Senior nurse leaders' perspectives on integrity,dishonesty and ethical boundaries

Study design

This qualitative interview study explored perceptions of integrity and dishonesty in nursing education and professional practice from the perspectives of senior nursing leaders. The study was guided by an interpretive phenomenological approach aimed at understanding the essence of participants’ lived experiences and the meanings they assign to ethical behavior in nursing. This approach sought to capture participants’ experiences and interpretations, while promoting open reflection and deeper emotional insight. ¹⁹ Semi-structured, in-depth interviews enabled participants to reflect openly on complex ethical situations and professional dilemmas, facilitating exploration of the meanings they attribute to integrity and dishonest behavior. The objective was to reveal the underlying meanings and common essences emerging from participants’ subjective interpretations of their experiences. ²⁰ The interviews were conducted by trained qualitative researchers, both women (one with a PhD working in the nursing education system and the other with a PhDc working in the Ministry of Health), who have experience in nursing education and leadership. Within this interpretive phenomenological orientation, thematic analysis was employed as a method for identifying patterns of meaning that reflect the essence of participants’ lived experiences rather than merely descriptive categories.

Study setting and recruitment

Participants were recruited using purposive sampling complemented by snowball sampling, to identify individuals with extensive experience in senior nursing leadership roles. Recruitment continued until thematic saturation was reached. Participants were recruited from three domains: senior academic leadership in nursing education (e.g., deans, heads of nursing campuses); senior clinical management (e.g., hospital nursing directors); and national-level policy and regulatory positions within the Ministry of Health. Participants were eligible if they had at least two years of experience in their current role and have previous experience in nursing education.

Interviews began with broad open-ended questions such as “How do you define integrity in nursing?” and “What types of dishonest behaviors have you encountered in academic or clinical contexts?” Follow-up questions were used to clarify and deepen participants’ responses to meanings of honesty and dishonesty; personal and observed experiences of academic and clinical dishonesty; perceived motivations and contextual factors; implications for patient care and professional identity; and recommendations for education and practice.

Data collection and analysis

All interviews were audio-recorded with participants’ consent and transcribed verbatim. Each interview lasted approximately 1 hour, and no written notes were taken during the interviews. Data was analyzed using thematic analysis following the approach described by Vaismoradi et al. (2013). ²¹ Thematic analysis in this study was conducted within a phenomenological interpretive framework, where codes and themes were developed to capture the essence and meaning of participants’ lived experiences rather than to merely categorize content. The analysis involved repeated reading of the transcripts, coding of meaningful units, grouping codes into categories, and identifying overarching themes. These themes were interpreted as representations of shared experiential meanings across participants, reflecting the essence of how integrity and dishonesty are understood in nursing practice.

Rigor

To enhance trustworthiness, two researchers [xx and yy] independently coded the transcripts and collaboratively developed themes. Differences in interpretation were discussed until consensus was reached. Reflexivity was maintained throughout the research process through continuous reflection on potential assumptions and biases. This reflexive process supported the phenomenological aim of remaining grounded in participants’ lived experiences while acknowledging researcher interpretation.

Ethical considerations

The study received ethical approval from the Helsinki Committee of the Shamir Medical Center (approval number: ASF-0281-22). Informed consent was obtained from all participants prior to the interviews.

The study adhered to ethical principles of autonomy, confidentiality, and non-maleficence. Participation was voluntary, and participants could withdraw at any time without consequence. To minimize potential fear of repercussions, interviews were conducted in private settings, names were not recorded, and no identifying information was included in transcripts. Data was accessible only to researchers and was used solely for research purposes.

Perceptions of integrity and dishonesty

The first theme presented leaders’ views of integrity and dishonesty, seen not as dichotomous but as a continuum shaped by context, severity, and consequences. Participants also described a hierarchical understanding of dishonest behavior, distinguishing between minor deviations and more severe actions. Notably, patient safety emerged as the primary moral threshold distinguishing tolerable deviations from unacceptable dishonest behaviors.

Most interviewees emphasized that integrity and dishonesty are not absolute constructs. Rather than conceptualizing these notions as dichotomous, they described them as existing along a continuum between integrity and dishonesty. In this view, both nursing students and professionals may be positioned at different points along the continuum. Accordingly, interviewee 6 (a director of a school of nursing with five years of experience in the role) stated: “Is it dichotomous [integrity and dishonesty]? No. There may be a place on a continuum. I think there are people who are more honest.” Similarly, interviewee 3, who has held a senior position in the Ministry of Health for 13 years, noted that “all of us,” from students to senior leaders within the system, occupy a place along this continuum: “You can sometimes look critically and see that actions are being carried out that are not entirely acceptable, and those performing them are the most senior people in the system.”

While interviewees agreed that integrity is a core professional value, they recognized that relational complexities can sometimes challenge absolute transparency. Interviewee 1 (the director of a school of nursing) explained: “I think that all of us… face situations where I cannot say that 100% of the time we only: ‘let’s say, you know, absolute things’. And what is truth? You know, it’s, like, relative, it’s not absolute. It is relative.”

Moreover, the interviewees noted that when considering the concept of dishonesty, they perceive it along a hierarchy based on context and the severity of dishonest behavior. In other words, they considered academic or administrative dishonesty to be “lighter” cases compared to clinical dishonesty, especially when patient harm might result. Interviewee 8 described where, in her view, the line is drawn between minor and serious cases: “This is the line I distinguish: as long as the behavior does not cause psychological or physical harm to the patient or the caregiver, on the contrary, it is an opportunity for improvement and investment, something to work on. But if the behavior endangers patients or even the caregiver, then we cannot overlook it.” Interviewee 6 added: “One can speak about [dishonest] behaviors that are more severe and those that are less severe.”

To emphasize the hierarchy of dishonesty, interviewees described minor cases with softened language (”cutting corners” and “deviating from rules”) rather than labeling them as outright fraud. Interviewee 5, a head nursing manager at one of the country’s largest hospitals for five years, described her view of minor dishonesty as “We had rules that we occasionally deviated from. I know that every rule has exceptions. But this is not at the level of dishonesty… I would say it is bending the rules.”

Reasons for dishonest behavior

In the discussion of factors leading to dishonesty, the interviewees identified several reasons, including cultural and social influences; individual and behavioral factors; academic and environmental pressures; and systemic and institutional constraints.

Recommendations for addressing the phenomenon

A substantial part of the interviews focused on strategies for eliminating or preventing dishonesty in both academic and clinical settings. The participants agreed that education for the values of professional integrity does not begin and end solely during formal academic training. On the contrary, they emphasized that integrity education is a lifelong process that must be continuously maintained among both students and practicing professionals. The recommendations centered on four main areas: examining each case of dishonesty individually; emphasizing the importance of education for integrity values, particularly following an incident of dishonesty; incorporating real-life examples from clinical practice into the educational process; and serving as a role model for students and professionals.

Leaders preferred restorative approaches rather than punitive responses. From the interviews, it emerged that the participants recommended thoroughly investigating each case of dishonesty and making decisions on a case-by-case basis. The interviewees agreed that enforcement measures are essential in all settings, both academic and clinical. However, the recommendation was not to rely exclusively on enforcement mechanisms, but rather to “look at the person” (Interviewee 2) and to consider the underlying reasons and circumstances of each incident. Interviewee 7 explained: “It depends on the circumstances of the case. You do not always have a punishment that fits every case and its specific circumstances.” Interviewee 3 further elaborated on how, in his professional opinion, cases of dishonesty should be addressed: “I think there is no uniform framework…each case must be considered individually, and therefore a disciplinary committee provides the opportunity for the individual to defend themselves, to express their perspective, and to convey their deep regret over what happened, or to offer an apology. Such a committee can certainly be composed of very experienced individuals within the system. It can assess each case on its own merits and can indeed reach the appropriate decision.”

The interviewees also agreed that following an incident of dishonesty, students or professionals should be given a second chance, rather than adopting a punitive “zero-tolerance” or “head-cutting” approach. Interviewee 7 explained: “…the system can adopt a head-cutting approach, but I do not think that head-cutting is the right way.” Interviewee 10 emphasized that “we cannot change a person’s DNA, but you can teach them or lead them to make this educational change. Ultimately, people do understand that this is a matter of human lives. When you explain and provide examples, you give them an opportunity.”

An additional theme that emerged as a means of addressing the phenomenon was education for integrity using real-life examples. The interviewees noted that this approach is effective for both students and practicing professionals. Interviewee 7 indicated that, among students, real cases of dishonesty should be brought “into classroom discussion,” while interviewee 1 added that “these examples should be linked to the consequences for the patient.” Regarding professionals, the interviewees suggested conducting more simulations based on real cases that occurred in practice and “flooding the process with examples that will be etched in memory” (Interviewee 5).

The final issue identified as effective in fostering integrity was the use of role modeling. The interviewees noted that, in their view, they serve as role models for students and junior professionals. Interviewee 6 stated: “We all need to understand that our conduct has an impact on the student… I cannot expect a student not to plagiarize a presentation if I present slides that are not my own, or if I have copied. Therefore, this requires ethical behavior, and it comes with holding a senior position.”

Moreover, some interviewees viewed role modeling as also involving acknowledgment and transparency in cases where individuals in senior positions themselves did not act with integrity. Interviewee 9 (head nursing manager in hospital) explained: “…it is also about setting an example in the sense that we are human. That is, I also make mistakes. This is not always simple in senior managerial roles and at the level of upper management.”

An open discussion about personal behavior and role modeling, led the most interviewees reported cases in which they had acted without full integrity during their professional careers. Interviewee 6 shared: “If we are talking about integrity, then in terms of integrity I cannot say that I never [acted dishonestly]. I never [acted dishonestly]. I try not to, but I cannot say that I never [acted dishonestly].” Nevertheless, all participants described themselves as honest individuals with strong professional values. Interviewee 4, that fill a senior position in academia, reflected on her own behavior: “I’m not saying you must be, like, an idiot and always just honest, honest, honest. There are also many things that happen…not everything needs to be told with absolute truth. And there are things that are not simple. But overall, this is what I stand by, and I think I am an honest person.”

Integrity in a continuum

Participants consistently described integrity and dishonesty as existing along a continuum rather than as mutually exclusive categories. This perception challenges traditional regulatory and educational frameworks,^22,23 which tend to conceptualize dishonest behavior as a clear and unequivocal violation. Instead, the leaders differentiated between “minor” deviations, often framed as bending or stretching rules, and more severe acts that cross a moral threshold, particularly when patient safety is compromised.

The prominence of patient safety as the defining boundary is highly significant. It suggests that within nursing leadership discourse, the ethical weight of dishonest behavior is evaluated less in terms of formal rule-breaking and more in relation to the potential for harm. This harm-based orientation aligns with the profession’s foundational commitment to human dignity and the prioritization of patient welfare. ²⁴ At the same time, constructing a hierarchy of dishonesty may inadvertently legitimize lower-level transgressions in academic ²⁵ or administrative contexts. When such behaviors are perceived as relatively harmless, they may become normalized, gradually weakening the ethical climate. Over time, this normalization may influence professional socialization processes, particularly when students encounter ambiguous messages about acceptable conduct during formative stages of identity development.^25,26 The findings therefore support viewing integrity and dishonesty not as fixed categories but as dynamic positions along a moral continuum that may shift across situations, career stages, and organizational contexts.

Furthermore, the leaders’ use of softened terminology, such as “cutting corners” or “bending the rules,” reflects a process of moral reframing. ²⁷ Linguistic minimization does not merely describe behavior; it can shape how actions are interpreted and judged. By reducing the perceived severity of a transgression, such language may subtly shift moral evaluations and attenuate accountability. ²⁸ In this sense, discourse itself becomes part of the ethical environment, influencing whether dishonest behaviors are confronted, tolerated, or implicitly justified.^29,30

When systems shape moral choices

The leaders’ accounts suggest that dishonesty does not emerge solely from moral deficiency but from a dynamic interplay between personal disposition and structural opportunity. Competitive academic environments, heavy workloads, and ambiguous regulations may create conditions in which dishonesty is perceived as a rational (or at times even necessary) strategy. When these contextual pressures intersect with prior experiences of unpunished dishonest acts, they can reinforce patterns of normalization. In this sense, dishonesty becomes not merely an individual lapse but a predictable outcome of certain organizational conditions. Thus, integrity cannot be understood purely as an individual trait; it is co-constructed within systems that either constrain or enable ethical action.

This systemic dimension becomes even more apparent when examining how organizational responses (or the lack thereof) shape ethical boundaries in practice. If structures create opportunities for diffusing dishonest acts, ³¹ institutional reactions determine whether those opportunities solidify into norms. Beyond individual interpretations, the findings highlight the powerful role of organizational culture and systemic arrangements in shaping patterns of integrity and dishonesty. Participants repeatedly described institutional leniency, limited enforcement tools, and procedural complexity as factors that indirectly sustain dishonest conduct. When leaders hesitate to initiate disciplinary processes due to insufficient evidence or fear of ineffective outcomes, a silent message may be conveyed: that certain behaviors are known yet tolerated. Such dynamics contribute to what might be termed an “ethics gap” ³² —a discrepancy between espoused professional values and enacted organizational practices.

This ethics gap is particularly significant in nursing, a profession grounded in trust and accountability. ³³ When formal codes emphasize integrity, but everyday practices reflect compromise or inconsistent enforcement, ethical standards risk becoming symbolic rather than operational. ³⁴ Over time, this misalignment may erode both cognitive and emotional trust. ³⁵ Importantly, students and junior nurses learn not only from curricula but from observation. ³⁶ When they encounter inconsistencies between declared principles and actual conduct, they may adopt a pragmatic understanding of ethics, one guided by feasibility and survival rather than principled commitment.

Educating integrity in imperfect contexts

Participants advocated a balanced approach that integrates enforcement with education and individualized consideration. Their rejection of rigid zero-tolerance policies reflects an understanding of ethical development as dynamic rather than static. ³⁷ By recommending case-by-case evaluation and opportunities for reflection, leaders positioned integrity as something that can be cultivated over time.

This approach resonates with contemporary models of professional identity formation, which view it as evolving through clinical supervisors’ mentorship, ethical competence, structure and cooperation. ³⁸

At the same time, the findings reveal a persistent tension between ethical ideals and professional realities. Consistent with evidence that organizational constraints, moral distress, power imbalances, and resource limitations can threaten nurses’ integrity, ³⁹ many participants acknowledged that complete transparency is not always feasible in complex clinical and managerial contexts. The candid admissions of senior leaders that they themselves had not always acted with full integrity underscore this complexity. Such reflections suggest that much like the principle that “to err is human,” ⁴⁰ deviations from complete honesty may also reflect the imperfect nature of human practice rather than deliberate moral disregard. This perspective suggests that integrity is a developmental process rather than an expectation of flawless conduct from the outset. Expecting flawless ethical behavior from students or new graduates may be unrealistic; integrity develops over time through experience, reflection, mentorship, and ongoing engagement with ethical challenges.

In summary, the senior nursing leaders’ reflections suggest that absolute directness may be an aspirational ideal rather than a constant reality. Clinical work, managerial responsibility, and interpersonal dynamics often require discretion, partial disclosure, or strategic communication. In such contexts, rigid notions of truthfulness may collide with competing obligations, such as protecting patients, staff, or institutional stability. These tensions do not necessarily indicate moral failure but rather the inherent ambiguity of professional practice.

For educators

The findings highlight the need to conceptualize integrity as a developmental process rather than a fixed attribute. This developmental perspective suggests that ethics education should not be confined to undergraduate nursing programs but should continue throughout professional careers as part of lifelong learning. Nursing education programs should move beyond a solely rule-based approach and incorporate reflective ethics education that addresses ambiguity and real-world complexity. Integrating case-based learning using authentic clinical scenarios may help students understand the consequences of dishonest behaviors. Educators should explicitly address the “continuum” of integrity identified in this study, helping students recognize how minor academic dishonesty may translate into professional conduct. Finally, faculty must be aware of their role-modeling influence and strive for consistency between declared ethical standards and their own behaviors.

For hospital leaders

Hospital leaders play a critical role in shaping ethical climates. Cultures that tolerate minor deviations or inconsistently address dishonesty may normalize it. Leaders should strengthen ethical infrastructures with clear policies, consistent enforcement, and safe reporting channels. Balanced approaches combining accountability with learning and rehabilitation may be more effective than purely punitive strategies. Leadership programs should emphasize ethical decision-making, transparency, and role modeling to influence staff behavior.

For policy makers

At the policy level, the study emphasizes aligning regulations with real-world complexities. Policies should clearly define dishonest behaviors while allowing case-by-case flexibility. Strengthening enforcement and reducing regulatory ambiguity may help close the “ethics gap.” National policies should foster collaboration between educational institutions and healthcare organizations to maintain ethical standards across the academic-clinical continuum. Supporting systems like training, reporting structures, and leadership accountability can enhance integrity and patient safety.

Strengths and limitations

This study has several strengths. It provides in-depth insights from senior nursing leaders across academia, clinical practice, and national policy, offering a comprehensive view of integrity across the educational-clinical continuum. The qualitative phenomenological approach enabled rich exploration of complex ethical perceptions, and participants’ extensive leadership experience enhances the findings’ relevance for decision-making and policy development.

However, there are limitations. The purposive sample may limit generalizability, reliance on self-reported perceptions may introduce social desirability bias, and findings may be influenced by cultural and organizational factors specific to the study setting.