Exploring ethical dilemmas in pediatric oncology nursing: A qualitative approach

Pre-analysis, transcription and playback

Interviews were recorded using a digital audio device to ensure secure data storage. Immediately after each interview, the recordings were replayed and transcribed verbatim using Microsoft Word to ensure an accurate representation of participants’ accounts. All transcripts were anonymized by removing any identifying information.

In addition to verbal data, field notes were taken during and immediately after the interviews to capture contextual and non-verbal elements (e.g., pauses, tone, and emotional expressions). These elements were not formally coded but were used to support the interpretation of the data.

An initial immersive reading was conducted to gain a comprehensive understanding of the data, followed by a more detailed analysis to identify emerging themes.

Initial and thematic coding

This stage identified minimum meaning units (MSUs), classified according to themes emerging from the verbatim. The initial coding was conducted by H.T. J.O, based on several iterative readings of the transcripts to ensure a comprehensive and consistent analysis. The coding process was subsequently reviewed and discussed with H.A, M.O and N.G., allowing for refinement and validation of the emerging themes. Each meaning unit was then associated with a specific thematic category.

Categorizing and linking data

The thematic categories were progressively refined through discussions among the research team (H.T., J.O., H.A., M.S., and N.G.) to establish links between main and secondary themes. These collaborative exchanges enabled the identification of thematic relationships, including oppositions and complementarities, thereby enhancing the depth and credibility of the analysis. A classification grid, initially developed from early interviews, was iteratively enriched throughout this phase.

Researcher reflexivity

The researchers acknowledge that their professional background in healthcare, particularly in oncology and nursing practice, may have influenced data interpretation. Their familiarity with the clinical context facilitated access to the field and a deeper understanding of participants’ experiences, while also requiring careful reflexivity to minimize potential bias.

Throughout the research process, reflexive discussions were conducted within the team to critically examine assumptions and interpretations. The researchers remained attentive to participants’ meanings, aiming to stay as close as possible to their lived experiences while engaging in an interpretative process consistent with IPA.

Presentation of results

The main themes were clearly identified as being directly related to the research question, while secondary themes enriched and contextualized certain aspects of the findings. The results are presented as themes organized into sub-themes in a structured manner.

Participants’ characteristics, such as age and years of experience, were summarized using descriptive statistics (numbers and percentages) to provide an overview of the study sample.

Rigor

The analysis followed the principles of interpretative phenomenological analysis, moving from detailed examination of individual accounts to the identification of shared patterns across participants. Coding was performed independently by two researchers (H.T and J.O), followed by discussions to reach consensus and ensure consistency. Discrepancies were resolved through iterative review of the data.

To enhance the credibility of the findings, several strategies were employed, including double coding, triangulation between researchers, and regular discussions within the research team to refine the themes.

This study was conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Ethical consideration

The study complied with ethical standards for research involving human subjects. Formal approval from an ethics committee was not required in accordance with local regulations. Institutional permission to conduct the study was obtained prior to data collection.

Participation was voluntary, and informed consent was obtained from all participants prior to the interviews. To ensure confidentiality and anonymity, no identifying information was included in the transcripts. Each participant was assigned a unique code, and all data were stored securely on password-protected devices accessible only to the research team. Audio recordings were anonymized during transcription and were not shared outside the research team. Participants were informed of their right to withdraw from the study at any time without any consequences.

Ethical tensions in communication and decision-making

Participants described communication with children and families as a major source of ethical tension. Nurses frequently found themselves caught between respecting the child’s right to information and the perceived need to protect them from psychological harm. Truth-telling , particularly in situations of therapeutic failure or transition to palliative care, was experienced as deeply problematic.

Some participants highlighted physicians’ reluctance to disclose difficult information directly to children, which placed nurses in an intermediary and often uncomfortable position:

“We still have a problem with the announcement of a diagnosis, especially when it involves therapeutic failure or a move to palliative care. Doctors are unable to communicate this to families” (N5)

This lack of transparency generated feelings of discomfort and ethical ambiguity among nurses, who felt complicit in withholding information:

“Not informing patients puts us in a delicate situation. We feel like thieves during care” (N11)

Informed consent was also perceived as ethically problematic. Participants described it as a formal process that often failed to ensure genuine understanding, particularly in contexts marked by limited health literacy:

“It’s just a signature without enough information to make a decision” (N8)

The child’s status as a minor further complicated these dynamics. Nurses reported tensions between parental authority and the child’s right to be informed and involved:

“There are many families who totally refuse to inform the child… but we respect their decision” (N17)

Similarly, situations of treatment refusal —whether from the child or the parents—placed nurses in ethically complex positions. When children refused care, nurses oscillated between persuasion and coercion, reflecting a tension between respect for autonomy and the perceived obligation to act in the child’s best interest:

“I force them to have the treatment because it’s in their best interest” (N1)

Parental refusal was often perceived as beyond the nurses’ scope of action, leading to frustration and a sense of powerlessness:

“We make every effort to convince them, but if they don’t agree, there’s nothing we can do” (N10)

These situations generated significant emotional distress, as nurses struggled to reconcile respect for family decisions with their professional commitment to protect the child.

Pain and care practices

A central theme emerging from the analysis was the ethical tension associated with causing pain while providing care . Participants described invasive procedures as both necessary and distressing, placing them in a position where they must inflict suffering for therapeutic benefit.

“Yes, we’re going to generate pain, but it’s temporary and negligible compared to the benefits of the treatment” (N19)

Despite this rationalization, many nurses reported feelings of guilt and emotional discomfort:

“You feel guilty, and I can’t forgive myself for having caused this child pain” (N5)

This tension was particularly pronounced among nurses who identified strongly with the children, especially those who were parents themselves:

“Since I’ve had children, I can’t do this kind of care anymore” (N7)

Pain management was further complicated by systemic limitations, including lack of adequate assessment, insufficient training, and limited access to analgesics:

“We don’t even assess pain” (N5)

Participants also highlighted physicians’ reluctance to prescribe strong analgesics, contributing to inadequate pain control:

“Doctors have a morphinophobia” (N12)

These factors contributed to a profound sense of moral distress, as nurses witnessed children’s suffering without being able to adequately relieve it Figure 1:

“You see the child suffering, and you can’t calm him down… it wears on me morally” (N11)

Professional integrity and safety

Medication errors emerged as a significant source of ethical concern, reflecting both individual responsibility and systemic challenges. Participants expressed a strong sense of accountability, emphasizing the importance of transparency and immediate action:

“If an error occurs, I immediately inform the doctor” (N13)

However, errors were often attributed to structural factors such as workload and prescribing issues:

“If you have ten patients, the quality of care decreases” (N18)

Beyond practical considerations, these situations were associated with intense emotional and moral suffering. Nurses described feelings of guilt and psychological distress, particularly when errors involved children:

“I became mentally ill; I couldn’t accept the fact that I’d made a mistake” (N6)

Witnessing colleagues’ errors also created ethical dilemmas. While some participants prioritized patient safety and chose to report errors:

“The child’s interest is paramount, even if it creates conflict” (N12)

Others hesitated due to fear of conflict, loyalty, or hierarchical pressures:

“It’s not easy… you can’t disclose if the person in charge hasn’t said anything” (N13)

These tensions illustrate the complex interplay between professional responsibility, team dynamics, and moral distress.

Systemic and contextual constraints

Participants emphasized that ethical dilemmas were not only individual but also deeply shaped by structural and contextual constraints. Resource limitations , in particular, forced nurses to make difficult decisions regarding prioritization of care:

“We prioritize according to the severity of the patients” (N2)

In some cases, economic considerations influenced access to treatment, raising concerns about equity:

“We give the treatment to the poorest first” (N5)

These situations generated feelings of injustice, frustration, and moral burden:

“It’s unfair to have to choose… you feel guilty” (N17)

End-of-life care represented another major area of ethical tension. Nurses described situations in which treatments were perceived as futile, yet continued due to family pressure or institutional norms:

“We’re just prolonging pain… why not let the child go in peace?” (N11)

Finally, issues related to confidentiality and privacy highlighted the impact of organizational constraints. Overcrowding, lack of infrastructure, and cultural factors limited the ability to ensure confidentiality:

“The rooms are often overcrowded, which makes it difficult to have private conversations” (N8)

These structural limitations reinforced nurses’ sense of powerlessness and contributed to the ethical complexity of their daily practice.