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Accessible Summary: What is known on the subject?: ECT is a treatment which has a long and complicated history. There is no consensus on its effectiveness and there is a great deal of polarized debate as to whether it should be used. MHNs are asked to work with people who are receiving ECT as part of their duties. What the paper adds to existing knowledge?: The paper seeks to move beyond the polarized arguments and to consider how MHNs can work with people where ECT is being considered or administered as part of their treatment in a manner which satisfies their professional obligations. Implications for practice: MHNs may need to broaden their understanding of ethics beyond the traditional biomedical ethics model of beneficence, non‐maleficence, justice and autonomy, as well as improving their understanding of social and political factors which may have an unseen effect of the use of ECT as a treatment in order to meet their professional obligations when working with people being administered ECT. INTRODUCTION: Electroconvulsive 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. Aim: To consider the ethical dilemmas and decision‐making processes facing MHNs involved in the administration of ECT. Method: A critical realist review of the literature surrounding ethical considerations and ECT was undertaken using thematic analysis. Findings: 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. Discussion: 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. Implications for practice: 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. [ABSTRACT FROM AUTHOR]