric
properties of NDT and to investigate the correlation between nurses professional behaviours and ethical decision-making.
Fourth, our data are based on nurses responses to hypothetical scenarios in NDT and the closed questionnaire format of the BIPN. Finally, factors influencing ethical decision-making and professional
behaviour were not focused on separately. Despite these limitations, we believe this study contributes to
nursing ethics in Turkey and offers insights into the relationship between ethical decision-making and professional conduct of nurses from a different culture.

Nurses ethical decision-making

In this study, most nurses were familiar with ethical dilemmas of NDT. Our findings support studies suggesting that nurses frequently face ethical dilemmas.41,47,48 Familiarity with such dilemmas may contribute to nurses awareness of ethical problems in health care and can increase their capability to reason and
find possible solutions for problems that require ethical decision-making. Nurses responses to dilemma 1
(resuscitation of an anomalous newborn) and dilemma 3 (an adults request to die) suggested that most of
them favour pro-life rather than life quality. Their responses to dilemma 3 and the last dilemma (a terminal adults right to know) revealed their concern for the patients life rather than respecting autonomy.
Responses to scenarios on forceful administration of medication and reporting a medication error indicated that they considered patients welfare from a paternalistic perspective. These findings can be
ascribed to nurses religious orientations and cultural backgrounds. Studies report that culture and
religion can affect ethical decision-making.4951 Islam, the main religion in Turkey, stresses sanctity
of life, and Turkish culture is highly patriarchal and collectivistic. In this study, nurses pro-life and paternalistic choices against patients autonomy imply that religious and cultural orientations influence ethical
decisions.
The mean NP score (47.89) was lower than other scores reported33,41 (54.5 (SD 6.75) in Crishams
study).47 PC scores were similar to those in previous studies.41,47,48 Results of this study indicate that nurses
consider principled thinking when making ethical decisions; however, their decisions are influenced by
cultural/work-related factors.
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Nurses professional behaviours

In this study, nurses professional behaviour levels were very low (5.97 (SD 3.80)). Karadag et al.52 also
found low professionalism scores (5.45 (SD 5.10)), whereas Adams and Millers53 average score was
16.70 (SD 3.60). Nurses professional behaviours may influence public perception of nursing and care
quality. Our findings have implications for practicing manager and educator nurses and should also be interpreted within the historical development of nursing in Turkey. Formal nursing education started in 1925,
and higher education was accelerated after the 1990s. The patriarchal Turkish culture affects nursing care
quality and nurses professional behaviours while shaping the hierarchical structure in hospitals where physicians are dominant in decision-making. Nurses also reported that differences in education levels; increasing workload in our country, as well as throughout the world; lack of job security and inadequate staff and
resources contributed negatively to their professional behaviours.

The correlation of nurses professional behaviours and ethical decision-making levels

Our results showed a weak positive correlation between NP scores and nurses professional behaviours, particularly for participation in research activities and professional organizations, maintaining competence,
and continuing education and autonomy (r .172.287).
Competence, continued education and professional autonomy are among basic criteria of professionalism. Professional autonomy entails exercising judgement of ones own work using professional values and
standards. Professional autonomy and competency are important as ethical decision-making requires independent reasoning and accountability. In this study, nurses lacking professional autonomy did not consider
themselves active decision makers, a finding consistent with literature.40,53 NP was also correlated with
participation in research (r .287). Independent research or participation in research is important for ethical
decision-making, which involves collecting data, defining the problem, considering alternative solutions,
finalizing an action and evaluating the results. However, research without ethics can lead to scientific
misconduct. Making ethical decisions requires integrity of researchers, and ability to distinguish right from
wrong while planning, conducting and reporting research. Although participation in research is important,
being ethical is the first and foremost requirement for professionalism. Nurses scores were low, despite the
correlation between nurses principled thinking and research dimension of professional behaviour. Since
our sample largely comprised clinical nurses not qualified to conduct research, their analytical and
problem-solving skills were lower than expected. The results indicate that nurses ethical decisionmaking levels are related to their low professional behaviour levels.

Conclusion
This study demonstrated that the NDT can be used for measuring the ethical decision-making levels of
nurses; however, additional testing of the validity and reliability is needed. Our results indicated that nurses
face ethical problems in practice; they considered principled thinking while making ethical decisions but
not at the expected level. Further studies from both empirical and philosophical perspectives may broaden
our understanding of the relationship between nurses professional behaviours and ethical decision-making.
Acknowledgements
This study is produced from doctoral dissertation. We would like to thank research assistants Sinem
Bozkurt, Sezen Ergin and Duygu C
urum who translated Nursing Dilemma Test into Turkish and assistant
professor Orhun Yakn for providing the back-translation. We would also like to thank Professor Selma
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Gorgulu, Gulumser Kublay, Nuket Ornek Buken and Fethiye Erdil who contributed with their expert
opinions during this study. We are also grateful to the participation of all nurses in this study.
Funding
The study was conducted without external funding.
Conflict of interest
There is no financial, personal or academic conflict of interest.
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