This study provides probably the first empirical data and responses to ethical issues by nurse managers in Malaysian hospitals. With this, the burden of ethical issues for nurse managers and the choice of ways for dealing with them could be understood.
Ethical issues experience
The burden of experience is notably high, where majority nurse managers had previous experiences and almost half of total participants experienced ethical issues between weekly to daily basis. Though most participants experienced ethical issues related to "staff management", the fact that "patient care" came second to this shows that nurses at managerial positions still continue to face frequent ethical issues challenges in "patient care". From the 11 pre-identified ethical issues, it is also evident that four of the five most important ethical issues were related to "patient care", which is in agreement with previous studies [13–15]. However, we did not obtain similar result to those studies that identified problems of medical resources allocation as one of the top ethical issues. Another study has also reported that ethical issue of scanty resources' distribution occurred frequently needing difficult decisions to be made on equity of patient care . A logical answer to our different result is because our participants were working under the instruction of the Heads of Department (usually a medical doctor) of each area of practice. This means nurse managers are able to manage resources, but are not solely responsible for decisions on resources allocation, hence not much burdened by this issue.
We found no significant association between areas of practice and experience with ethical issues. This is in line with Wood M's study (1999) which concluded that nurse managers acquired competency in ethics through education and years of experience. Their focus on the types of ethical issues and decision-making were not confined within certain areas of practice .
Dealing with ethical issues
The finding of more than half participants reported feeling stressful suggests that dealing with ethical issues is rather burdensome. Among the 11 pre-identified ethical issues, "working with unethical or incompetent colleague" was voted the most stressful. Despite a decline in quality due to overproduction of nurses, majority still possess high competency and professionalism . Therefore, unfamiliar situation like dealing with unethical or incompetent colleague would be considerably stressful. Issues regarding "patient care" were relatively less stressful than other areas of management more likely because nurse managers tend to discuss these with doctors and not just among themselves.
Majority participants generally chose "discuss with other nurses" to deal with ethical issues. For sensitive issues regarding "patient care", nurse managers felt "discuss with doctors" was the best option probably as the immediate reliable measure for dealing with the issues. Filipova AA's study (2009) suggested that the way ethical issues are handled reflects the ethics of an organization . Hence, this result implies that the working environment between doctors and nurse managers are still at best situation in the hospitals.
Our study also found out that those who participated in committees that discuss ethical issues ("ethics committees") did not prefer referring the issues to the committee. A logical explanation would be the understanding that "ethics committees" approach depends on the involvement of many parties from different backgrounds . Hence, referring all issues to "ethics committees" would not be feasible due to logistic reasons. If issues are small and require decisions be made quickly, it is understandable that one would utilize a more convenient and immediate measure instead. In addition, de Casterle BD et al. (2002) also pointed out that past discussions leading nowhere or ending in negative consequences could create an atmosphere in which frequent ethical issues are not discussed . Conversely, Parker F (2007) claimed that "ethics committees" meetings could promote professional growth by providing them the opportunity for learning how to address ethical issues from multi-disciplinary experts' different perspectives . Hence, nurse managers engaged in "ethics committees" could have learnt from previous decisions on how to address some ethical issues.
To date, the Malaysia Nursing Board has come out not only with its code of ethics, but with 25 other guidelines to ensure nursing practice is carried out according to the accepted norms. Although this is so, only about half of total nurse managers would refer to the code of ethics for dealing with ethical issues. Nevertheless, similar finding was also obtained in other studies. When deciding on how to handle ethical issues, nurse managers usually rely on three things: their personal skills, the management team or other nurses, or the code of ethics. In most cases, the latter was the least referred. Its usefulness in decision making had even been criticized. One criticism was that although code of ethics compliance is crucial to prevent unethical or illegal practices, it inadequately guides one's thoughts in formulating a viewpoint or judgement in dealing with ethical issues [23, 24].
The fact that we could not find any association between areas of practice and choice of dealing with ethical issues points out to the suggestion that any organizational improvement going to be made need not be targeted to certain areas of practice.
A couple of study limitations related to the use of self-administered questionnaire are worthy of attention. Firstly, we used a list of pre-identified ethical issues originally intended to avoid inconsistencies in the answers. Hence, we did not ask their experience with issues such as ethics of organ transplant and surrogate decision-making as in a previous study . However, some of our hospitals have no organ transplant service, so participants were unable to answer it anyway; moreover, surrogacy is prohibited in the country. In addition, not using open-ended questions or exhaustive list in this study lead to limited options that precluded new input and provision of exact descriptions from the participants on the types of ethical issues they experienced. As a result, we could not identify whether or not there were any ethical issues that may be unique to nurse managers in these hospitals especially those that may be related to their cultural and social backgrounds. Secondly, our participants were not randomly selected. While questionnaires were distributed to all nurse managers with the expectation of full participation, only two-third responded. Therefore, possibility exist that non-respondent nurse managers might be representative of specific group of population with unique experience and understanding of ethical issues. However, our method obtained better response compared to 15% - 52% in previous studies which utilized traditional mailing system as communication means [13–15], where responses were largely dependent upon participants' willingness to return pre-stamped envelopes back to the sender. A third limitation is that participants' experiences were based on their recall of past encounters of ethical issues. We solely relied on their own knowledge about ethical issues to correctly recall they have previously experienced them.