In a dynamic health care environment where advanced technology intersects with patient acuity and limited resources, nurses sometimes face complicated ethical issues. These issues are usually challenging and may easily result in moral dilemmas [1].

Emergency nurses are particularly exposed to clinical nursing care. Emergency nursing care has some special characteristics. The patients are by definition in serious conditions and have many emergencies, requiring urgent care at any hour of the day. In dangerous and unpredictable care situations, emergency nurses face various nursing risks, complicated nursing ethical problems and dilemmas, each of which can entail legal responsibility [2]. Moreover, frequent exposure to ethical dilemmas has a negative effect on the physical and mental health of emergency nurses and on their daily work. These negative effects include not only reduced job satisfaction and induced job burnout [3], [4], but also impaired quality of emergency care. Eventually, patient care is affected [5], [6].

Effective nursing ethics decision-making is regarded as one of the core competencies for nurses, and developing ethical decision-making skills among nurses is an effective way to resolve ethical issues in nursing practice [7]. Ethical decision-making is defined as the ability to make the most appropriate decision about an ethical issue based on intuition, ethical nursing principles, codes of ethics, and moral reasoning in clinical nursing practice [8]; it is a rational process involving cognitive activity and moral judgment of the decision. It includes recognition and identification of problems, evaluation of alternatives, and selection of a course of action [9]. The level of nurses’ ethical decision-making ability has a direct effect on the quality of nursing care and nurse-patient relationship [10]. Emergency nurses are regularly under high pressure and face risks. When faced with serious and unpredictable situations, emergency nurses should be able to make an appropriate ethical decision within a short timeframe to forestall adverse consequences, such as injury and death [11]. Therefore, emergency nurses’ ethical decision-making abilities are worthy of scholarly attention. However, few quantitative studies have been conducted on the subject, especially in China.

Empathy is sometimes described as an ethical emotion. Empathy refers to the cognitive ability to comprehend another person’s feeling. It generates an emotional resonance with those feelings and motivates a willingness to respond appropriately to another’s needs [12]. Empathic interaction promotes patient satisfaction and has positive effects on patient outcomes [13]. Previous studies have found a significant correlation between empathy and ethical decision-making ability, and that empathic individuals may be more likely to make altruistic decisions [14], [15]. In ethics, however, the very existence of empathy is contested [16]. Cecchetto et al. [17] suggested that empathy and alexithymia affects individuals’ emotional response in moral decision-making, but it ultimately does not lead to deviation for the ethicality of the behaviors. This previous finding motivated the design of the current investigation into emergency nurses’ empathy and its relationship with their ability to make ethical decisions.

Professional values may be an important variable that influences the ethical decision-making. Professional values involve the standards guiding action accepted by practitioners and professional groups, and are used to evaluate the integrity of an individual or organization [18]. In nursing clinical practice, the decisions made by nurses may create value conflicts, some of which can lead to complex ethical issues. To effectively deal with ethical dilemmas, an understanding of values is essential [19]. Professional values could guide nurses’ judgement and decision-making in clinical settings and ethical decision-making when dealing with issues with an ethical dimension. Positive professional values might help nurses improve their decision-making ability and the quality of care they provide [20]. Although Iacobucci [21] found no significant correlation between self-perceived confidence in decision-making on issues with an ethical dimension and an individual’s professional values among nursing students, this finding requires further investigation. Additionally, ethical decision-making of emergency nurses may be influenced by personal characteristics such as clinical experiences; work environment; and participation in in-service ethics training programs [22], [23]. These findings would need to be further investigated as well.

A theoretical framework was established based on the dual process theory of moral decision-making (Fig. 1) [24]. The theory proposes that making ethical decisions involves both automatic emotional responses and controlled cognitive inference guided by acquired abstract moral principles. The emotional responses and controlled cognitive process are integrated during decision-making. Empathy allows a nurse to perceive and, to an extent, understand patients’ ideas, values, and beliefs—and also their feelings in ethical dilemmas, which are a reflection of their emotional responses [25]. Nursing professional values are attained from a continuous cognitive process, and they form a basis for behaviors in making decisions with ethical implications [26]. Therefore, we hypothesized that both empathy and nursing professional values may influence the ethical decision-making ability of an emergency nurse.

This study was designed to evaluate the ethical decision-making ability of emergency nurses and explore the influence of emergency nurses’ empathy and professional values on ethical decision-making ability. The study sought to provide a reference for nursing managers in evaluating the ethics decision-making of the emergency nurses they supervise. Additionally, it aimed to provide a theoretical basis for the design of interventions seeking to further improve the professional competence of emergency nurses.