Abstract
BACKGROUND: Ethical dilemmas in emergency and critical care nursing often involve complex decision-making that impacts patient outcomes, emotional well-being of healthcare providers, and team dynamics. Understanding these dilemmas and the decision-making processes involved is crucial for improving nursing practices and patient outcomes in this context. OBJECTIVE: This study aims to explore the ethical dilemmas and decision-making processes of emergency and critical care nurses, using the Four Box. Method ethical decision-making framework. METHODS: A multi-method qualitative approach was employed, incorporating in-depth individual interviews (IDI), focus group discussions (FGD), and case studies to capture diverse perspectives. Data were collected from 28 nurses working in emergency and critical care settings at Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital through purposive sampling. The interviews and focus groups were audio recorded, transcribed verbatim in Amharic, translated into English, and entered into OpenCode software for analysis. Inductive thematic analysis method was applied to analyze the data. RESULTS: The study revealed several key ethical dilemmas faced by nurses, including balancing patient autonomy with beneficence, and the allocation of limited resources during crises, opioid administration for pain management vs. respiratory depression, and conflicts regarding informed consent. Nurses reported emotional and professional impacts from these dilemmas, contributing to moral distress, burnout, and ethical fatigue. Nurses emphasized the importance of interdisciplinary collaboration and structured decision-making frameworks to navigate these challenges. However, the lack of consistent access to ethics consultations and peer support during critical moments was noted as a significant barrier. CONCLUSION AND RECOMMENDATION: Nurses encounter complex ethical dilemmas that impact their emotional well-being and job satisfaction. Effective decision-making requires applying ethical principles, adhering to guidelines, and consulting peers. The study reveals the need for improved support systems, including more frequent and comprehensive ethics training, better access to ethics consultations, and structured frameworks to guide decision-making in high-pressure situations. CLINICAL TRIAL REGISTRATION: The study is not a clinical trial, a clinical trial number is not applicable.