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Background: Working as an ambulance nurse involves facing ethically problematic situations with multi-dimensional suffering, requiring the ability to create a trustful relationship. This entails a need to be clinically trained in order to identify ethical conflicts.

Aim: To describe ethical conflicts in patient relationships as experienced by ambulance nursing students during clinical studies.

Research design: An exploratory and interpretative design was used to inductively analyse textual data from examinations in clinical placement courses.

Participants: The 69 participants attended a 1-year educational programme for ambulance nurses at a Swedish university.

Ethical consideration: The research was conducted in accordance with the Declaration of Helsinki. Participants gave voluntary informed consent for this study.

Findings: The students encountered ethical conflicts in patient relationships when they had inadequate access to the patient’s narrative. Doubts regarding patient autonomy were due to uncertainty regarding the patient’s decision-making ability, which forced students to handle patient autonomy. Conflicting assessments of the patient’s best interest added to the conflicts and also meant a disruption in patient focus. The absence of trustful relationships reinforced the ethical conflicts, together with an inadequacy in meeting different needs, which limited the possibility of providing proper care.

Discussion: Contextual circumstances add complexity to ethical conflicts regarding patient autonomy, dependency and the patient’s best interest. Students felt they were fluctuating between paternalism and letting the patient choose, and were challenged by considerations regarding the patient’s communication and decision-making ability, the views of third parties, and the need for prioritisation.

Conclusion: The essence of the patient relationship is a struggle to preserve autonomy while focusing on the patient’s best interest. Hence, there is a need for education and training that promotes ethical knowledge and ethical reflection focusing on the core nursing and caring values of trust and autonomy, particularly in situations that affect the patient’s decision-making ability.