aitamaa_ethics nursing.pdf

8/10/2019 AITAMAA_ETHICS NURSING.pdf

1/15

http://nej.sagepub.com/Nursing Ethics

http://nej.sagepub.com/content/17/4/469Theonline version of this article can be found at:

DOI: 10.1177/0969733010364896

2010 17: 469Nurs EthicsElina Aitamaa, Helena Leino-Kilpi, Pauli Puukka and Riitta SuhonenEthical problems in nursing management: The role of codes of ethics

Published by:

http://www.sagepublications.com

can be found at:Nursing EthicsAdditional services and information for

http://nej.sagepub.com/cgi/alertsEmail Alerts:

http://nej.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

http://nej.sagepub.com/content/17/4/469.refs.htmlCitations:

What is This?

- Jul 7, 2010Version of Record>>

by Daniela Agheorghiesei on October 29, 2012nej.sagepub.comDownloaded from
http://nej.sagepub.com/http://nej.sagepub.com/http://nej.sagepub.com/content/17/4/469http://nej.sagepub.com/content/17/4/469http://www.sagepublications.com/http://www.sagepublications.com/http://nej.sagepub.com/cgi/alertshttp://nej.sagepub.com/cgi/alertshttp://nej.sagepub.com/subscriptionshttp://nej.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsPermissions.navhttp://nej.sagepub.com/content/17/4/469.refs.htmlhttp://nej.sagepub.com/content/17/4/469.refs.htmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://nej.sagepub.com/content/17/4/469.full.pdfhttp://nej.sagepub.com/content/17/4/469.full.pdfhttp://nej.sagepub.com/http://nej.sagepub.com/http://nej.sagepub.com/http://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://nej.sagepub.com/content/17/4/469.full.pdfhttp://nej.sagepub.com/content/17/4/469.refs.htmlhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsReprints.navhttp://nej.sagepub.com/subscriptionshttp://nej.sagepub.com/cgi/alertshttp://www.sagepublications.com/http://nej.sagepub.com/content/17/4/469http://nej.sagepub.com/


2/15


3/15

problem is defined as a situation in which a problem or dilemma is experienced between your own values

and norms and those of other people: a situation which by your own account is not correct or should not

occur.2

Ethical problem solving on different levels is an essential part of ethics in nursing management. It is nurse

managers responsibility to work towards resolving ethical problems and give support to their subordinates

ethical decision making.3-7 Furthermore, nurse managers should be able to articulate the application ofethical principles to nursing, integrate high ethical standards and core values into everyday nursing practice,

and create an environment with high ethical standards.8 Protecting patients interests and ensuring the quality

of their care are significant parts of ethical nursing management. Nurse managers should provide opportu-

nities for nurses to reach more professional competence. In addition, issues concerning the public image and

social relations of the organization are the responsibility of nurse managers.9 Managers role is essential in

the development and maintenance of organizational culture. They influence the values, attitudes and beha-

viours of an organization, and their aim should be to ensure that ethical standards are upheld on a continuous

basis.10

Ethical problems in nursing have been studied in different clinical settings,2,11-13 and organization ethics

has also been investigated.14,15 Most studies on ethical problems concerning nursing seem to be conducted

among nurses,2,11,13

with less research on ethical problems in nursing management. Some quantitative stud-ies concerning ethical problems encountered by nurse managers can be identified,3,4,7,16 in addition to qua-

litative studies about more specific areas of ethics in nursing management.14,17

Ethical problems in nursing management can be classified into those related to patient care, staff and the

organization. Among these, problems with patient care are of primary concern.9 In studies conducted among

nurse managers, issues of developing and maintaining the quality of care are among those most frequently

mentioned as ethical problems.3,4,7 Wilson14 named quality of care as one of the main categories of ethical

themes in nursing administration. Cooper et al.16perceived the failure to provide service of the highest qual-

ity as the most commonly mentioned ethical problem. When comparing ethical issues between staff nurses

and nurse managers work, Cooper et al.18 noted that both these groups seem to have quite similar views

regarding the number of ethical issues, and they experience widespread disappointment with the quality

of service provided by health care organizations. In a study by Breslin et al.,

19

a Canadian bioethicist panelwas asked about the most common ethical challenges that patients and their relatives face in health care. The

highest ranking challenge was disagreement between patients and/or families and health care professionals

about treatment decisions.

Among staff-related ethical problems the most common difficulty seems to be employee relations. In a

study by Cooper et al.,16 relationships with other health care professions were ranked among the 10 most

common ethical issues (out of 40), and one in four respondents (n 325) chose 4 or 5 on a scale where 5

represented a major ethical problem. In other studies, employee relations were measured as one issue regard-

less of profession or status of relationships. Lack of competency among nursing staff has also been found to

be a fairly common ethical problem.3,4,7,16 The selection of employees has been reported to be among the

least common ethical problems.3,4,7

Where organizations are concerned, ethical conflict between the administrative role and nurse managers

professional role is one of the main problems. Nurse managers emphasize their professional values of pro-

viding high quality care for all patients, while one of an organizations aims can be assumed to be a quick and

economically effective service leading to lower staff costs. For nurse managers, this results in an ethical con-

flict.3,4,14,20 In addition, resource allocation is mentioned as one of the most common ethical problems.3,4,7,14

A qualitative study examining ethical conflict between nurse managers and their organizations carried out in

Canada identified four themes: voicelessness, where to spend the money, the rights of individuals versus

the needs of the organization, and unjust practices by senior administration and/or the organization. By voi-

celessness the authors17 meant that nurse managers felt devalued and powerless. Esterhuizen9 emphasizes

470 Nursing Ethics 17(4)

http://nej.sagepub.com/http://nej.sagepub.com/http://nej.sagepub.com/http://nej.sagepub.com/


4/15

that negative publicity can also damage public confidence in an organization, and that conflict in this area is

also of interest to nurse managers.

Nurses in managerial positions have a responsibility to take care of their staff and provide the necessary

support for them in ethically problematic situations.9 Staff nurses in acute care hospitals perceive many kinds

of moral distress. Staffing and the competence of other nurses and physicians are issues that cause moral dis-

tress, in addition to situations in which nurses have to carry out work assignments for which they do not feelthey have professional competence.13 Moral problems seem to be especially related to circumstances in

which nurses experience feelings of powerlessness with regard to the well-being of patients. In relation to

colleagues, the most common morally problematic situations concern the lack of appropriate behaviour

towards patients or colleagues, insufficient knowledge on the part of nurses, and keeping silent about errors.2

In a literature review about nurses perceptions of ethical issues in the care of older people, the following

sources of these issues for nurses were found to be: doctors, lack of financial and personnel resources,

patients families, societal and organizational attitudes, routine-centred care, and relationships with peers.11

Many problems mentioned in these studies may be seen as being closely related to nursing management

actions.

Many countries have codes of ethics defined by health care professionals for ethical guidance. These

codes indicate the values of the profession and inform professionals about how they should act based on thosevalues.21,22 For nursing practice, there are also the International Council of Nurses code of ethics21 and the

proposal for a code of ethics and conduct for European nurses defined by the European Federation of Nursing

Regulators.23 The European code was drawn up in 2008 and is meant to protect European citizens by estab-

lishing ethical standards in nursing throughout Europe.23,24 In a European study, nurses perceived that they

had poor understanding of their professional codes of ethics.25,26 The usefulness of codes of ethics in decision

making has also been criticized.9,22,27-29 This critique concerns mainly the changed context of nursing, influ-

enced by an increasing dominance of economic discourse, growing multidisciplinarity and an intensified

legal framework. According to Meulenbergs et al.,22 the nursing profession is no longer as independent,

self-instituting and self-regulating as previously, which entails a reversal in the function of nursing codes

of ethics.15

In some countries, codes of ethics, ethical principles and standards have also been formulated for man-agement personnel. The UKCode of conduct for NHS managers guides NHS managers and health bodies

in their work, decisions and choices, and reassures the public about professional standards and accountabil-

ity.30 The code of ethics of the American College of Healthcare Executives contains ethical standards for

executives and their responsibilities to the profession, patients, organization, employees and society.31 There

is also a Finnish code of ethics for nurse managers.32

Nurse managers have indicated that they have a responsibility to identify and solve ethical issues in their

workplace.3,4,7 When making decisions about ethical problems nurse managers use their own personal val-

ues, discussions with management or nurse colleagues, acts on patients rights, and their professional codes

of ethics. The least used of these has been shown to be the professional codes of ethics.7,33-35However, to the

best of our knowledge, there seems to be no research about the role of codes of ethics in nursing management.

Research questions

The aim of this study was to identify the ethical problems that occur in nurse managers work and the role of

codes of ethics in their solution. The ultimate goal is to improve ethical decision making in nursing

management.

For this study, an ethical problem was widely understood as a difficult matter concerning a question of

what is good or right. The concept was not explained to the participants because the aim was to discover their

own views about experiencing ethical problems. By codes of ethics is meant the written professional codes

Aitamaaet al. 471



5/15

for the different professions in health care. Thirteen Finnish codes and theICN code of ethics for nurses were

mentioned in the questionnaire. The following research questions were set:

1) What kind of ethical problems appear in nursing management?

2) What is the role of the codes of ethics in resolving these problems?

3) What background factors are associated with ethical problems and with the use of codes of ethics intheir solution?

Methods

Data collection

Data collection was facilitated by a structured questionnaire developed for this study on the basis of a liter-

ature review and expert analysis by five nurse managers with broad experience of different levels of nursing

management. The items for measurement of the ethical problem issues in the questionnaire were mostly

based on earlier studies (Table 1) but also contributed by experts (two items) and taken from the content

of codes of ethics. The content and wording of the questionnaire were pilot tested by eight professionals withexperience in nursing management.

The first part of the questionnaire (seven questions) included background factors: age, gender, job

position, length of management experience, organization type and number of staff (nurse subordinates).

Furthermore, one question was included to measure participation in ethics training after graduation (yes/

no). The second part of the questionnaire (32 items) comprised 5-point Likert-type scales divided into three

dimensions: patient-, staff- and organization-related ethical problems. The frequency with which the nurse

managers faced selected ethical problems in their work was measured by 16 items. These items used a 5-

point scale: daily, weekly, monthly, less than monthly or never. The use of codes of ethics in dealing with

ethical problems (16 items, the same as those used in the previous question) was measured on a 4-point scale:

always or almost always, often, sometimes, never. Higher scores indicated more ethical problems or

solutions used more often.The data were collected in 2007 by mail in 21 specialized health care or primary health care organizations

in two out of 20 hospital districts in southwest Finland. Finnish municipalities arrange primary health care in

local health centres and contract specialized health care from hospital districts. For practical reasons, two of

these hospital districts and all the hospitals and health care centres in their areas were selected for this study.

The target sample included all nurse managers (N 501), comprising 76 nurse managers (middle or strategic

level) and 425 head nurses (in charge of a ward). A total of 205 usable responses were returned (response rate

41%): 31 were from nurse managers at middle or strategic level (41%) and 174 from nurse managers in

charge of a ward (41%).

Permission to gather data was given at all participating organizations according to national standards. The

respondents were informed about the aim of the study and that their participation was voluntary. Both anon-

ymity of the responses and confidentiality were explained to them.

Participants (Table 2)

The respondents age ranged from 29 to 62 years (mean 50). The majority were female (96%) and more than

half (60%) worked in specialized health care. Most respondents were experienced nurse managers. They had

on average of 12 years experience in health care management (range 0.145, n 203). The number of nurse

subordinates they were responsible for ranged mainly (58%) between 10 and 29. Most of the nurse managers

at middle or strategic level had more than 100 subordinates.




6/15

Analysis

The data were analysed statistically using the SPSS 14.0 and SAS 9.1 software packages. Descriptive statis-

tics (frequencies, means and standard deviations) were used to describe the variables. The chi-squared test or

Wilcoxons two-sample test were used to compare the distributions of the categorical variables, as appropri-

ate. Sum scores (patient-, staff- and organization-related) were formed by calculating the mean values for

the single items concerning the ethical problems encountered and the role of codes of ethics in their solution.

The single items are ordinal in nature and therefore caution should be applied when interpreting the results of

the sum scores. The internal consistency of the sum scores was evaluated using Cronbachs alpha. Associa-

tions between the sum scores and the background variables were analysed using Students t-test. The levels

between the sum scores were compared using the pairedt-test. P-values less than 0.05 were interpreted as

being statistically significant.

Results

Ethical problems in nursing management

In nursing management, ethical problems have been shown to be related to patients, staff and the organiza-

tion.7 The results were therefore placed into these categories (Tables 3 and 4).

The most common ethical problems relating to patients concerned the provision of good care and devel-

oping the quality of care, which, together, over half of the respondents said they encountered at least weekly.

Table 1.Elements of the questionnaire and their sources

Ethical problem Source

Patient related Esterhuizen 19969

Providing good care to patients Borawski 19953; Camunas 19944; Cooper et al. 200216; Sietsema &

Spradley 19877; Wilson 199814Developing the quality of care Borawski 19953; Camunas 19944; Sietsema & Spradley 19877

Conflict between the demands of patients careand staffs exhaustion

Experts

Conflict between nursing staff and patients Breslin et al. 200519

Conflict between nursing staff and patientsrelatives

Breslin et al. 200519

Conflict caused by patients different culture ExpertsStaff related Esterhuizen 19969

Conflict among nursing staff Borawski 19953; Camunas 19944; Sietsema & Spradley 19877

Conflict between nursing staff and otherprofessionals

Borawski 19953; Camunas 19944; Sietsema & Spradley 19877;Cooper et al. 200216

Nursing staffs behaviour or attitudes ICN 200621; NHS 200230

Career and assignments of nursing staff AONE 20058; Taja ry 200332

Selecting staff members Borawski 19953; Camunas 19944; Sietsema & Spradley 19877

Incompetent nurses Borawski 19953; Camunas 19944; Sietsema & Spradley 19877;Cooper et al. 200216

Organization related Esterhuizen 19969

Allocation of scarce human resources Camunas 19944; Sietsema & Spradley 19877; Wilson 199814

Allocation of financial resources Camunas 19944; Sietsema & Spradley 19877; Wilson 199814

Conflict between nursing and organizationalvalues

Camunas 19944; Cooper et al. 200216

Public image of organization Esterhuizen 19969

Aitamaaet al. 473



7/15

Conflict between nursing staff and patients or their relatives was among the least frequently encountered

problems (Table 3).

In staff-related conflict, the most frequent ethical problems were those concerning relationships among

nursing staff or between nursing staff and other professionals (Table 3).

Among the organization-related problems, the most common was the allocation of scarce human

resources. This was also the most frequent problem identified, and no respondents answered never in this

case. Over two-thirds of the participants indicated that they encountered ethical problems daily or weekly in

this area. The allocation of financial resources was also one of the most frequent problem areas, whereas con-

flict between nursing and organizational values was less common (Table 3).

The highest sum variable score was reported for encountering organization-related ethical problems and

the lowest for staff-related problems. The differences between patient-related and organization-related

issues, and between staff-related and organization-related problems, were statistically significant (Table 4).

Table 2.Characteristics of respondents

Characteristic No. % Mean (SD) Range

GenderFemale 197 96

Male 8 4Age (years) 50.0 (6.8) 2962


8/15

Use of professional codes of ethics for solving ethical problems

Professional codes of ethics were used by the nurse managers to solve ethical problems, with frequency of

use varying according to the ethical problem concerned. Codes of ethics were used most often with patient-

related problems, followed by staff-related problems; they were used least for organization-related issues.

The differences between all three sum variables were statistically significant (P< 0.0001) (Table 4).

Table 3.Ethical problems in nursing management

Ethical problem

Frequency

No.Daily(%)

Weekly(%)

Monthly(%)


9/15


10/15

and assignments of nursing staff, selecting staff members, and conflict between nursing and organizational

values. In primary health care, codes of ethics were used more often for issues concerning the development of

quality care. Nurse managers who had participated in ethics training after graduation used codes of ethics

more often for questions regarding nurses incompetence, and career and assignments of nurses, as well

as for conflict between nursing and organizational values (Table 7).

Two statistically significant associations were found in the analyses of the sum variables for the use of

codes of ethics in problem solving. Middle level and strategic nurse managers used codes of ethics more often

for solving organization-related problems than managers in charge of a ward (mean score 2.59 versus 2.22,

P 0.0056). Nurse managers who had participated in ethics training after graduation used codes of ethics

more often with ethical problems regarding staff than those who had not undergone any training (mean score

2.53 versus 2.32,P 0.031).

Table 6.Association of background factors with ethical problems occurring in nursing management

Background factor Ethical problem No.

Frequency of ethical problem

P-value

Daily:no.

(%)

Weekly:no.

(%)

Monthly:no.

(%)

Rarely:no.

(%)

Never:no.

(%)

Organization type Selecting staff membersPrimary health care 76 2 (3) 18 (24) 21 (28) 34 (45) 1 (1) 0.039Specialized health care 122 2 (2) 16 (13) 31 (25) 72 (59) 1 (1)

Conflict between nursingstaff and patients relatives

Primary health care 77 1 (1) 13 (17) 17 (22) 43 (56) 3 (4) 0.018Specialized health care 120 1 (1) 6 (5) 25 (21) 71 (60) 17 (14)

Participation in ethicaltraining after graduation

Conflict between nursingstaff and patients relatives

Participated 87 0 (0) 8 (9) 27 (31) 45 (52) 7 (8) 0.035Not participated 111 2 (2) 11 (10) 15 (14) 70 (63) 13 (12)

Conflict between nursingstaff and patients

Participated 89 0 (0) 8 (9) 29 (33) 50 (56) 2 (2) 0.049Not participated 110 2 (2) 8 (7) 21 (19) 72 (65) 7 (6)

Age Conflict among nursing staff 49 years 85 19 (22) 25 (29) 24 (31) 17 (20) 0 (0) 0.04750 years 104 11 (11) 28 (27) 29 (28) 32 (31) 4 (4)

Incompetent nurses49 years 85 4 (5) 19 (22) 27 (32) 34 (40) 1 (1) 0.01450 years 104 3 (3) 13 (12) 28 (27) 57 (55) 3 (3)

Career and assignments ofnursing staff49 years 85 5 (6) 16 (19) 31 (36) 33 (39) 0 (0) 0.01650 years 104 1 (1) 16 (15) 30 (29) 54 (52) 3 (3)

Nursing staffs behaviour orattitudes49 years 85 5 (6) 22 (26) 34 (40) 24 (28) 0 (0) 0.00250 years 103 4 (4) 16 (16) 31 (30) 49 (48) 3 (3)

Aitamaaet al. 477



11/15

Discussion

The purpose of this study was to identify the ethical problems encountered by Finnish nurse managers and the

role of codes of ethics used for their solution. The findings indicate that nurse managers perceive many kinds

of ethical problems in their work, the most common of which are related to the allocation of scarce personnel

resources and ensuring the quality of care, as seen also in previous studies carried out since the 1980s.3,4,7

These results were regardless of different managerial positions as well as organization type. Questions con-

cerning resources and quality issues are of current interest in health care in many countries. At present in

Finland, there is a greater demand for than supply of health care services, and economic issues are more rel-

evant than before.22,36 Quality issues are also under examination and development.

Table 7.Association of background factors with use of codes of ethics in resolving ethical problems

Background factor Ethical problem No.

Frequency of using codes of ethics

P-value

Always:no.

(%)

Often:no.

(%)

Sometimes:no.

(%)

Never:no.

(%)

Job position Allocation of financial resourcesIn charge of a ward 168 7 (4) 45 (27) 81 (48) 35 (21) 0.029Middle or strategicmanagement

30 4 (13) 13 (43) 1 0 (33) 3 (10)

Career and assignments ofnursing staff

In charge of a ward 169 7 (4) 45 (27) 93 (55) 24 (14) 0.010Middle or strategicmanagement

29 3 (10) 15 (52) 7 (34) 4 (14)

Selecting staff membersIn charge of a ward 168 1 6 (8) 45 (27) 79 (47) 28 (17) 0.041

Middle or strategicmanagement

30 3 (10) 16 (53) 7 (23) 4 (13)

Conflict between nursing andorganizational values

In charge of a ward 169 18 (11) 54 (32) 78 (46) 19 (11) 0.018Middle or strategicmanagement

30 8 (27) 11 (37) 9 (30) 2 (7)

Organization type Developing the quality of carePrimary health care 75 21 (28) 33 (44) 15 (20) 6 (8) 0.029Specialized health care 122 17 (14) 67 (55) 34 (28) 4 (3)

Participation in ethicaltraining after graduation

Incompetent nursesParticipated 89 11 (12) 39 (44) 32 (36) 7 (8) 0.029Not participated 108 8 (7) 30 (28) 54 (50) 16 (15)

Career and assignments ofnursing staff

Participated 88 4 (4) 35 (40) 41 (47) 8 (9) 0.013Not participated 108 5 (5) 25 (23) 59 (55) 19 (18)

Conflict between nursing andorganizational values

Participated 90 13 (14) 42 (47) 30 (33) 5 (6) 0.0005Not participated 107 12 (11) 23 (21) 57 (53) 15 (14)




12/15

Good care and quality issues are dependent on many factors, such as organizational culture, attitudes and

competencies. Sufficiency of human resources is also a very significant factor.37 Because of the descriptive

and general nature of this study, a possible interdependence of resource problems and quality of care was not

investigated. However, the literature indicates that this could be so. For example, the theme of how to spend

the money in the study by Gaudine and Beaton17 includes problems such as how to meet the needs of

patients while staying on budget. The lack of financial and personnel resources as a reason for inadequatecare has also been reported in studies concerning the care of older people.11 The frequency of these ethical

problems measured in this study needs serious attention, especially because there is no reason to assume that

the bases of these problems are temporary in nature.

The results appear to show that codes of ethics are used most with patient-related and least with

organization-related problems. This could support the suggestion of Meulenbergs et al.22 that codes of ethics

should accommodate the changing context of nursing. Codes of ethics emphasize the professionalpatient

relationship and the ideal state of patient care, and ignore the importance of the economic side of health

care.27 Nevertheless, codes of ethics appear to be useful in many kinds of problems in spite of the findings

of previous studies7,33,34 showing that nurse managers mostly make decisions and choices based on their own

values and discussion with colleagues. Ethical problems are most certainly varied, complicated and unique

matters, and there is a need for multiform guidance for resolving them. Without recourse to any other means,personal values and discussion are too unstable and uncertain to serve as guidelines in solving ethical prob-

lems. It is important for nurse managers to be able to have closely argued, clear and transparent solutions

because they should be role models and teachers to their subordinates in ethical decision making. Codes

of ethics are one possible resource open to them.

Ethical problems and the use of codes of ethics in nursing management seem to be associated with dif-

ferent background factors. In this study, nurse managers in strategic or middle management appeared to use

codes of ethics more than those who are in charge of a ward. This result can even be seen as unexpected

because codes of ethics are mainly aimed at nurses who are actually working with patients. Nurses in charge

of a ward are closer to daily practice and could thus be expected to make more use of codes of ethics. How-

ever, there is also a code for nurse managers in Finland, which may be one reason for this result. Second,

previous studies of nurse managers resources used in ethical decision making show that administrative col-leagues are used much more frequently than codes of ethics.33,34 It is not known how much ward nurse man-

agers use discussion with their own superiors and whether this could have an effect on the results. Third,

differences may be associated with higher levels of education achieved by middle- or strategic-level nurse

managers and the different tasks and duties involved at various management levels. On the basis of this study

we cannot draw firm conclusions about the reasons for this difference.

Participation in ethics training also seems to increase both the ability to perceive ethical problems and the

use of codes of ethics in resolving them. However, this reasoning is not very clear. It is possible that nurse

managers who are interested in ethical issues and are able to perceive ethical problems, and use the available

codes of ethics, are also more inclined to take courses in ethics. The younger nurse managers perceived ethi-

cal problems more often than their older counterparts. It can be assumed that the younger managers ethics

education would be more recent, which may be a reason for this result. All these findings may support the

idea that education and training strengthen readiness to be aware of ethical problems and preparedness to

resolve them. However, it could also be assumed that nurses should be selected more on the basis of their

genuine ethical awareness and attitudes. The similarities of the ethical problems regardless of job position

or organization type can be considered to indicate that the problems revealed are the same throughout the

Finnish health care system, which makes the findings surrounding the most common ethical problems more

significant.

Some limitations need to be taken into account in interpreting the results. These have to do with the instru-

ment, the nature of the concepts in the questionnaire and the response rate. First, a suitable established

Aitamaaet al. 479



13/15

questionnaire was not found, which is why one was developed especially for this study and there was of

course no previous information about its reliability and validity. However, the items are based on the liter-

ature and expert analysis. The internal consistencies of the sum variables for the ethical problems and the use

of codes of ethics in their solution were satisfactory (Table 4; also see Burns and Grove 38). Second, some of

the questions may have been ambiguous and could have caused some response bias. Previous literature

shows that the concept of an ethical problem can be understood in different ways. The frequencies of ethicalissues are thus only suggestive in nature, but the resulting order of the ethical problems is more valuable.

Each participant may understand the concept of an ethical problem rather differently, but when ranking prob-

lems they use their own ideas in the same way with each one. The use of codes of ethics as a concept is also

problematic. The Finnish codes of ethics for different nursing professionals were mentioned in the question-

naire and were thus not open to interpretation, but ways of using them could vary and be understood in dif-

ferent ways. Respondents may think only of using the codes in a concrete manner, or they could also realize

that they use them unconsciously. The latter means that the values and advice contained in the codes are

already internalized and there is no need to think about their content.26 Thus, the order of the problems in

which the codes of ethics were used is more significant than exact frequencies of use. Third, the relatively

low response rate may also decrease the validity and generalizability of the results. However, the sample was

large enough (n 205) and it represented nurse managers at all levels and from different types of organiza-tions with no systematic under- or over-representation of specific groups.

Conclusion and recommendations

This study provided an overview of the ethical problems encountered in nursing management, but more quali-

tative studies are needed for shaping the features andnature of these issues. The findings indicate the importance

of resource allocation and issues of quality of care as sources of ethical problems in nurse managers work. Fur-

ther qualitative study could provide a more exact description of ethical problems related to resource and care

quality as well as other issues. Second, the basis and mechanisms of ethical decision makingin nursing manage-

ment are not well known. More research is needed to find out the values, principles or codes that guide solutions

to ethical problems. More information is required about the concrete mechanisms of how decisions are made inethically problematic situations. Furthermore, the concrete choices for and solutions of ethical problems should

be studied to investigate the types of choices that are made and the nature of the argumentation used.

Nurse professionals codes of ethics seem to have limited value when it comes to resource allocation.

Thus, clear guidelines should be drawn up for nursing management personnel to serve as an aid in ethical

decision making for resource allocation issues and, moreover, to combine economically effective activities

and a high quality of care. Education is important when aspiring to better ethical competence and the creation

of a strong and common basis for ethical thinking in all nursing practice and management. There is also a

need for wide discussion about values in health care, which should be conducted in both health care orga-

nizations and society. Nurse managers should be involved in this discussion and also be capable of stating

arguments for solutions for themselves, their subordinates, stakeholders and the public. This is extremely

important, especially in situations where structures and resources of health care are re-evaluated becauseof societal changes.

Conflict of interest statement

The authors declare that there is no conflict of interest.

References

1. Thompson IE, Melia KM, Boyd KM.Nursing ethics, third edition. Edinburgh: Churchill Livingstone, 1994.




14/15

2. Van der Arend AJG, Remmers-van den Hurk CHM. Moral problems among Dutch nurses: a survey.Nurs Ethics

1999; 6: 46882.

3. Borawski DB. Ethical dilemmas for nurse administrators.J Nurs Adm 1995; 25(78): 602.

4. Camunas C. Ethical dilemmas of nurse executives.J Nurs Adm 1994; 24(78): 4551.

5. Schank MJ, Weis D, Ancona J. Reflecting professional values in the philosophy of nursing.J Nurs Adm 1996; 26(7

8): 5560.6. Shirey MR. Ethical climate in nursing practice: the leaders role.JONAS Healthc Law Ethics Regul2005; 7: 5967.

7. Sietsema MR, Spradley BW. Ethics and administrative decision making.J Nurs Adm 1987; 17(4): 2832.

8. American Organization of Nurse Executives. AONE nurse executive competencies.Nurse Leader2005; (Feb): 506.

9. Esterhuizen P. Is the professional code still the cornerstone of clinical nursing practice?J Adv Nurs1996; 23: 2531.

10. Kane-Urrabazo C. Managements role in shaping organizational culture.J Nurs Manag2006; 14: 18894.

11. Rees J, King L, Schmitz K. Nurses perceptions of ethical issues in the care of older people.Nurs Ethics2009; 16:

43652.

12. Gallagher E, Alcock D, Diem E, Douglas A, Medves J. Ethical dilemmas in home care case management.J Healthc

Manag2002: 47: 8597.

13. Rice EM, Rady MY, Hamrick A, Verheijde JL, Pendegast DK. Determinants of moral distress in medical and sur-

gical nurses at an adult acute tertiary care hospital. J Nurs Manag2008; 16: 36073.14. Wilson DM. Administrative decision making in response to sudden health care agency funding reductions: is there

a role for ethics?Nurs Ethics 1998; 5: 31929.

15. Schluter J, Winch S, Holzhauser K, Henderson A. Nurses moral sensitivity and hospital ethical climate: a literature

review.Nurs Ethics 2008; 15: 30421.

16. Cooper RW, Frank GL, Gouty CA, Hansen MC. Key ethical issues encountered in healthcare organizations: per-

ceptions of nurse executives.J Nurs Adm 2002; 32: 3317.

17. Gaudine AP, Beaton MR. Employed to go against ones values: nurse managers accounts of ethical conflict with

their organizations.Can J Nurs Res 2002; 34(2): 1734.

18. Cooper RW, Frank GL, Hansen MC, Gouty CA. Key ethical issues encountered in healthcare organizations: the

perceptions of staff nurses and nurse leaders.J Nurs Adm 2004; 34: 14956.

19. Breslin MJ, MacRae SK, Bell J, Singer PA and the University of Toronto Joint Centre for Bioethics Clinical EthicsGroup. Top 10 health care ethics challenges facing the public: views of Toronto bioethicists. BMC Med Ethics

2005; 6(5): 18.

20. Brosnan J, Roper JM. The reality of political ethical conflicts: nurse manager dilemmas. J Nurs Adm 1997;

27(9): 426.

21. International Council of Nurses.The ICN code of ethics for nurses. http://www.icn.ch/icncode.pdf (2006, accessed

March 2010).

22. Meulenbergs T, Verpeet E, Schotsmans P, Gastmans C. Professional codes in a changing nursing context: literature

review.J Adv Nurs 2004; 46: 3316.

23. European Council of Nursing Regulators. FEPI Working Group on Ethical Codes. http://www.fepi.org/en/work-

ing-groups.php (2009, accessed March 2010).

24. Lasso L, Stievano A, Gonzales Jurado MG, Rocco G. Code of ethics and conduct for European nursing.Nurs Ethics

2008; 15: 82136.

25. Heikkinen A, Lemonidou C, Petsios K, et al. Ethical codes in nursing practice: the viewpoint of Finnish, Greek and

Italian nurses.J Adv Nurs 2006; 55: 3109.

26. Tadd W, ClarkeA, Lloyd L, et al.The value of nurses codes: European nurses views.Nurs Ethics 2006; 13: 37693.

27. Edgar A. How effective are codes of nursing ethics? In: Tadd W (ed.)Ethical and professional issues in nursing:

perspectives from Europe. Basingstoke: Palgrave Macmillan, 2004: 15574.

28. Pattison S. Are nursing codes of practice ethical?Nurs Ethics2001; 8: 518.

29. Downie RS, Calman KC.Healthy respect. Oxford: Oxford University Press, 1998.

Aitamaaet al. 481



15/15

30. National Health Service, United Kingdom.Code of Conduct for NHS managers. http://www.dh.gov.uk/prod_con-

sum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4085904.pdf (2002, accessed March 2010).

31. American College of Healthcare Executives.ACHE codes of ethics. http://www.ache.org (2007, accessed March

2010).

32. Terveystieteiden akateemiset johtajat ja asiantuntijat ry (Taja ry). (Association of Health Science Academic Lead-

ers and Experts.) Hoitotyon johtajan, ylihoitajan eettiset ohjeet. (Code of ethics for nurse managers.) Ylihoitajalehti2003: 31(2); 15 (in Finnish).

33. Borawski DB. Resources used by nurse administrators in ethical decision-making.J Nurs Adm1994; 24(3): 1722.

34. Camunas C. Codes of ethics as resources for nurse executives in ethical decision making.J NY State Nurs Assoc

1994; 25(4): 47.

35. Cooper RW, Frank GL, Gouty CA, Hansen MM. Ethical helps and challenges faced by nurse leaders in the health-

care industry.J Nurs Adm 2003; 33: 1723.

36. Ryynanen O-P, Myllykangas M. Terveydenhuollon etiikka. Arvot monimutkaisuuden maailmassa. (Ethics in health

care. Values in a complicated world.) Juva: WSOY, 2000 (in Finnish).

37. Pasternak A. Hoitovirheet ja hoidon aiheuttamat haitat. (Medical errors and adverse events in medical care.)

Duodecim 2006; 122: 245970 (in Finnish).

38. Burns N, Grove S.The practice of nursing research: conduct, critique, and utilization. Philadelphia, PA: Elsevier/Saunders, 2005.


aitamaa_ethics nursing.pdf

Documents