Original Manuscript

Ethical problems in nursingmanagement: The views ofnurse managers

Elina AitamaaUniversity of Turku, Finland; Satakunta Hospital District, Finland

Helena Leino-KilpiUniversity of Turku, Finland; Turku University Hospital, Finland

Silja Iltanen and Riitta SuhonenUniversity of Turku, Finland; Satakunta Hospital District, Finland

AbstractBackground: Nurse managers have responsibilities relating to the quality of care, the welfare of the staffand running of the organization. Ethics plays significant role in these responsibilities. Ethical problems arepart of daily management, but research in this area is limited.Objective: The aim of this study was to identify and describe ethical problems nurse managers encounterin their work to get more detailed and extensive view of these problems.Methods: The data consisted of nine interviews with nurse managers at different management levels inprimary healthcare and specialized healthcare organizations, and it was analysed by inductive contentanalysis.Ethical considerations: Permission to conduct the interviews including ethical approval was given at allparticipating organizations according to national standards. The respondents were informed about the aimof the study, and voluntary participation, anonymous response and confidentiality were explained to them.Findings: Four main categories were found: conflicts in practical situations, lack of appreciation, disregardof problems and experienced inadequacy. Problems could also be divided to patient-related, staff-related,organization-related and other problems.Discussion: The findings correspond with results from earlier studies but add knowledge of the nature anddetails of nurse managers’ ethical problems. New information is produced related to the ethical problemswith nurse managers’ own courage, motivation and values.Conclusion: Nurse managers identified a variety of different ethical problems in their work. Thisinformation is useful in the development of ethics in nursing management. Further research about thefrequency and intensity of nurse managers’ ethical problems is needed as well as possible differences indifferent levels of management.

KeywordsEthical problem, ethics, interview, nurse manager, nursing management

Corresponding author: Elina Aitamaa, Department of Nursing Science, University of Turku, FI-20014, Finland.

Email: elina.aitamaa@utu.fi

Nursing Ethics1–13

ª The Author(s) 2015Reprints and permission:

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Introduction

Ethics is significant in healthcare administration, especially in a time of continuous changes of economical,

technical and behavioural circumstances and development.1 In the Global Competency Model of the World

Health Organization (WHO),2 professional behaviour in accordance of healthcare ethics and values is

emphasized.

Nurse managers (NMs) are part of healthcare administration, managing nurses, who are the greatest

number of health workers. NMs are working at different levels in healthcare organizations: ward, middle

and strategic management. They have ethical responsibilities to the healthcare organization, to patients

cared in this organization and to the nursing staff employed by this organization.3 NMs play a role in clar-

ifying organizations’ mission, vision and values to their staff.4 They are ensuring continuous upholding of

ethical standards among staff5 and supporting nurses’ ethical competence.6 NMs should influence nursing

staff and act as arbiters between organizational and professional values.7 They also play a strategic role in

patient safety that is sensitive to ethics and promoting nursing practice where the humanity and dignity of

patients are respected.8 Ethical leadership in nursing has been found to be responsive to practitioners and the

contextual system. It also requires receiving and providing support, so that capacity of practice and discus-

sion about ethics in daily context may be increased.9

To maintain and develop good ethical management practice in healthcare, guidelines have been created.

In the United Kingdom, Code of Conduct of National Health Service (NHS) managers10 sets out the core

standards of conduct expected of NHS managers. The principles emphasized responsibilities to patients, so

that their care and safety should be managers’ first concern. Other principles highlight the respect of all the

interest parties in healthcare, including the patients, staff and public, accepting responsibilities and showing

commitment to working as a team member. Manager’s own behaviour and personal development are also

underlined: the manager should be honest and act with integrity and take responsibility for her own learning

and development. The Code has been made to guide managers in the work they do and decisions and choices

they have to make.10 Encountering ethical problems and seeking solutions to them are part of NMs’ work.11

In the literature, the concept ‘ethical problem’ is defined in various ways. According to Thompson

et al.,12 an ethical problem can be understood as a difficult matter requiring a moral solution. Fundamentally

it is a question of what is right or wrong or good or bad. The concept ‘ethical dilemma’ is used to denote a

situation in which a choice has to be made between two alternatives that appear undesirable. The concepts

‘ethical’ and ‘moral’ are often used as synonyms, as are ‘ethical problems’ and ‘moral problems’.12,13 Van

der Arend and Remmers-van den Hurk14 have defined moral problem as ‘a situation in which a problem or a

dilemma is experienced between our own values and norms and those of other people: a situation which by

your own account is not correct or ‘‘should not occur’’’. Concept ‘ethical conflict’ is also used. Gaudine and

Beaton15 have defined it this way: ‘When an individual’s personal values clash with those of the employing

organization, the result is ethical conflict’. Not all articles have a clear definition of what is meant by ethical

problems in the study in question. In this study, the concept ‘ethical problem’ is used in the same meaning as

in the study of Van der Arend and Remmers-van den Hurk.14

There are some studies of ethical problems in nursing management in 1990s.16,17 Results were quite in

common level, such as problems in staffing or maintaining good care. Research made in the 2000 concen-

trated on the consequences of ethical problems to different stakeholders. There are not only studies concern-

ing ethical problems in nursing management in general3,11,18 but also studies regarding ethical conflicts

against organization,15 workplace stress,19 negative workplace behaviours,20 case studies21 and nurse mid-

dle manager ethical dilemmas.22 Still, there is a need for qualitative research to get more detailed informa-

tion of the nature of NMs’ ethical problems.

Ethical problems are part of daily management. In Camunas’16 study, among NMs, nearly all (94%, n¼315) respondents reported encountering ethical problems when making daily management decisions. In

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nursing management, ethical problems can be divided into three categories: organization-related, staff-

related and patient-related problems.23 Toren and Wagner21 describe divided loyalties in NMs’ work:

employees (nurses) versus the organization, employees versus patients and employees versus the profes-

sion. In some surveys, the most frequently encountered ethical problems have concerned staffing, develop-

ing and maintaining good care and allocation of scarce resources.11,16,17 An ethical conflict between the

administrative role and nursing professional role has been identified in several studies.16–19 In Israeli study,

among nurse middle managers, the most common and most distressing ethical dilemmas were in adminis-

trative situations, other categories being clinical situations such as inappropriate care and interpersonal

situations.22 In the study of Gaudine and Beaton,15 NMs’ ethical conflicts in hospitals are divided into four

categories: ‘voicelessness’, ‘where to spend the money’, ‘rights of the individual versus needs of the orga-

nization’ and ‘unjust practices on the part of senior administration and/or the organization’, all associated

with distress and frustration.

In relation to staff, ethical problems have also been found in staff relations, hiring and termination and

promoting employees,16,17 but the nature and details of these problem areas were not described. Stress and

guilt among the nursing staff in relation to patient care are also challenges to NMs.23 Negative workplace

behaviours have been identified as an ethical dilemma for NMs when trying to treat everyone fairly and

respecting the individual dignity and integrity of professionals.20

NMs mentioned bioethical issues such as right to die, quality of life and appropriate care as a source of

role conflict in patient care, but the issues were not identified in detail.16 In a survey study of ethics and

human right issues among nurses in leadership roles, the most frequently experienced issue was ‘protecting

patient rights and human dignity’ (62.7%), one-third of the respondents working in the area of gerontology

and long-term care. It also indicates that the advocate role is very important to nurses in leadership role.3

To conclude, ethical problems are perceived to appear in NMs’ work. However, the nature and variety of

these problems have been rarely studied, and there is a need to know more in order to develop the ethics in

nursing management and by that to improve the running of the organization, the quality of care and the wel-

fare of the staff. Knowledge is also needed for developing instruments for the measurement of ethical prob-

lems in nursing management and to obtain generalizable results.

Aim and research questions

The aim of this study was to identify the ethical problems NMs encounter in their work and describe the

nature of these problems from NMs’ point of view. The ultimate goal is to improve the ethics in nursing

management. The following research question was addressed:

� What kind of ethical problems NMs encounter in their work related to patients, staff and

organization?

Methods

Design and participants

The data were collected using semi-structured interviews with NMs (n ¼ 9). The qualitative method was

selected because of the limited knowledge of the ethical problems in NMs’ work but the known existence

of these problems. The interviewees were purposefully and continuously selected by the researcher during

data collection. Purposeful sampling was used to get rich and diverse data. Interviewees represented varied

and relevant experience of working in management and was aimed to represent the widest breadth of pos-

sible ethical problems they encounter in nursing management. They also had acquaintance with ethical

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questions by belonging ethical committees or teams, by doing ethical-related research or by writing about

ethics. They represented strategic (n ¼ 2), middle (n¼ 4) and ward management level (n ¼ 3) both in spe-

cialized and primary healthcare organizations in different parts of Finland 2010 (Table 1). Managers in mid-

dle or ward management worked in different areas of healthcare such as older people care, paediatric,

medical, surgical, emergency or psychiatric clinics. Strategic-level managers were in charge of the nursing

practice of the whole organization. The participants were aged 43–61 years (mean 52 years), and they had

been working as managers for 1–27 years (mean 14 years).

Data collection

Data were collected by interviews. The broad interview framework, the research questions, was beforehand

sent to respondents. This gives interviewees time to think those themes before, aim being to get a richer

description during the interview.24 NMs were asked to describe the ethical problems they had encountered

in their work as concrete cases related to patients, staff, organization and other possible issues. Additional

questions such as ‘what do you mean by that?’ or ‘what is the ethical problem here?’ were asked when nec-

essary. The interviews were audio taped with the participants’ permission. The background information col-

lected from the participants included age, current job position, level of education, length of managing

experience and current unit. Special knowledge or experience of ethical issues was also asked. The inter-

viewees chose the places where the interviews were carried out, and they lasted between 30 and 75 min

(mean 61 min).

Analysis

Inductive content analysis was used because of the descriptive aim of the study and limited previous

research literature.25,26 First, the data were transcribed verbatim. Then, meaning units, that is, words, sen-

tences or paragraphs answering the research question, were identified. The meaning units were marked and

then the expressions were condensed and coded (Figure 1). Then, the coded expressions were grouped based

on similarities first into subcategories and second into the larger main categories. The analysis focused on

manifest contents, visible and obvious components in the text.25 The meaning units were also grouped to

patient-related, staff-related, organization-related and other problems (Table 2). Citations from the inter-

views are reported with the results. Minor revisions have been made to maintain confidentiality.

Ethical considerations

Permission to conduct the interviews, including ethical approval was given at all participating organizations

according to national standards.27 The respondents were informed about the aim of the study, and voluntary

participation, anonymous response and confidentiality were explained to them. All the participants gave

their written consent at the beginning of the interview.

Table 1. Organizations and job positions of interviewees.

Primary healthcare Specialized healthcare

Ward management 1 2Middle management 2 2Strategic management 1 1

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Results

The main categories of ethical problems in NMs’ work that emerged from the data were conflicts in prac-

tical situations, lack of appreciation, disregard of problems and experienced inadequacy. Each of these cate-

gories contains patient-related, staff-related and organization-related problems; in addition, there were

some other problems related to the managers themselves (Table 2).

Table 2. Ethical problems in nurse managers’ work.

Patient-relatedproblems

Staff-relatedproblems

Organization-relatedproblems

Otherproblems

Conflicts inpracticalsituations

Disagreements inpatient care

Conflicts between staffmembers; ambivalenceabout justice and fairnessin personnelmanagement

Conflicts with owners orpersons elected to a positionof trust; conflicts betweenown and organizationalvalues

Lack ofappreciation

Paternalistic culture;inequality ofpatients;indiscreettreatment ofpatients

Lack of collegial behaviour;problems withcollaboration with otherprofessionals

Lack of valuing nursingprofession; negative publicimage

Disregard ofproblems

Not patient-oriented routinesand habits

Not listening to staff;excessive collegiality ofphysicians

Protection of incompetent keypersons; permitting unfairtreatment; avoidingresponsibilities

Lack ofmanagers’ownmotivation

Experiencedinadequacy

Prioritization inpatient care;limited power;limitedcircumstances

Fatigue of the staff;problems with evaluatingand rewarding staffmembers

Scarce resources Limitationscaused byconfidentiality

Meaning unit Condensed meaning unit Code

Physician’s and patient’s wishes differ andthe nurse should carry out the order

Disagreements in patient’s care betweenpatient and physician

Disagreements inpatient’s care

Patient wants a lot of help including mattershe could do himself and the nurse shouldcarry out rehabilitating care

Disagreements in patient’s care betweenpatient and nurse

Collegiality is a little bit lost and nursescriticizes the others very easily, even topatients

Inappropriate ways to criticize each other Lack of collegialbehavior

If we cannot trust our colleagues, do theyhelp each other

lack of confidence

Figure 1. Examples of meaning units, condensed meaning units and codes.

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Conflicts in practical situations

Conflicts in practical situations included situations where there were at least two different opinions as to

what was the right way to act. Situations where conflicts exist are obvious and conflicting values are easily

found, and there usually is open discussion between two or more parties.

Related to patient care, conflicts emerged between patients and staff, between nurses and physicians and

between patient and their relatives. Values related to these issues were, on one hand, patient’s autonomy and

self-determination and, on the other hand, professionals’ or relatives’ understanding of patient’s best.

Between patient and staff, these conflicts included refusal of care, coercion and power. For some reason,

staff’s understanding of necessary care differed from the patients’ opinion. Differences of opinion on

patient care also appeared between nurses and physicians, especially when the patient was not strong

enough to make his or her own decisions. Acting as an advocate to patients was thought to be nurses’ respon-

sibility. Relatives may also disagree about patient care with staff or the patient. Sometimes disagreements

were related to treatment, which the patient or relatives had perceived as unfair or inappropriate. In the case

of complains on treatment, NMs’ problem is to find out what actually happened. As one NM put it,

We receive patient complaints, and the patient’s or relative’s side of the story is totally different from the nursing

staff’s side; who should be believed? (Participant 3)

Related to staff, NMs named two types of problems linked to the value of justice. First, there were con-

flicts between staff members emerging when members of staff did not get along. There was negative

behaviour, bullying and scapegoating, and staff members were typically not able to solve their problems

in a constructive way. Problems of this kind impair the functionality of the whole unit. NMs considered

these as ethical problems because it was difficult to know who was right and who should be believed. A

second type of staff-related conflict was ambivalence as to justice and fairness in personnel management.

Decisions need to be made about shifts, holidays, education and rewarding. Problems appear if employ-

ees’ and organizations’ needs are opposed or if employees’ needs and hopes are in conflict with each

other. Employee selection may be difficult, as can all kind of evaluation, if the criteria used are insuffi-

cient. Nurses’ rights may be a problem; especially in situations where the patient is aggressive or violent,

there is the question of how much abuse nurses should stand.

Related to organization, conflicts with owners or persons elected to a position of trust (politicians)

are related to the Finnish system where public healthcare organizations are owned by municipalities.

Especially, in primary healthcare, politicians have direct power over many kinds of decisions. NMs

encountered conflicts between their professional expertise and politicians’ decisions which – according

to NMs – may be influenced by short-term political goals. One NM explained,

In municipalities, political decision-makers are almost demanding that they should be given operational manage-

ment . . . but after all, they are laymen. (Participant 9)

Conflicts between one’s own and organizational values were another organization-related conflict sit-

uation. NMs’ own values were based on their nursing professional values. In their management role, they

were expected to act according to the organization’s values. Their management role presumed justifying

organizational values to their staff even if they did not agree with them.

Lack of appreciation

This category contains descriptions of situations or issues where NMs have perceived some participants

being undervalued or not taken into account when making decisions. The values included here are equality,

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respect and – regarding to patients – human dignity. The lack of appreciation is more NM’s experience than

open disagreement, so there are no public defence of opposing values.

Related to patients, lack of appreciation finds expression in paternalistic culture, inequality of patients

and indiscreet treatment of patients. The culture of paternalism was still more or less in evidence in hospi-

tals. Nurses and physicians thought that they knew what was best for patients better than the patients them-

selves. As one ward manager put it,

We in healthcare still somehow think that the patient is ours when he/she comes to hospital. (Participant 4)

Lack of appreciation may focus on some groups of patients, for example, alcoholics, so that they are

not treated similar to others. Indiscreet treatment of patients may appear as heavy-handed treatment or

rude talk. Sometimes, nurses tried to justify their behaviour by the patient’s behaviour or unrealistic

expectations or by their own tiredness. NMs have a duty to advance the culture of caring, so that

patients’ rights may come true.

Related to staff, lack of appreciation was expressed as lack of collegial behaviour and problems with

collaboration with other professionals. Lack of collegial behaviour appeared as lack of collaboration, cri-

ticizing colleagues without good reason, denying help to a colleague, not trusting colleagues’ work and not

committing to group decisions. Problems with collaboration with other professionals mean unsatisfactory

multiprofessional teamwork. Especially, physicians were seen to be acting based on medicine, not taking

account of nursing perspective.

Related to organization, lack of appreciation was mentioned in two kinds of problems: lack of valuing the

nursing profession and negative public image of the organization. Lack of valuing the nursing profession

was expressed in that NMs were not taken into account in decision-making, and they were obligated to

implement decisions, even if the decisions involved nursing professionals. NMs felt that organizations are

led on physicians’ terms, and the professions are not equal. Lack of valuing was also experienced by nursing

staff because not enough resources are given to nursing. NMs felt that their authority and influence was

limited as described by one NM working in middle management:

. . . different professions are not equal in our organization . . . and it is very deep-rooted that physicians are the

primary and most valuable group on whose terms the whole organization runs. (Participant 3)

Organizations were described to have a negative public image as consequence of some individual

cases or broader issues in media. NMs felt that as a result, every single nurse is branded, and this has

an effect on work motivation among nurses.

Disregard of problems

Disregard of problems consisted of matters that NMs considered wrong but somehow accepted as existing

in the organization culture, or at least there was nothing active going on to correct them. According to NMs,

these problems are perceived commonly in the organization also by other professionals.

Related to patients, there were accounts of not patient-oriented routines and habits as an expression of a

caring culture that has developed for historical reasons, so that routines are more inclined to serve profes-

sionals or organization than patients. There are not necessarily any conflicts, but the patient’s role is not as

participative as it should be.

Related to staff, there are two problems in this category: not listening to staff and excessive collegiality

on the part of physicians. According to NMs, they get messages from the staff that they are not sufficiently

listened to. This could have to do with organization culture where management is more about giving orders

than interacting. One strategic-level NM thought that

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. . . staff, is it that there is no time to listen to them, or is there something in the attitudes, is the management more

like giving orders . . . (Participant 8)

Another problem was that from NMs’ point of view physicians’ collegiality goes too far. Physicians

interfere very rarely with each other’s actions, including patient care and professional behaviour. There

were accounts of excessive collegiality related to patient care, multiprofessional co-operation and staff

conflicts.

Related to organizations, disregard of problems was manifested in three forms. First, there was protec-

tion of incompetent key persons. They were described as persons who were just ‘waiting for retirement’ or

who had lost their competence and/or their motivation for some other reason. A person of that kind in a key

position has a wide effect, usually resisting changes and development. One NM told that

. . . characters near retirement age in responsible position as managers, and I mean characters in a bad way . . .

not capable of supervising that the work in the ward or in the clinic is still going on properly. (Participant 6)

Second, permitting unfair treatment was described. When the person responsible for the unfair treatment

is at high level in the hierarchy, it is possible that nothing may be done about the problem. One reason men-

tioned here was that the unfair person is indispensable to the organization. Third, avoiding responsibilities

was reported. NMs explained that there were problems that were recognized, but nothing was done to

resolve them, or resolving was inefficient and slow. Management overlooked its responsibilities and ‘let

them be’, so that nursing staff were forced to face them without support from managerial level.

As other problems, NMs described lack of motivation on their part if they only got little support for their

actions. In difficult situations, courage to be under fire is also needed. One NM told that in a difficult

situation:

I also think . . . there will later be some consequences for myself. (Participant 1)

Experienced inadequacy

NMs described situations where they did not have enough ways to do the best possible thing. There were

many kinds of obstacles which are very difficult to impact: legislative, financial and cultural. NMs expe-

rienced inadequacy in these situations.

Patient-related problems in the category of experienced inadequacy were prioritization of patient care,

limited power and limited circumstances. Prioritization in patient care was described as situations where it

was not possible to care for all the patients as well as they should be cared for. One NM from a long-term

care clinic told that

patients cannot necessary have a wash as often as they should and staff cannot take patients outdoors as much as

they should and problems occur with eating as well. (Participant 8)

Another problem, limited power, was described as situations where legislation sets limits to care.

Especially, with children, there are situations where parents have a right to make decisions which nursing

professionals do not think are in the child’s best interest. Third, limited circumstances in patient care were

described especially with long-term or dying patients. The hospital culture or physical circumstances set

limitations to a natural death in a peaceful environment with one’s own familiar belongings.

Related to staff, experienced inadequacy related was reported by NMs as fatigue on the part of staff. Mul-

tiple and rapid changes in the healthcare system were described as being more or less exhausting for staff.

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Managers feel that so much is demanded of the professionals, and they cannot do enough for staff’s welfare

in midst of all the changes.

Related to organization, scarce resources, either financial or personnel related, were mentioned as an

ethical problem. If there are not enough nurses for all patients, choices must be made about what kind of

functions, patients and units need them most. The problem may be lack of financial resources, or there are

not enough nurses available. Choices must also be made between patient care, staff education and devel-

opment projects.

As other problems causing experienced inadequacy, NMs described limitations caused by confidential-

ity placing them in a difficult position. One NM told,

A manager gets a lot of information about staff’s private affairs which influence a person’s work and behaviour,

but the manager cannot tell anything to others. (Participant 7)

Managers use the information when making decisions but cannot explain the reasons to other employees.

This may weaken staff’s trust in manager. Confidentiality may also cause situations where NM does not get

necessary information and feels inadequacy.

Discussion

NMs identified a variety of different ethical problems in their work. The existence of these ethical problems

was known.11 However, this study provided new and more detailed knowledge about content of NMs’ ethi-

cal problems which are here grouped into four categories: conflicts in practical situations, lack of apprecia-

tion, disregard of problems and experienced inadequacy. Findings also enlighten the context of the

problems with more detailed information. Problems were also divided to patient-related, staff-related,

organization-related and other issues. However, in the future, it would also be interesting to explore the

problems in different levels: micro, meso and macro. As other issues, NMs described ethical problems with

their own courage, motivation and values, which seem not to have been reported before. Results highlight

NMs’ own descriptions of the ethical problems.

Conflicts in practical situations related to patients are often linked to patients’ rights as autonomy, self-

determination and right to good care, which in many countries have regulated by law. Problems appear if

healthcare professionals think themselves as experts who have the best knowledge for patient’s best and

patient’s own opinions are understated. The culture in healthcare is continuously chancing, and the patient’s

role in decisions concerning his own care is increased and still increasing. In Finland, for example, there are

new regulations for patient’s right to choose their place of care28 and for electronic pages for citizens where

they may read their own documents entered in the Prescription Centre or electronic Patient Data Archive.29

Protection of patients’ rights is reported to be nurses’ most frequent ethical issue in nursing practice in a

study made in the United States.30 Ethical issues in patient care have been indicated to also belong to NMs’

role.3 Redman and Fry3 concluded that the main issue is protecting patient rights and human dignity and that

being an advocate for patients’ rights is very important in NMs’ role. New regulations and changes in

healthcare culture may not only cause new ethical problems but also give some help when trying to solve

problems. NMs should actively follow these changes when acting as an advocate for patients’ rights and

supporting nursing staff in their patient care.

In conflicts in practical situations, related to staff, NMs underlined justice as a very important value in

their work. Besides conflicts between staff members, they described normal tasks in personnel management

such as planning work shifts and holidays, hiring employees, rewarding or punishing personnel as ethical

problems, when trying to treat everyone fairly. However, there is no unambiguous description of justice in

personnel management in healthcare. NMs and nurses may have different views on justice, for example, in

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planning work shifts and holidays. For example, some may think that every nurse should have equal amount

of different shifts, others thinking that nurse’s wishes and situation in life should be taken account. NMs

seem to be aware of their ethical responsibilities for nursing staff as well in supporting their work in patient

care as in personnel management forwarding nurses well-being and coping at work. Nurses encounter daily

ethical challenges in their work, and there is an urgent need for strategies to retain nurses at work. Ethics

support and ethics-related interventions are needed for that.30 More information is needed about nurses’

experiences of the support they are getting. Results of Canadian studies have indicated that nurses in prac-

tice were lacking the support needed to provide ethical care.31 Education and work experience in nursing

help NMs to understand nurses’ values and their ethical problems, but there may still be insufficient under-

standing of needs of clinical nurses as one nurse claims in Gaudine et al.’s32 study.

In conflicts in practical situations, related to organization, problems in administrative level seem to be

common and significant in NMs’ work in different countries.11,15,16,22 Especially, conflict between organi-

zational values and NMs’ professional values has been described in many studies.16–19 In Israeli study

among nurse middle managers, the highest intensity and frequency of moral distress were found for admin-

istrative issues.22 In our study, having originally been trained as nurses and still identifying themselves as

nurses, the interviewees’ personal values seemed to be the same as the nursing profession’s. Their role as

managers requires that they emphasize the administrative goals and values often related to economical

effectiveness. However, the quality of care and effective use of recourses should not be conflicting, and

economically effective actions are also ethical.

Lack of appreciation was described from many perspectives: related to patients, related to staff and

related to organization. In a Canadian descriptive study of ethical conflicts in the workplace as experi-

enced by NMs, Gaudine and Beaton15 described one theme as ‘voicelessness’ including expressions such

as ‘nursing not valued’ and ‘nurse managers not present during decision-making on issues that affect nur-

sing’. This is very similar to ‘lack of valuing nursing profession’ in our study. There may be reasons

related to the history of medicine as a much older science than nursing and longer education and better

social status of physicians. Political supervision of the interests may uphold also this kind of attitudes. But

Gaudine et al.32 have reported ethical conflicts with organizations shared by nurses and physicians, and

both groups described lack of respect. They had told about feelings being not respected, valued and sup-

ported by the organization as individuals and as well as their professional group. Lack of respect was indi-

cated also between nurses and NMs.32 Appreciation is very subjective feeling and the reasons causing

feelings of lack of appreciation may also vary. However, it could be argued that appreciation should

be earned by the professionals’ own actions and merits. NMs should consider what they can do to increase

the appreciation of themselves and the whole profession.

Disregard of problems was also encountered related to patients, related to staff and related to organi-

zation. Very serious problems were described related to organization meaning that administration at the

highest level allows even unfair treatment to take place. Gaudine and Beaton15 had a theme close to this:

‘unjust practices on the part of senior administration and/or the organization’. Quite the same theme,

‘administration turning a blind eye’, was reported in the study where nurses and physicians have experi-

enced very troublesome issues where administration know about the problem but ‘turn a blind eye’.32

NMs seem to be quite powerless with problems of this kind, when there is a question of the highest admin-

istration, but they should mind of their own actions, so that they are not ‘turning a blind eye’. NMs also

described lack of motivation and courage of their own, which may lead disregarding of problems and

cause ethical problems to their nursing staff.

Experienced inadequacy was described with many issues, including expressions of lack of power,

resources and knowledge. Nursing staff is critical resource in hospitals and staffs fatigue needs serious

attention. Employer has no right to risk employees’ health by demanding too much from them. Insufficient

or scarce resources are mentioned as ethical problem also by nurses22,32 and physicians.32 Interesting is that

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NMs themselves experience same kind of problems in which they should support their nursing staff. NMs

are criticizing administration and in the same time they are part of it and at the receiving end of nurses’

criticism and demands. Obviously, NMs also need support in their duties to solve ethical problems and sup-

porting their staff.

Validity of the study

The trustworthiness of this study may be assessed by the concepts of credibility, dependability and transfer-

ability.25 The NMs in this study represented different organizations and different clinics, which is why the

variation of the data was rich, and a variety of description was provided by NMs, strengthening its credibility.

The sample remains small (n¼ 9). However, the main categories appeared very early, after a few interviews,

and were repeated almost in all of the interviews. However, more interviews might have produced a wider range

of examples. Credibility is also increased by using quotations in the text. All the interviewees were given writ-

ten information and the interview themes in advance, so there was no risk of inconsistency during data collec-

tion, which strengthened the dependability of the study. The aim of descriptions of the interviewees and the

process is to make it easier for the reader to assess transferability, which is the third aspect of trustworthiness.

Conclusion

Ethical problems impair the running of the healthcare organization, and they should be made visible.

Therefore, new tools and methods need to be developed or adapted into healthcare organizations to bring

up these situations. The results found in this study could help to formulate the content of such tool. There

is a need for open discussion of ethical problems and ethics in patient care within healthcare organiza-

tions. When ethical problems are perceived and solutions found to them, it has improving impact to the

main responsibilities of healthcare organizations – responsibilities to patients care and safety.

The nursing profession and the status of NMs also need to be discussed. NMs themselves are in key posi-

tion in this discussion, and they should make their actions for patient care and organizational functions more

clear and visible. Nurses are greatest number of health workers. They need to be supported in their work to

perceive and discuss ethical issues in daily practice and make ethically decisions, so that they can provide

high-quality nursing practice.

There is also a need for further research on ethics in management. More information is needed of the

reasons for ethical problems and frequency and severity of the problems. Very little is known about the val-

ues, resources and mechanisms adopted when resolving ethical problems. The information assists to

develop ethically high-level management, which improves the quality of patient care, staff welfare and

effective running of the organization.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit

sectors.

References

1. World Health Organization (WHO). People-Centred Health Care: A policy framework, http://www.wpro.who.int/

health_services/people_at_the_centre_of_care/documents/ENG-PCIPolicyFramework.pdf (2007, accessed July

2014).

Aitamaa et al. 11

by guest on May 10, 2015nej.sagepub.comDownloaded from

2. World Health Organization (WHO). The WHO Global Competency Model, http://www.who.int/employment/com-

petencies/WHO_competencies_EN.pdf (2012, accessed March 2014).

3. Redman BA and Fry ST. Ethics and human rights issues experienced by nurses in leadership roles. Nurs Leader

Forum 2003; 7(4): 150–156.

4. Shirey MR. Ethical climate in nursing practice: The leader’s role. JONA’s Healthc Law Ethics Regul 2005; 7(2):

59–67.

5. Kane-Urrabazo C. Management’s role in shaping organizational culture. J Nurs Manag 2006; 14(3): 188–194.

6. Poikkeus T, Leino-Kilpi H and Katajisto J. Supporting ethical competence of nurses during recruitment and per-

formance reviews – the role of nurse leader. J Nurs Manag 2014; 22(6): 792–802.

7. Gallagher A and Tschudin V. Educating for ethical leadership. Nurs Educ Today 2010; 30: 224–227.

8. Kangasniemi M, Vaismorandi M, Jasper M, et al. Ethical issues in patient safety: implications for nursing manage-

ment. Nurs Ethics 2013; 28(8): 904–916.

9. Makaroff KS, Storch J, Pauly B, et al. Searching for ethical leadership in nursing. Nurs Ethics 2014; 21(6): 642–658.

10. National Health Service United Kingdom. Code of conduct for NHS managers, http://webarchive.nationalarchives.

gov.uk/þ/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/

DH_4910714 (2002, accessed February 2015)

11. Aitamaa E, Leino-Kilpi H, Puukka P, et al. Ethical problems in nursing management: the role of codes of ethics.

Nurs Ethics 2010; 17(4): 469–482.

12. Thompson IE, Melia KM, Boyd KM, et al. Nursing ethics. 5th ed. Edinburgh: Elsevier-Churchill Livingstone,

2007.

13. Beauchamp TL and Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press,

2009.

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

1999; 6: 468–482.

15. Gaudine AP and Beaton MR. Employed to go against one’s values: nurse managers’ accounts of ethical conflict

with their organizations. Can J Nur Res 2002; 34(2): 17–34.

16. Camunas C. Ethical dilemmas of nurse executives. J Nurs Adm 1994; 24(7–8): 45–51.

17. Borawski DB. Ethical dilemmas for nurse administrators. J Nurs Adm 1995; 25(7–8): 60–62.

18. Cooper RW, Frank GL, Gouty CA, et al. Key ethical issues encountered in healthcare organizations: perceptions of

nurse executives. J Nurs Adm 2002; 32(6): 331–337.

19. Dellve L and Wikstrom E. Managing complex workplace stress in health care organizations: leaders’ perceived

legitimacy conflicts. J Nurs Manag 2009; 17(8): 931–941.

20. Lindy C and Schaeffer F. Negative workplace behaviours: an ethical dilemma for nurse managers. J Nurs Manag

2010; 18(3): 285–292.

21. Toren O and Wagner N. Applying an ethical decision-making tool to a nurse management dilemma. Nurs Ethics

2010; 17(3): 393–402.

22. Ganz FD, Wagner N and Toren O. Nurse middle manager ethical dilemmas and moral distress. Nurs Ethics. Epub

ahead of print 29 January 2014, http://nej.sagepub.com.ezproxy.utu.fi:2048/content/early/2014/01/26/

0969733013515490.full.pdfþhtml (accessed July 2014)

23. Esterhuizen P. Is the professional code still the cornerstone of clinical nursing practice? J Adv Nurs 1996; 23(1):

25–31.

24. Englander M. The interview: data collection in descriptive phenomenological human scientific research. Journal of

Phenomenological Psychology 2012; 43: 13–35.

25. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and

measures to achieve trustworthiness. Nurs Educ Today 2004; 24(2): 105–112.

26. Hsieh H-F and Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15(9):

1277–1288.

12 Nursing Ethics

by guest on May 10, 2015nej.sagepub.comDownloaded from

27. National Advisory Board in Ethics. Responsible conduct of research and procedures for handling allegations of

misconduct in Finland. Guidelines of the Finnish Advisory Board on Research Integrity, http://www.tenk.fi/

sites/tenk.fi/files/HTK_ohje_verkkoversio040413.pdf.pdf#overlay-context¼fi/ohjeet-ja-julkaisut (2012, accessed

July 2014).

28. Health Care Act 2010/1326, http://www.finlex.fi/fi/laki/ajantasa/2010/20101326 (accessed July 2014)

29. Act on the Electronic Processing of Client Data in Social and Health Care Services 19§, 28.3.2014/250, http://

www.finlex.fi/fi/laki/ajantasa/2007/20070159 (accessed July 2014)

30. Ulrich CM, Taylor C, Soeken K, et al. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs

2010; 66(11): 2510–2519.

31. Storch J, Makaroff KS, Pauly B, et al. Take me to my leader: the importance of ethical leadership among formal

nurse leaders. Nurs Ethics 2013; 20(2): 150–157.

32. Gaudine A, Lefort SM, Lamb M, et al. Ethical conflict with hospitals: the perspective of nurses and physicians.

Nurs Ethics 2011; 18(6): 756–766.

Aitamaa et al. 13

by guest on May 10, 2015nej.sagepub.comDownloaded from