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What are the ethical dilemmas in the decision making processes of nursing people given Electroconvulsive therapy? A critical realist review of qualitative evidenceElectroconvulsive therapy (ECT) has a complex and contentious place in psychiatric care. Mental health nurses (MHNs) are of obligated to be part of this practice despite ethical concerns. To consider the ethical dilemmas and decision-making processes facing MHNs involved in the administration of ECT. A critical realist review of the literature surrounding ethical considerations and ECT was undertaken using thematic analysis. Four key themes emerged: the MHN as an advocate and conflict in their role, issues surrounding consent, questionable efficacy and unknown method of action, side effects, and legal issues and clinical guidelines. Using a critical realist framework for understanding, the decision-making process and ethical considerations are viewed as part of the empirical and actual parts of reality, while the potential for other, unseen causal powers to be at play is acknowledged. MHNs need to ensure they have an adequate ethical underpinning to their practice to enable them to navigate contentious areas of practice such as ECT to practice effectively and preserve safety. This may require moving beyond the traditional biomedical model of ethics. Developing an appreciation of unseen causal factors is also an essential part of MHNs’ developing professional competency.