Concept analysis of moral disengagement among nurses in the intensive care unit: A hybrid model
Abstract
Background & Aim: Moral disengagement may result in unethical behavior, compromising patient safety in Intensive Care Units. This study aims to provide a clear and culturally grounded definition of moral disengagement among Iranian ICU nurses.
Methods & Materials: This research employed a hybrid concept analysis model based on Schwartz-Barcott and Kim’s approach in three phases: 1) Theoretical phase: A comprehensive literature review was conducted using relevant keywords in Iranian and international databases. Sixteen relevant peer-reviewed articles were selected and analyzed using conventional content analysis based on Graneheim and Lundman’s method. 2) Fieldwork phase: In-depth semi-structured interviews were conducted with 20 ICU nurses selected via purposive sampling. Data were coded and analyzed using qualitative content analysis to extract themes. 3) Final analysis phase: The data from the previous phases were integrated to develop a refined and context-based definition.
Results: In the theoretical phase, key attributes included moral justification, cognitive reconstruction, detachment from ethical standards, and absence of moral emotions. Fieldwork analysis yielded 301 codes categorized into three main themes and seven subthemes, emphasizing illegitimate legitimization through commitment avoidance, self-justification, and cognitive reconstruction, as well as assurance of job and psychological security, and feelings of individual and organizational satisfaction. The findings from these phases contributed to the final definition.
Conclusion: Moral disengagement among ICU nurses is defined as: “The employment of protective mechanisms of justification, pleasant cognitive reconstruction of the event, and commitment avoidance to legitimize unethical activities aimed at preserving job security, psychological safety, and individual and organizational satisfaction.” This definition offers a practical foundation for future research and ethical interventions in critical care.
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3. Zhao H, Xia Q. Nurses' negative affective states, moral disengagement, and knowledge hiding: The moderating role of ethical leadership. Journal of Nursing Management. 2019 Mar;27(2):357-70. https://doi.org/10.1111/jonm.12675
4. Hardy SA, Bean DS, Olsen JA. Moral identity and adolescent prosocial and antisocial behaviors: Interactions with moral disengagement and self-regulation. Journal of Youth and Adolescence. 2015 Aug;44(8):1542-54. https://doi.org/10.1007/s10964-014-0172-1
5. Butt A, Abdi SK, Hamid A, Dogar FA, Fatima J. Criminal thinking, moral disengagement and psychological wellbeing in prisoners. Journal of Fatima Jinnah Medical University. 2019 Nov 16;13(2):51-4.
6. Fida R, Tramontano C, Paciello M, Ghezzi V, Barbaranelli C. Understanding the interplay among regulatory self-efficacy, moral disengagement, and academic cheating behaviour during vocational education: A three-wave study. Journal of Business Ethics. 2018 Dec;153(3):725-40. https://doi.org/10.1007/s10551-016-3373-6
7. Hodge K, Hargreaves EA, Gerrard D, Lonsdale C. Psychological mechanisms underlying doping attitudes in sport: Motivation and moral disengagement. Journal of Sport and Exercise Psychology. 2013 Aug 1;35(4):419-32. https://doi.org/10.1123/jsep.35.4.419
8. Kuilman L, Jansen GJ, Middel B, Mulder LB, Roodbol PF. Moral reasoning explained by personality traits and moral disengagement: A study among Dutch nurse practitioners and physician assistants. Journal of Advanced Nursing. 2019 Jun;75(6):1252-62. https://doi.org/10.1111/jan.13939
9. Austen K, Hutchinson M. An aged life has less value: A qualitative analysis of moral disengagement and care failures evident in Royal Commission oral testimony. Journal of Clinical Nursing. 2021 Dec;30(23-24):3563-76. https://doi.org/10.1111/jocn.15864
10. Newman A, Le H, North-Samardzic A, Cohen M. Moral disengagement at work: A review and research agenda. Journal of Business Ethics. 2020 Dec;167(3):535-70.
https://doi.org/10.1007/s10551-019-04173-0
11. Azimpour A, Karimian N, Azarnioushan M, Johari L. Moral Disengagement in Medicine and Nursing: A Narrative Review. Medical Ethics Journal. 2022;16(47).
12. Forozeiya D, Vanderspank-Wright B, Bourbonnais FF, Moreau D, Wright DK. Coping with moral distress-The experiences of intensive care nurses: An interpretive descriptive study. Intensive and Critical Care Nursing. 2019 Aug 1;53:23-9. https://doi.org/10.1016/j.iccn.2019.03.002
13. Pishgooie A-H, Barkhordari-Sharifabad M, Atashzadeh-Shoorideh F, Falcó-Pegueroles A. Ethical conflict among nurses working in the intensive care units. Nursing Ethics. 2019;26(7-8):2225-38. https://doi.org/10.1177/0969733018796686
14. Bandura A. Mechanisms of moral disengagement. In W Reich (Ed), Origins of terrorism: Psychologies, ideologies, theologies, and states of mind: Cambridge, England: Cambridge University Press; 1990.
15. Kuilman L, Jansen GJ, Mulder LB, Roodbol PF. The predictive values of a deliberative and a paternalistic attitude towards two situations of moral conflict: A study among Dutch nurse practitioners and physician assistants. Scandinavian Journal of Caring Sciences. 2022;36(3):863-73. https://doi.org/10.1111/scs.13029
16. Christian JS, Ellis AP. The crucial role of turnover intentions in transforming moral disengagement into deviant behavior at work. Journal of Business Ethics. 2014;119:193-208. https://doi.org/10.1007/s10551-013-1631-4
17. Schwartz BD, Kim HS. An expansion and elaboration of the hybrid model of concept development. in: BL Rodgers & KA Knafl (Eds), Concept Development in Nursing: Foundations, Techniques and Applications: WB Saunders & Co Phil.; 2000.
18. Chinn PL. Nursing research methodology: Issues and implementation. Wolters Kluwer Legal & Regulatory U S. 1986.
19. Jasemi M, Valizadeh L, Zamanzadeh V, Keogh B. A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care. 2017;23(1):71. https://doi.org/10.4103/0973-1075.197960
20. Slepski LA. Emergency preparedness: Concept development for nursing practice. Nursing Clinics. 2005;40(3):419-30. https://doi.org/10.1016/j.cnur.2005.04.011
21. Tacconelli E. Systematic reviews: CRD's guidance for undertaking reviews in health care. The Lancet Infectious Diseases. 2010;10(4):226. https://doi.org/10.1016/S1473-3099(10)70065-7
22. Medina YF, Mendieta CV, Prieto N, Acosta Felquer ML, Soriano ER. A systematic scoping review of essential methodological elements for developing a tool to improve the reporting of consensus studies in classification, diagnostic criteria, and guidelines development. Journal of Multidisciplinary Healthcare. 2024 Dec 31:5813-30. https://doi.org/10.2147/JMDH.S484715
23. Nazeer MNM, Aholaakko T-K. Using photon disinfection technologies for reducing bioburden in hospitals. British Journal of Nursing. 2023;32(17):818-25. https://doi.org/10.12968/bjon.2023.32.17.818
24. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105-12. https://doi.org/10.1016/j.nedt.2003.10.001
25. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods. 2006;18(1):59-82. https://doi.org/10.1177/1525822X05279903
26. Lu Y, Jian M, Muhamad N, Hizam-Hanafiah M. Data saturation in qualitative research: A literature review in entrepreneurship study from 2004-2024. Journal of Infrastructure, Policy and Development. 2024;8(12):9753. https://doi.org/10.24294/jipd.v8i12.9753
27. Wutich A, Beresford M, Bernard HR. Sample sizes for 10 types of qualitative data analysis: an integrative review, empirical guidance, and next steps. International Journal of Qualitative Methods. 2024;23:16094069241296206. https://doi.org/10.1177/16094069241296206
28. Gunbayi I. Rigor in qualitative research. Journal of Action Qualitative & Mixed Methods Research (JAQMER). 2024;3(2).
29. Copeland D. Stigmatization in nursing: Theoretical pathways and implications. Nursing Inquiry. 2022 Apr;29(2):e12438. https://doi.org/10.1111/nin.12438
30. Fida R, Tramontano C, Paciello M, Guglielmetti C, Gilardi S, Probst TM, Barbaranelli C. 'First, do no harm': The role of negative emotions and moral disengagement in understanding the relationship between workplace aggression and misbehavior. Frontiers in Psychology. 2018 May 11;9:671. https://doi.org/10.3389/fpsyg.2018.00671
31. Sade RM. Why physicians should not lie for their patients. The American Journal of Bioethics. 2012 Mar 1;12(3):17-9. https://doi.org/10.1080/15265161.2012.656800
32. Hyatt J. Recognizing moral disengagement and its impact on patient safety. Journal of Nursing Regulation. 2017 Jan 1;7(4):15-21. https://doi.org/10.1016/S2155-8256(17)30015-7
33. Bandura A, Barbaranelli C, Caprara GV, Pastorelli C. Mechanisms of moral disengagement in the exercise of moral agency. Journal of Personality and Social Psychology. 1996 Aug;71(2):364. https://doi.org/10.1037//0022-3514.71.2.364
34. Hakimi H, Joolaee S, Ashghali Farahani M, Rodney P, Ranjbar H. Moral neutralization: Nurses' evolution in unethical climate workplaces. BMC Medical Ethics. 2020 Nov 17;21(1):114. https://doi.org/10.1186/s12910-020-00558-3
35. Farsi Z, Dehghan‐Nayeri N, Negarandeh R, Broomand S. Nursing profession in Iran: An overview of opportunities and challenges. Japan Journal of Nursing Science. 2010 Jun;7(1):9-18.
https://doi.org/10.1111/j.1742-7924.2010.00137.x
36. Chegini Z, Jafari‐Koshki T, Kheiri M, Behforoz A, Aliyari S, Mitra U, et al. Missed nursing care and related factors in Iranian hospitals: A cross‐sectional survey. Journal of Nursing Management. 2020;28(8):2205-15.
https://doi.org/10.1111/jonm.13055
37. Antes AL, Dineen KK, Bakanas E, Zahrli T, Keune JD, Schuelke MJ, et al. Professional decision-making in medicine: Development of a new measure and preliminary evidence of validity. PLoS One. 2020;15(2):e0228450. https://doi.org/10.1371/journal.pone.0228450
38. Ke Y, Li F. Moral disengagement, moral identity, and counterproductive work behavior among emergency nurses. Nursing Ethics. 2025 Feb;32(1):111-24. https://doi.org/10.1177/09697330241238336
39. Mansor M, Afthanorhan A, Mohd Ibrahim R, Mohd Salleh AM. The Mediating Role of Moral Disengagement in Predicting Deviant Workplace Behavior Among Nurses in Malaysia. Journal of Client-Centered Nursing Care. 2023;9(2):143-56. https://doi.org/10.32598/JCCNC.9.2.502.1
40. Mohammadpour A, Salehi H, Moghaddam MB. Psychometric properties of the Persian version of the nursing moral disengagement scale. Journal of Medical Ethics and History of Medicine. 2023 Dec 30;16:15. https://doi.org/10.18502/jmehm.v16i15.14614
41. Yildiz B, Yildiz H, Ozbilgin M. How do compulsory citizenship behaviors affect moral disengagement in organizations? Significance of anger toward the organization during the COVID-19 pandemic. Frontiers in Psychology. 2022 Nov 25;13:1038860. https://doi.org/10.3389/fpsyg.2022.1038860
42. Jouybari L, Talebi Z, Sanagoo A. Moral Disengagement: When New Unethical Behaviors Become Justifiable. Iranian Journal of Medical Ethics and History of Medicine. 2023;16(1):31-4. https://doi.org/10.18502/ijme.v16i3.15939
43. Berengestaneki ZM, Zeydi AE, Nia SHS, Gorji MAH. Relationship between Moral Disengagement and Quality of Care in Nurses Caring for Covid-19 Patients Hospitalized in the Intensive Care unit of the Medical-educational Centers of Mazandaran University of Medical Sciences (2021-2022). Journal of Mazandaran University of Medical Sciences. 2023 Dec 10;33(2):117-28.
2. Abdollahi A, Hashemi F, Faraji HR, Hosseinian S, Allen KA. Moral disengagement: Mediator between moral perfectionism and Machiavellian behavior among undergraduates?. Psychological Reports. 2021 Dec;124(6):2761-73. https://doi.org/10.1177/0033294120964067
3. Zhao H, Xia Q. Nurses' negative affective states, moral disengagement, and knowledge hiding: The moderating role of ethical leadership. Journal of Nursing Management. 2019 Mar;27(2):357-70. https://doi.org/10.1111/jonm.12675
4. Hardy SA, Bean DS, Olsen JA. Moral identity and adolescent prosocial and antisocial behaviors: Interactions with moral disengagement and self-regulation. Journal of Youth and Adolescence. 2015 Aug;44(8):1542-54. https://doi.org/10.1007/s10964-014-0172-1
5. Butt A, Abdi SK, Hamid A, Dogar FA, Fatima J. Criminal thinking, moral disengagement and psychological wellbeing in prisoners. Journal of Fatima Jinnah Medical University. 2019 Nov 16;13(2):51-4.
6. Fida R, Tramontano C, Paciello M, Ghezzi V, Barbaranelli C. Understanding the interplay among regulatory self-efficacy, moral disengagement, and academic cheating behaviour during vocational education: A three-wave study. Journal of Business Ethics. 2018 Dec;153(3):725-40. https://doi.org/10.1007/s10551-016-3373-6
7. Hodge K, Hargreaves EA, Gerrard D, Lonsdale C. Psychological mechanisms underlying doping attitudes in sport: Motivation and moral disengagement. Journal of Sport and Exercise Psychology. 2013 Aug 1;35(4):419-32. https://doi.org/10.1123/jsep.35.4.419
8. Kuilman L, Jansen GJ, Middel B, Mulder LB, Roodbol PF. Moral reasoning explained by personality traits and moral disengagement: A study among Dutch nurse practitioners and physician assistants. Journal of Advanced Nursing. 2019 Jun;75(6):1252-62. https://doi.org/10.1111/jan.13939
9. Austen K, Hutchinson M. An aged life has less value: A qualitative analysis of moral disengagement and care failures evident in Royal Commission oral testimony. Journal of Clinical Nursing. 2021 Dec;30(23-24):3563-76. https://doi.org/10.1111/jocn.15864
10. Newman A, Le H, North-Samardzic A, Cohen M. Moral disengagement at work: A review and research agenda. Journal of Business Ethics. 2020 Dec;167(3):535-70.
https://doi.org/10.1007/s10551-019-04173-0
11. Azimpour A, Karimian N, Azarnioushan M, Johari L. Moral Disengagement in Medicine and Nursing: A Narrative Review. Medical Ethics Journal. 2022;16(47).
12. Forozeiya D, Vanderspank-Wright B, Bourbonnais FF, Moreau D, Wright DK. Coping with moral distress-The experiences of intensive care nurses: An interpretive descriptive study. Intensive and Critical Care Nursing. 2019 Aug 1;53:23-9. https://doi.org/10.1016/j.iccn.2019.03.002
13. Pishgooie A-H, Barkhordari-Sharifabad M, Atashzadeh-Shoorideh F, Falcó-Pegueroles A. Ethical conflict among nurses working in the intensive care units. Nursing Ethics. 2019;26(7-8):2225-38. https://doi.org/10.1177/0969733018796686
14. Bandura A. Mechanisms of moral disengagement. In W Reich (Ed), Origins of terrorism: Psychologies, ideologies, theologies, and states of mind: Cambridge, England: Cambridge University Press; 1990.
15. Kuilman L, Jansen GJ, Mulder LB, Roodbol PF. The predictive values of a deliberative and a paternalistic attitude towards two situations of moral conflict: A study among Dutch nurse practitioners and physician assistants. Scandinavian Journal of Caring Sciences. 2022;36(3):863-73. https://doi.org/10.1111/scs.13029
16. Christian JS, Ellis AP. The crucial role of turnover intentions in transforming moral disengagement into deviant behavior at work. Journal of Business Ethics. 2014;119:193-208. https://doi.org/10.1007/s10551-013-1631-4
17. Schwartz BD, Kim HS. An expansion and elaboration of the hybrid model of concept development. in: BL Rodgers & KA Knafl (Eds), Concept Development in Nursing: Foundations, Techniques and Applications: WB Saunders & Co Phil.; 2000.
18. Chinn PL. Nursing research methodology: Issues and implementation. Wolters Kluwer Legal & Regulatory U S. 1986.
19. Jasemi M, Valizadeh L, Zamanzadeh V, Keogh B. A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care. 2017;23(1):71. https://doi.org/10.4103/0973-1075.197960
20. Slepski LA. Emergency preparedness: Concept development for nursing practice. Nursing Clinics. 2005;40(3):419-30. https://doi.org/10.1016/j.cnur.2005.04.011
21. Tacconelli E. Systematic reviews: CRD's guidance for undertaking reviews in health care. The Lancet Infectious Diseases. 2010;10(4):226. https://doi.org/10.1016/S1473-3099(10)70065-7
22. Medina YF, Mendieta CV, Prieto N, Acosta Felquer ML, Soriano ER. A systematic scoping review of essential methodological elements for developing a tool to improve the reporting of consensus studies in classification, diagnostic criteria, and guidelines development. Journal of Multidisciplinary Healthcare. 2024 Dec 31:5813-30. https://doi.org/10.2147/JMDH.S484715
23. Nazeer MNM, Aholaakko T-K. Using photon disinfection technologies for reducing bioburden in hospitals. British Journal of Nursing. 2023;32(17):818-25. https://doi.org/10.12968/bjon.2023.32.17.818
24. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105-12. https://doi.org/10.1016/j.nedt.2003.10.001
25. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods. 2006;18(1):59-82. https://doi.org/10.1177/1525822X05279903
26. Lu Y, Jian M, Muhamad N, Hizam-Hanafiah M. Data saturation in qualitative research: A literature review in entrepreneurship study from 2004-2024. Journal of Infrastructure, Policy and Development. 2024;8(12):9753. https://doi.org/10.24294/jipd.v8i12.9753
27. Wutich A, Beresford M, Bernard HR. Sample sizes for 10 types of qualitative data analysis: an integrative review, empirical guidance, and next steps. International Journal of Qualitative Methods. 2024;23:16094069241296206. https://doi.org/10.1177/16094069241296206
28. Gunbayi I. Rigor in qualitative research. Journal of Action Qualitative & Mixed Methods Research (JAQMER). 2024;3(2).
29. Copeland D. Stigmatization in nursing: Theoretical pathways and implications. Nursing Inquiry. 2022 Apr;29(2):e12438. https://doi.org/10.1111/nin.12438
30. Fida R, Tramontano C, Paciello M, Guglielmetti C, Gilardi S, Probst TM, Barbaranelli C. 'First, do no harm': The role of negative emotions and moral disengagement in understanding the relationship between workplace aggression and misbehavior. Frontiers in Psychology. 2018 May 11;9:671. https://doi.org/10.3389/fpsyg.2018.00671
31. Sade RM. Why physicians should not lie for their patients. The American Journal of Bioethics. 2012 Mar 1;12(3):17-9. https://doi.org/10.1080/15265161.2012.656800
32. Hyatt J. Recognizing moral disengagement and its impact on patient safety. Journal of Nursing Regulation. 2017 Jan 1;7(4):15-21. https://doi.org/10.1016/S2155-8256(17)30015-7
33. Bandura A, Barbaranelli C, Caprara GV, Pastorelli C. Mechanisms of moral disengagement in the exercise of moral agency. Journal of Personality and Social Psychology. 1996 Aug;71(2):364. https://doi.org/10.1037//0022-3514.71.2.364
34. Hakimi H, Joolaee S, Ashghali Farahani M, Rodney P, Ranjbar H. Moral neutralization: Nurses' evolution in unethical climate workplaces. BMC Medical Ethics. 2020 Nov 17;21(1):114. https://doi.org/10.1186/s12910-020-00558-3
35. Farsi Z, Dehghan‐Nayeri N, Negarandeh R, Broomand S. Nursing profession in Iran: An overview of opportunities and challenges. Japan Journal of Nursing Science. 2010 Jun;7(1):9-18.
https://doi.org/10.1111/j.1742-7924.2010.00137.x
36. Chegini Z, Jafari‐Koshki T, Kheiri M, Behforoz A, Aliyari S, Mitra U, et al. Missed nursing care and related factors in Iranian hospitals: A cross‐sectional survey. Journal of Nursing Management. 2020;28(8):2205-15.
https://doi.org/10.1111/jonm.13055
37. Antes AL, Dineen KK, Bakanas E, Zahrli T, Keune JD, Schuelke MJ, et al. Professional decision-making in medicine: Development of a new measure and preliminary evidence of validity. PLoS One. 2020;15(2):e0228450. https://doi.org/10.1371/journal.pone.0228450
38. Ke Y, Li F. Moral disengagement, moral identity, and counterproductive work behavior among emergency nurses. Nursing Ethics. 2025 Feb;32(1):111-24. https://doi.org/10.1177/09697330241238336
39. Mansor M, Afthanorhan A, Mohd Ibrahim R, Mohd Salleh AM. The Mediating Role of Moral Disengagement in Predicting Deviant Workplace Behavior Among Nurses in Malaysia. Journal of Client-Centered Nursing Care. 2023;9(2):143-56. https://doi.org/10.32598/JCCNC.9.2.502.1
40. Mohammadpour A, Salehi H, Moghaddam MB. Psychometric properties of the Persian version of the nursing moral disengagement scale. Journal of Medical Ethics and History of Medicine. 2023 Dec 30;16:15. https://doi.org/10.18502/jmehm.v16i15.14614
41. Yildiz B, Yildiz H, Ozbilgin M. How do compulsory citizenship behaviors affect moral disengagement in organizations? Significance of anger toward the organization during the COVID-19 pandemic. Frontiers in Psychology. 2022 Nov 25;13:1038860. https://doi.org/10.3389/fpsyg.2022.1038860
42. Jouybari L, Talebi Z, Sanagoo A. Moral Disengagement: When New Unethical Behaviors Become Justifiable. Iranian Journal of Medical Ethics and History of Medicine. 2023;16(1):31-4. https://doi.org/10.18502/ijme.v16i3.15939
43. Berengestaneki ZM, Zeydi AE, Nia SHS, Gorji MAH. Relationship between Moral Disengagement and Quality of Care in Nurses Caring for Covid-19 Patients Hospitalized in the Intensive Care unit of the Medical-educational Centers of Mazandaran University of Medical Sciences (2021-2022). Journal of Mazandaran University of Medical Sciences. 2023 Dec 10;33(2):117-28.
| Issue | Articles in Press | |
| Section | Original Article(s) | |
| Keywords | ||
| moral disengagement; nurses; intensive care unit; concept analysis; hybrid model | ||
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How to Cite
1.
Khanipour-Kencha A, Jackson AC, Bahramnezhad F. Concept analysis of moral disengagement among nurses in the intensive care unit: A hybrid model. NPT. 2025;:X-X.
