Professional Ethics in Nursing: An Integrative Review

This integrative review examines the concept of professional ethics in nursing, including its definition, values, duties, rights, and responsibilities. It also explores the impact of internal and external factors on professional ethics in nursing. The review highlights the need for greater understanding of professional ethics in nursing to support nurses' moral decision-making and address the challenges in healthcare and society.

REVIEW PAPER
Professional ethics in nursing: an integrative review
Mari Kangasniemi, Piiku Pakkanen & Anne Korhonen
Accepted for publication 9 December 2014
Correspondence to M. Kangasniemi:
e-mail: [e-mail]
Mari Kangasniemi PhD RN
Adjunct Professor/University Lecturer
Department of Nursing Science, Faculty of
Health Sciences, University of Eastern
Finland, Kuopio, Finland
Piiku Pakkanen BNSc RN
MNSc-Student
Department of Nursing Science, Faculty of
Health Sciences, University of Eastern
Finland, Kuopio, Finland
Anne Korhonen PhD RN
Specialist in Clinical Nursing Science
Department of Pediatrics and Adolescence,
Oulu University Hospital, Finland
K A N G A S N I E M IM . , P A K K A N E N P .& K O R H O N E N A . ( 2 0 1 5 )Professional ethics
in nursing:an integrative review.Journal of Advanced Nursing 00(0),000–000.
doi: 10.1111/jan.12619
Abstract
Aim. To conduct an integrative review and synthesize current primary studies of
professional ethics in nursing.
Background.Professionalethics is a familiar concept in nursing and provides an
ethical code for nursing practice. However, little is known about how
professional ethics has been defined and studied in nursing science.
Design and data sources.Systematicliteraturesearchesfrom 1948–February
2013,using the CINAHL, PubMed and Scopus electronic databases to look at
previously published peer-reviewed studies.
Review method.A modified version of Cooper’s five-stage integrative review was
used to review and synthesize current knowledge.
Results.Fourteenpapers were included in this research.According to our
synthesis,professionalethicsis described asan intra-professionalapproach to
care ethics and professionals commit to it voluntarily.Professionalethics consist
of values,duties,rights and responsibilities,regulated by nationallegislation and
internationalagreements and detailed in professionalcodes.Professionalethics is
well established in nursing,but is constantlychangingdue to internal and
external factors affecting the profession.
Conclusion.Despite the obviousimportance ofprofessionalethics,it has not
been studied much in nursing science.Greater knowledge of professionalethics is
needed to understand and support nurses’moraldecision-making and to respond
to the challenges of current changes in health care and society.
Keywords:ethics, integrative review, nurse roles, nursing, profession
Introduction
Ethics have been internationally recognized as a fundamen-
tal part of the work of nurses.The ethicalquestions that
nurses face in their work range from the clinical issues they
face every day with patients (Ulrich et al.2010) to specific
disease and treatment related decisions (Pavlish et al.2012,
Winterstein 2012).In addition,ethicalquestions are raised
about their collaborationwith colleagues(Ulrich et al.
2010) and other professions (Engel& Prentice 2013,Ewa-
shen et al.2013).Severalstudieshave highlighted ethical
questions that have arisen as a result of the high moral dis-
tress that nurses experience in practice (Ulrich et al.2010,
Dekeyser Ganz & Berkovitz 2012,Oh & Gastmans 2013,
Wocial & Weaver 2013). For example, they have to handle
the burden of balancing ethicalnursing values of good and
© 2015 John Wiley & Sons Ltd 1

individualized carewith the externalpracticalvaluesof
effective,productiveand economicalpractices(Goethals
et al. 2010, Palese et al. 2012). To manage ethical questions
as a part of their daily work, they need to think about ethi-
cal issueson an individuallevel,and from a professional
perspective, which includes shared goals and work values.
Background
Nursing has its own aims, like other professions, but it also
has an obligation to contribute to the developmentof a
healthy society (Aikens1916/1943,Abbott 1983, Kasher
2005, McCurry et al. 2009). A profession refersto an
occupationalgroup thatpossesspecialized skillsthat are
based in some way on esoteric knowledge (Abbott1983).
The group responds autonomously, but, at the same time, it
needs to meet the demands of the public it serves (Frankel
1989).The current,overallaim of the nursing profession is
to promote healthy lifestyles to individuals and communities
(McCurry et al. 2009, World Health Organization 2011,
International Council of Nurses (ICN) 2012). However, the
aim of the profession is constantly changing due to societal
(Helmstadter 2009),economic (Bertoluzzi& Palese 2010)
and educationalinfluences (Bertoluzzi& Palese 2010,Car-
ney 2010,Palese et al.2012).There has also been a move
away from just treating disease towards promoting healthy
living and disease prevention (Jirwe et al.2009, Kristiansen
et al.2010). Allof those changes raise value issues that are
considered on an ethical level by each profession.
Nursing history shows that ethics has been an elementary
part of the profession since the early days (Nightingale 1952,
Sellman 1997). Ethics refers to the values and principles con-
cerning defect human conduct and professional ethics refers
to the generalmoralnorms that are acceptable in a certain
occupationalgroup (Beauchamp & Childress 2009) to deal
with morally ambiguous situation (Frankel1989) and thus
prevent and avoid,ethicalharm (Brecher 2014).It is intra-
professionalby nature and it is this enforcement of formal
ethics that createsvisibility and, therefore,confidence
between professionals and, in particular, between profession-
als and the public (Abbott 1983). Professional ethics usually
appearin formal codes,including referencesto corporate
norms (Frankel1989),obligations and perceptions of rela-
tionshipsbetween colleaguesand with the public (Abbott
1983, Frankel 1989, Beauchamp & Childress 2009).
In the field of nursing,professionalethics may have had
a differentmeaning in years gone by,perhaps referring to
nurses’personalcharacteristics(Sellman 1997,Dekeyser
Ganz & Berkovitz 2012,Kangasniemi& Haho 2012),vir-
tues(Begley 2010)or their etiquette and correctmanner
(Aikens 1916/1943,Johnstone1987, Freitas1990, Brad-
shaw 2000).In addition to individualbehaviour,profes-
sional ethics currentlyfocus on groups of professionals
guided by shared ethicalcodes (Liaschenko & Peter 2004,
Meulenbergs et al.2004,Milton 2007, Begley 2010,Kan-
gasniemi& Haho 2012, Brecher 2014).In this sense,pro-
fessional ethics is linked to the organizationaland
institutionalethics guiding nurses’everyday work (Thomp-
son 1999,Poikkeus et al.2014),and being linked to other
healthcare professions(Liaschenko & Peter2004, Milton
2007,Kangasniemi& Haho 2012). Thus, nursing ethics is
not differentfrom otherhealth professions,as it includes
the same rules of ethicalvalues and norms,but the empha-
Why this review is needed?
● The history ofnursing shows thatprofessionalethics has
been an inherent part of the profession since the very early
days.
● Professionalethics is changing and is affected by internal
and external factors.
● Despite the fact that professionalethics is wellestablished
in nursing,there is no realsynthesis understanding of eth-
ics in nursing.
What are the key findings?
● There hasbeen very little research focused into profes-
sional ethics in nursing science.
● In nursing, professionalethicsconsistsof values,rights,
duties and responsibilities and the overall aim is to protect
patients and give nurses the guidance they need to contrib-
ute the development of healthy society.
● Professionalethicsis an integralpart of nursing,but it
need to be regularly re-evaluated to respond to current
changes in nursing practice.
How should the findings be used to influence research
and practice?
● The question of professionalethicsis highly topical in
nursing science and the factthat it is constantly evolving
reflects changes in the profession,different codes of ethics
in different countries and in societies in general. Therefore,
it is importantto be aware ofthe constantvalues ofthe
profession to develop professional ethics in conscious way.
● The developmentof professionalethicsin nursing could
help to create and maintain the sustainable bridge between
representativesof the same profession,both locally and
globally.
● To supportnurses professionalethics,more scientific dis-
cussion and nursing sciencestudiesis needed,together
with educational support for nurses in everyday practice.
2 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.

sis on ethicalissues in nursing profession and the way that
they have emergedover the years may be different.
Although ethics is centralto the nursing profession and a
lot of scientific attention has been paid to the ethicalques-
tions affecting nurses,few studies have focused on profes-
sional ethics in nursing but a synthesisof findingsis
lacking.
The review
Aim
The aim of this study was to conduct an integrative review
and synthesizeprimary studiesof professionalethicsin
nursing,to deepen and clarify our discussions on the sub-
ject.Two research questions were addressed:how has pro-
fessionalethics been studied and what do professional
ethics in nursing comprise?
Design
Cooper’s (1982,1984) five-stage integrative review method
was used,as modified by Whittemore and Knalf(2005):
problem identification,data collection,evaluation ofdata
(quality appraisal), analysis and interpretation of data (data
abstraction)and presentationof results (Cooper 1982,
1984, 13).
The first stage,problem identification,was based on pre-
liminary literature search and the researchers’recognition
that greater understanding of professionalethics in nursing
was clearly needed. Because previous knowledge was sparse
and of differenttypes,we felt that an integrative review
would be an effective way to identify and synthesize the
information (Cooper 1984, 19, Whittemore & Knalf 2005).
Search methods
The second stagewas data collection included literature
search.Purposivesamplingwith specificdatabasesand
yearswas used,limited to professionalethicsin nursing
(Booth 2006).Information wasretrieved using electronic
database searches (Cooper 1982)and conducted using the
CINAHL, PubMed and Scopusdatabases(Figure 1).To
avoid any possible bias,previousstudiesin all languages
were looked at.Years were notrestricted and alloriginal
articles since the beginning of databases, earliest 1948, until
February 2013 were included.Search termslinked to the
profession were used (professionalethic, work ethic and
ethic of work) and ethicalterms (code,value,duty, right,
norm and responsibility).
Search outcome
The original 4,377 articleswere selected in fivestages,
based on their titles (n = 245),abstracts (n = 90),full-texts
(n = 46),removaldue to duplication (n = 32) and by using
inclusion and exclusion criteria.This resulted in 14 articles
being selected (Figure 1).
Our inclusion criteria were peer-reviewed scientific papers
and papers where the main focus was on nurses’ professional
ethics. We excluded papersthat focused on education,
studentsor research,ethical dilemmas,decision-making
and codes or other disciplinessuch as social work or
engineering.
Quality appraisal
The third stage was evaluation of data, i.e. quality appraisal
of the selected 14 articles. As usual with an integrative review
method, a detailed quality appraisal criteria was not appro-
priate (Cooper 1984, 63, Whittemore & Knalf 2005), due to
the methodologicalpluralism,low numbers of publications
and long publishing periods. However, six descriptive criteria
concerningmethodologicalstructure(modified based on
Bowling 2002,Gazarian 2013)were used to illustrate the
quality of the selected articles. All 14 articles were included
in the review and were evaluated in six quality domains on a
three-point scale as ‘yes’, ‘poor’ or ‘not reported’ (Table 1).
Data abstraction
The fourth stage was data analysis and interpretation (Coo-
per 1984, 79). During the first stage, all original papers were
read to get an overview of the content. After that data were
extracted,so thatall the individualarticles could be tabu-
lated according to author(s), years, countries, design and tool
and sample sizes and characteristics of the study (Table 1).
The next step was to analyse and interpret the content about
professionalethics by following the principles ofinductive
content analysis (Graneheim & Lundman 2004).
Data synthesis
The fifth stage was presenting the results on all the elements
of professionalethics(Cooper1984, 113, Whittemore &
Knalf 2005). Because only three qualitative and three quanti-
tative methods were used and there were eighttheoretical
papers, the results of the analysis were presented as a narra-
tive synthesis (Whittemore & Knalf 2005). The analysis was
conducted by two researchers (MK,PP), up untilcategoriz-
ing stage (see Graneheim & Lundman 2004). During the first
© 2015 John Wiley & Sons Ltd 3
JAN: REVIEW PAPER Professional ethics in nursing

phase, the researchers read selected articles several times and
independently categorized the content.After that,the next
drafts were developed during shared discussions in several
meetings and at final the complete analysis was conducted in
collaboration between three researchers (MK, PP, AK).
Results
Description of the studies
Of the 14 papers we looked at, eight were theoretical, three
were quantitative and three were qualitative studies.They
were all publishedbetween1987–2010(Table 1). The
quantitative studies used standardized instruments,such as
the Nursing ProfessionalValue Scale (NPVS) (Weis &
Schank 2000),The Rokeach Values Survey (Rassin 2008)
and two differentquestionnaires developed by the authors
of the studies (Altun 2002,Rassin 2008).The qualitative
studies used groundedtheory (Memarian et al. 2007,
Vanaki & Memarian 2009)and the method developed by
Collaizi (Crout et al.2005) and were conducted with open
(Crout et al. 2005) and semi-structuredinterviews
(Memarian et al. 2007, Vanaki & Memarian 2009).
Professionalethics in nursing was the main focus of five
studies (Johnstone 1987,1989,Fowler 1993,Chadwick &
Thompson 2000,Verpeetet al. 2003), while the others
Limitations: Years
CINAHL 1981–2013
PubMed 1948–2013
Scopus 1960–2013
Search words
(and combinations):
professional ethic, work ethic
and ethic of work combined
with code, value, duty, right,
norm and responsibility
Excluded based
on titles
(n = 4135)
Accepted based on titles
(n = 245)
CINAHL n = 71
PubMed n = 98
Scopus n = 76
Exclusion criteria:
- Focused on
education;
students;
researchers,
ethical
dilemmas;
decision
making; codes
or other
Inclusion criteria:
- Peer-reviewed,
scientific paper
- Search term or
synonym
mentioned in
title
Accepted based on abstracts
(n = 90)
CINAHL n = 27
PubMed n = 25
Scopus n = 38
Accepted based on full texts
(n = 46)
CINAHL n = 13
PubMed n = 9
Scopus n = 24
Excluded based
on abstracts
(n = 155)
Inclusion criteria:
- Peer-reviewed,
scientific paper
- Focused on
nurses’
professional
ethics
Duplicate
removed (n = 32)
Selected full
texts
n = 14
Electronic searches
(N = 4377)
CINAHL = 434
PubMed = 1908
Scopus = 2035
Excluded based
on full texts
(n = 44)
disciplines
Figure 1Flow diagram of literature searches and selection.
4 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.

Table 1 The description of 14 eligible studies.
Author(s) year, Country Purpose Design and tools Sample size and characteristics
Quality appraisal criteria
(scale: y = yes, p = poor, nr = not
reported)
Altun (2002), Turkey Determine the relationship
between the degree of
burnout experienced by
nurses and their
professional values.
Quantitative questionnaire
(developed based on literature
and the Maslach Burnout
Inventory scale)
Nurses (n = 160) from two hospitals
-Median age: 20–30 (83.8%)
-Median working experience: 1–5 years
(83.8%)
-Education: 52.5% 2-year diploma
(registered) nurses, 47.5% high-school
graduates (practical nurses)
(p) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(p) Explicit theoretical framework
(y) Limitations presented
(y) Implications discussed
Chadwick and Thompson
(2000), United Kingdom
Describe professional
ethics by nurses and
physicians from industrial
point of view.
Theoretical discussion, literature Literature, 41 references, published
between 1971–1998
(nr) Aims and objectives clearly
described
(n) Study design not adequately descried
(y) Research methods appropriate
(y) Explicit theoretical framework
(n) Limitations not presented
(y) Implications discussed
Crout et al. (2005),
Australia 2005
To explore and describe
nurses’ experiences of
coming to work when ill.
Qualitative, individual interviews
(an unstructured, in-depth
interview technique), Colaizzi-
method as modified by Beck for
analyse
RN (n = 11): 10 women and one man
-Age 26–45 years
- Median working experience
8.25 years
-Education: 73% university graduates,
9% in hospital, 18% educated
overseas
(p) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(p) Explicit theoretical framework
(p) Limitations presented
(p) Implications discussed
Dobrowolska et al. (2007),
Poland
To present a comparative
analyses of codes of ethics
for nurses.
Theoretical, comparative study
and analysis, literature
Codes of ethics (4):
-The ICN0s Code of Ethics for Nurses
-The UK0s Code of Professional
Conduct
-The Irish Code of Conduct for each
Nurse and Midwife
-The Polish Code of Professional Ethics
for Nurses and Midwives
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(p) Explicit theoretical framework
(nr) Limitations presented
(p) Implications discussed
Fowler (1993), Canada Examine the role of
professional association in
relation to professional
ethics.
Theoretical, literature Literature, 26 references, published
between 1896–1993
(y) Aims and objectives clearly described
(p) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(p) Limitations presented
(y) Implications discussed
© 2015 John Wiley & Sons Ltd 5
JAN: REVIEW PAPER Professional ethics in nursing

Table 1 (Continued).
Author(s) year, Country Purpose Design and tools Sample size and characteristics
Quality appraisal criteria
(scale: y = yes, p = poor, nr = not
reported)
Johnstone (1987),
Australia
To focus on the
phenomenon of
professional ethics.
Theoretical discussion,
philosophical analysis, literature
Literature, 49 references, published
between 1957–1986
(nr) Aims and objectives clearly
described
(p) Study design adequately described
(y) Research methods appropriate
(nr) Explicit theoretical framework
(nr) Limitations presented
(y) Implications discussed
Johnstone (1989),
Australia
Examine the failure of
professional ethics to
prevent patients’ rights’
abuses in health care
contexts.
Theoretical discussion, literature Literature, 16 references, published
between 1953–1989
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(nr) Explicit theoretical framework
(nr) Limitations presented
(y) Implications discussed
Kangasniemi et al. (2010),
Finland
To examine and structure
nurses’ rights.
Theoretical discussion, literature Literature, 35 references, published
between 1998–2009
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(p) Limitations presented
(p) Implications discussed
Liaschenko and Peter
(2004), United States
To discuss limitations of
the concept of
professional ethics and
the contribution of ethics
of work.
Theoretical discussion, literature Literature, 41 references, published
between 1900–2003
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(p) Limitations presented
(y) Implications discussed
Memarian et al. (2007),
Iran
To identify the factors
influencing clinical
competency in nursing.
Qualitative, Grounded Theory,
semi-structured individual
interviews
Nurses (n = 36), (including clinical
nurses, nurse educators, hospital
managers and members of Nursing
Council in Tehran 2005
-Age 38–65 years
-Clinical experience 8–24 years
-Nursing experience 8–35 years
-Education: Bachelor degree
(n = 15.42%), master level
(n = 11.31%), PhDs (n = 10.28%)
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(p) Limitations presented
(y) Implications discussed
6 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.

Table 1 (Continued).
Author(s) year, Country Purpose Design and tools Sample size and characteristics
Quality appraisal criteria
(scale: y = yes, p = poor, nr = not
reported)
Rassin (2008), Israel Measure professional and
personal values among
nurses.
Quantitative, two questionnaires
(The Rokeach Values Survey and
questionnaire relied on values
expressed in the Israeli nurses0
code of ethics 1996–2004
Nurses (n = 323): 82% women and
18% men
-Average age 39 years
-Education: RN with Bachelor degree
(42.5%), Master degree (13.3%), no
further qualifications (33%), licensed
vocational nurses (11.3%)
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(p) Explicit theoretical framework
(y) Limitations presented
(p) Implications discussed
Vanaki and Memarian
(2009), Iran
To highlight nurse’s
clinical competency and
to explain the process
which clinical competency
was acquired.
Qualitative, grounded theory,
individual semi-structured open-
ended interviews
Nurses (n = 36), (including clinical
nurses, nurse educators, hospital
managers and members of Nursing
Council in Tehran 2005
-Age 38–65 years
-Clinical experience 8–24 years
-Nursing experience 8–35 years
-Education: Bachelor degree (n = 15,
42%), Master level (n = 11.31%),
PhDs (n = 10.28%)
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(y) Limitations presented
(y) Implications discussed
Verpeet et al. (2003),
Belgium
To prove and illustrate
legal and professional
documents reflection of
professional ethics.
Theoretical discussion, content
analysis, literature
Literature, 30 references, published
between 1980–2002
(p) Aims and objectives clearly described
(p) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(p) Limitations presented
(p) Implications discussed
Weis and Schank (2000),
United States
To describe the Nursing
Professional Values Scale
(NPVS) and its
development.
Quantitative, Nurses Professional
Values Scale questionnaire
Nurses (n = 599)
-Education: including Baccalaureate
and Masters0 students and practicing
nurses
(y) Aims and objectives clearly described
(y) Study design adequately described
(y) Research methods appropriate
(y) Explicit theoretical framework
(y) Limitations presented
(y) Implications discussed
© 2015 John Wiley & Sons Ltd 7
JAN: REVIEW PAPER Professional ethics in nursing

looked atthe relationship between professionalethics and
clinicalcompetency (Memarian et al.2007,Vanaki& Me-
marian 2009), work ethics (Liaschenko & Peter 2004,
Crout et al. 2005)and nursing codes (Dobrowolska et al.
2007).Four studiesfocused on the valuesof professional
ethics in nursing (Weis & Schank 2000, Altun 2002, Rassin
2008,Kangasniemiet al. 2010).Three ofthe studies were
conducted in Australia (Johnstone 1987,1989,Crout et al.
2005),two in Iran (Memarian et al.2007,Vanaki & Me-
marian 2009), two in the USA (Weis & Schank 2000, Lias-
chenko & Peter 2004)and one each in Belgium (Verpeet
et al. 2003),Canada (Fowler 1993),Finland (Kangasniemi
et al. 2010), Israel (Rassin 2008),Poland (Dobrowolska
et al. 2007),Turkey (Altun 2002)and the UK (Chadwick
& Thompson 2000).
The analysisrevealed five categoriesrelating to profes-
sional ethics: the aims, values and professional ethics of reg-
ulation,the role thatcodes play in professionalethics and
the changing nature of professional ethics.
The aim of professional ethics in nursing
Our results show that professional ethics in nursing has been
described as a branch of care ethics (Johnstone 1987) and has
been linked to the intra-professional(Liaschenko & Peter
2004,Verpeet et al.2003,Vanaki& Memarian 2009) and
holistic approach to care,including professionalrules and
regulations. Professional ethics is based on personal commit-
ment and accountability in the nurse’s role. They involve self
respect and self-evaluation and help to form nurses’respec-
tive relationships with patients,nurse managers and other
stakeholders (Vanaki & Memarian 2009).
Professionalethics in nursing includes the description of
professionalresponsibilitiesand duties that supportand
maintain thesocietalpurposeof the profession (Verpeet
et al.2003,Liaschenko & Peter 2004,Vanaki& Memari-
an 2009).It includes demanding that professionals provide
services and carry out care competently, effectively and in a
way that will not causeavoidableharm to the patient
(Johnstone 1989).
The relationship between professionalethics and clinical
competence has been recognized (Chadwick & Thompson
2000, Weis & Schank 2000, Liaschenko & Peter2004,
Dobrowolska et al. 2007, Memarian et al. 2007, Vanaki &
Memarian 2009).Professionalethics,in terms ofaccount-
ability and responsibility,influenceclinical competence
(Memarian et al.2007, Vanaki & Memarian 2009) and
result in nurses observing rules,regulationsand patient
rights (Memarian et al.2007).They also require continual
learning (Vanaki & Memarian 2009).
Values in professional ethics
Professionalethicsis based on professional(Chadwick &
Thompson 2000,Weis & Schank 2000, Liaschenko &
Peter 2004, Dobrowolskaet al. 2007, Memarian et al.
2007, Rassin 2008) and personalvalues(Rassin 2008).
Professionalnursing valuesare human dignity,equality
(Altun 2002, Rassin 2008),preventingsuffering(Rassin
2008),honesty (Weis& Schank 2000) and responsibility
(Weis & Schank 2000,Vanaki & Memarian 2009).They
create the basis for nurses’duties and rights,which help to
achievethe goals of the profession (Dobrowolska et al.
2007, Kangasniemiet al. 2010).Nurseshave professional
duties (Chadwick & Thompson 2000, Weis & Schank
2000,Liaschenko & Peter 2004,Dobrowolska et al.2007,
Memarian et al. 2007) and obligations(Liaschenko&
Peter 2004) towardsthe patient,the nursing profession,
their colleagues,other health professionalsand society
(Liaschenko & Peter2004, Verpeetet al. 2003).Nurses’
professionalrights (Dobrowolska et al.2007,Kangasniemi
et al. 2010) are based on legislationand professional
values,and so-called earned rightsbased on particular
education or experience (Kangasniemiet al. 2010).Nurses
have the professionalright to be respected by society,act
as an advocatefor patientsand refuse to take part
in-patientcare if it is againsttheir own values (Chadwick
& Thompson 2000,Weis & Schank 2000,Liaschenko &
Peter 2004, Dobrowolskaet al. 2007, Memarian et al.
2007,Kangasniemiet al.2010).
Professionalethics is also related to an individual’s per-
sonalexperience ofvalues (Rassin 2008)and is influenced
by many factors,including individualissues,such as age
and sex/gender and work-related issues, such as work expe-
rience,a nurse’s position in the unit,the working environ-
ment (Memarian et al. 2007, Rassin 2008, Vanaki &
Memarian 2009) and the nursing specialty (Rassin 2008).
Professional ethics related to the regulation and codes
Professionalethics has been guided and documented in leg-
islation,advisory documents,nursing ethics textbooks and
codes and is linked to the current era and the legislation at
that time (Johnstone 1987).Generallegislation defines the
aim of the profession on a nationaland societallevel(Kan-
gasniemiet al. 2010),but there are also lawsfocused on
nursing and health care (Verpeet et al. 2003).
In many countries,national or internationaladvisory
documents help to inform policies,provide a professional
identity and regulatethe nursing profession.Professional
ethicsis also covered in nursing ethicstext-books,which
8 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.

provide guidance forethicalnursing practice and profes-
sional identity. (Verpeet et al. 2003.)
Professional ethics is formulated and condensed in profes-
sionalcodes (Verpeet et al.2003),that focus on individual
professions.These codescombine the contentsof profes-
sional ethics(Weis & Schank 2000, Liaschenko & Peter
2004, Dobrowolska et al. 2007, Memarian et al. 2007) and
aim to support clinical care and guide the professional
ethic (Verpeetet al. 2003, Liaschenko& Peter 2004,
Dobrowolska et al. 2007).
The changing nature of professional ethics
Society and surrounding culture affect the values of profes-
sional ethics and the way that is implemented (Rassin
2008),but society also creates an environmentwhere pro-
fessionalethics can be maintained and fulfilled (Liaschenko
& Peter 2004, Verpeetet al. 2003, Vanaki & Memarian
2009). Variations in values emerge when it comes to differ-
ent generationsof nurses,their position in the workplace
and the type of unit they work in.Culture,education,age,
length ofwork experience,professionalposition and field
of expertise also affects nurses’values (Rassin 2008).Pro-
fessionalethics has to be taughtin an educationalsetting,
not just as ethicaltheories and how they should be applied
(Johnstone 1989),togetherwith contextualissuesrelating
to the surrounding culture, education and professional envi-
ronment (Rassin 2008).
Discussion
Based on our results,professionalethicsin nursing is a
well-known,but relatively unstudied,area of nursing sci-
ence.Professionalethics is based on professionaland per-
sonal commitment, including rights, duties and
responsibilities.They lay down the valuesand principles
that regulatethe conductof professionalsin relation to
their patients and clients,colleagues,other professions and
organization.The aim of professionalethicsis to protect
patients and give nurses guidance they need to contribute to
the development of a healthy society.Professionalethics in
nursing is often formulated in codesof ethics.They are
related notonly to internationalnursing valuesbut also
reflect national legislation. The nature of professional ethics
in nursing is changing,reflecting the current era and socie-
tal context.
In this discussion,we will focus on four topicalscientific
questions.The first question is what is the purpose of pro-
fessionalethicsin nursing? According to ourresults,this
purpose can be divided into the internaland externalneeds
of the profession.Internally,the main role ofprofessional
ethics is to define ethicalideology and provide nurses with
guidance how to work in a morally accepted way.This
includes describing values, responsibilities and duties (Chad-
wick & Thompson 2000,Liaschenko & Peter 2004,Ver-
peet et al. 2003, Dobrowolska et al. 2007, Memarian et al.
2007,Rassin 2008,Vanaki & Memarian 2009)and com-
bining them with professionalrights (Dobrowolska et al.
2007, Kangasniemi et al. 2010).
The externalrequirement for professionalethics must be
recognized (Liaschenko & Peter 2004,Kasher 2005).The
main purpose of this is to provide a ‘trade description’for
generalpublic, which describesnurses’rights,dutiesand
responsibilities, tells people how they can expect to be trea-
ted and cared for by nurses and helps profession to achieve
its goals in society.Rights and duties in professionalethics
describe nurses’ responsibilities and expects to execute them
in the best interests of patients (Johnstone 1989,Kangasni-
emi et al. 2010).
The balancing act between the internal and external aims
of professionalethicscan be seen throughoutits written
history.Internally,ethics have been formulated to support
nurses entering the profession for charitable,religious and
career reasons. Arguments for internal and external require-
mentshave varied from thereligious(Nightingale1952,
Bradshaw 2013)to the biological(Aikens 1916/1943)and
society’sexpectationsof the nurses’role (Radsma 1994,
Helmstadter2009).However,the key focushas been on
nurses’ choices and characteristics (Freitas 1990).
The externalexpectationsof the nursing profession are
topical and obviousand these include pressure from the
ethicallyand legally improved position of patientsand
increases organizationaland economicalpressures.The role
of the nurse is also changing,with the move towards
advanced nursing practicesand nurse-led hospitals,where
nurses can diagnose problems and issue prescriptions.This
means that the rights and duties in relation to their patients
need to be reconsidered (Kangasniemiet al. 2010) and
those between professions and the ethicalresponsibilities of
the profession need to be clarified.
It is noteworthy thatnurses’should remain constant,
even through theirresponsibilitiesin society may change
and their values and principles may be affected by changes
in individualization orglobalization.Being awareof the
content of professional ethics gives us an opportunity to dif-
ferentiate the stable elementsfrom the changing ones,so
that nurses can put the constant elements into practice.For
example,under the currenteconomicalpressures,nurses’
are required to prioritizecare in practice (Hunter2007,
Langeland & Sørlie 2011),but they stillhave to conform
JAN: REVIEW PAPER Professional ethics in nursing
© 2015 John Wiley & Sons Ltd 9

to the professionalethics that require them to take care of
patients and protect their human dignity.Thus, the aware-
ness of the nature of values of professionalethics provides
an opportunity to evaluate,influence and develop profes-
sional ethics in a conscious way.
The second question is,what are the changes in the pro-
fession and in health care,that influence professionaleth-
ics? The nursing profession is shaped by professionalethics
that is based on currentand shared internationalvalues
(International Council of Nurses (ICN) 2012). Those values
are reflected in ethicalcodesat nationallevel,such as in
South Africa (South African Nursing Council (SANC)
2005),Canada (Canadian Nurses Association (CNA) 2008)
and GreatBritain (Nursing & Midwifery Council 2008),
that representvariationsbetween countriesand influence
professionalethics.These includethe description ofthe
degree ofautonomy (Tadd et al.2006)and the weightof
such valuesas responsibility and beneficence.In addition,
professionalethics is also affected by changes with nursing,
such as increased multiculturalism (Xiao et al.2013),val-
ues held by differentgenerations (Sherman 2006)and the
variation in nursing philosophies around the world.Ethics
can also be affected by an individualnurse commitment to
their career (Wang et al.2012),which could threaten their
adherence to professional ethics. However, these all provide
opportunities to highlightthe importance ofshared values
beyond time-related challenges.The development of profes-
sionalethics in nursing could help to create and maintain
the bridge between representatives ofthe same profession,
both locally and globally.
The inter-professionalapproach to professionalethics
needs to be highlighted, in relation to the changes in profes-
sion and health care(Engel & Prentice 2013, Ewashen
et al. 2013). Inter-professionalworking is required to
achieve high-quality patient care,but the risk is that barri-
ers to multi-professionalcollaborationin ethical issues
might be ignored (Poikkeus et al.2014).Work ethics have
been presented as a way offocusing on the shared multi-
professionalgoal, instead ofindividualprofessionalinter-
ests. It could help to avoid hierarchical comparison between
tasks and professions (Liaschenko & Peter 2004,Thylefors
2012).Joint working by differentprofessions is very topi-
cal, as health problems have been seen as multi-dimensional
in western countries and globally.This means thatprofes-
sionalsneed to take a widerview aboutethicsin health
care and social services.
The third question is how well do nurses understand their
own role and responsibilitiesin relation to their profes-
sional ethics? Traditionally, nurses have taken responsibility
for acquiring professionalethics during educationand
clinicalpractice and following these ethics throughout their
work (Verpeetet al. 2003,Liaschenko & Peter 2004,Do-
browolska et al.2007).In addition, nurseshave reported
that they feel morally distressed,due to major challenges in
currenthealthcare practice (Oh & Gastmans 2013).They
say they cannot practice their profession as ethically as they
would like due to limited economical and human resources.
Perhaps it is time that nurses saw promoting and even forc-
ing, professional ethics as part of their role and responsibili-
ties. This requiresmore scientificdiscussion and nursing
science studies, together with educational support for nurses
in everyday practice.
As a result, professionalethicsare not static,but are
influenced by severalchangesduring any given era (Lias-
chenko & Peter 2004, Meulenbergset al. 2004, Milton
2007, Begley 2010,Kangasniemi& Haho 2012). Nurses’
scientific,evidence-basedknowledgeinfluencesnot only
their work but it is also affected by changes in society and
globalsense (Viens 1989,Liaschenko & Peter 2004,Meu-
lenbergs et al. 2004). The nursing profession is pressured to
adaptto externalexpectationsand the contentof profes-
sional ethicsneedsto be frequently evaluated.However,
there needs to be a balance between the core and static val-
ues and principles and those that are changing.For exam-
ple, individual patient’swishes have to be taken into
account,while ensuring thatthe profession’shigh ethical
standard to protect and promote human dignity is met. The
real challenge is to balance these two requirements in pro-
fessional ethics.
The fourth question is why we found such an unexpect-
edly low numberof previousprimary studieson profes-
sionalethicsin nursing,as we only identified 14 studies?
Although it is well-established concept, research on the con-
text of professionalethics is missing (Kasher 2005).Under-
standably, the most frequently used methodological
approach hasbeen theoreticalexamination.There is an
obvious need for increased and advanced knowledge of pro-
fessionalethics,in the field of ethics and empiricalknowl-
edge is needed.However, the current requirementfor
producing evidence-based knowledge abouteffectiveness is
often inappropriate.More conceptualand philosophical
research isneeded to update professionalethicsand gain
and deeperunderstandingof the patient (Dobrowolska
et al. 2007, Kangasniemiet al. 2010, Brecher2014). In
addition,awareness of professionalethics is reported to be
inadequate in practice (Schank et al.1996,Liaschenko &
Peter 2004, Gonzalez-dePaz et al. 2012), implying that
there is a need for improved empirical researchand
education.In future,literature reviews that cover the basic
valuesof nursingand other healthcareprofessions,and
M. Kangasniemi et al.
10 © 2015 John Wiley & Sons Ltd

inter-professionalethics,are needed to deepen our under-
standing of the nature of professional ethics.
More discussion is needed about how to use and combine
data published over a long period of time and how to eval-
uate quality in articles from different decades.It is particu-
larly noteworthy that the methodologicalrigour and
evaluationof theoreticalstudiesin the field of moral
research is insufficient or challenge to assess.
Limitations
The limitations of this review concern the search strategies
and the heterogeneity of the selected studies (Whittemore &
Knalf 2005). As Whittemore and Knalf (2005) reported, elec-
tronic search on databases are effective,but they may only
identify about half of the eligible studies, because of inconsis-
tent search terminology and indexing problems.Thus, the
search bias of this study could have be avoided by using both
ancestry and descendency approaches(Cooper 1982) by
manual searches(Evans & Kowanko 2000), and using
unpublished material (Petticrew 2001). However, to improve
validity, the broadest possible search terms were used and all
possible studies that covered the research topic were included
(Cooper 1982).The methodologicalrigour of search strate-
gies was improved by consulting an informatician and the
studieswere selected with thecollaboration of all the
authors.To avoid publishing and language bias,no specific
years or language limitations were used. Although we placed
no limitation on the language that the paper was published
in all the original papers in our searches included at least the
title and/or the abstract in English. All the selected full texts
were available in English, but our selection was not based on
language, just on our inclusion and exclusion criteria.
The variety of research methods and the fact that publi-
cation search spanned severaldecadescould imply that
there was not sufficient consideration given to their quality.
Scientific writing and academic journalrequirementshave
changed radically during thatperiod. Early articleswere
less structured,research questionswere fragmented and
methodologywas poorly reported.However, excluding
papers from the early days of nursing science could lead to
publication bias and the risk that we could miss important
information.In particular,ethicalquestions are contextual
by nature and synthesis of previous knowledge requires rec-
ognising earlier publications.However,this historicalsensi-
tivity is nottaken into accountby quality criteria,as they
tend to focus on their current requirements.
In this review,quality criteria with generalmethodologi-
cal aspects were used,which mainly aimed to describe and
evaluate selected articles.For this reason,all the studies
featured in this review were selected because of their contri-
bution to the knowledge of the professional ethics.
Conclusions
Professional ethics in nursing is rarely studied and the prob-
lems are poorly examined.Professionalethics create a basis
for the nursing profession.It comprises the values,rights,
duties and responsibilities ofnurses when interacting with
patients and clients, colleagues, other professions and organi-
zation. The overall purpose of professional ethics is to guide
how nurses contribute the developmentof healthy society.
Professionalethics is changing,due to the status of profes-
sion, current legislation and regulation. Without me research,
there is a risk that professional ethics in nursing will become
static unable to guide professionals in practice. By neglecting
our scientific responsibility to focus on professional ethics in
nursing, we are not making nurses aware of the issues or sup-
porting their ethicaldecision-making in an environmentof
continuouslychanginghealth care. That is why more
research on professional ethics in nursing is needed in future,
to help nurses provide high-quality care for patients and con-
tribute to the development of a healthy society.
Funding
This research received no specific grantfrom any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the finalversion and meetat
least one of the following criteria [recommended by the IC-
MJE (http://www.icmje.org/ethical_1author.html)]:
•substantialcontributionsto conceptionand design,
acquisition ofdata, or analysisand interpretation of
data;
•drafting the article or revising it critically for important
intellectual content.
References
Abbott A. (1983) Professional ethics. American Journal of
Sociology 88, 855–885.
Aikens C.A. (1916/1943)Studiesin Ethics for Nurses,5th edn.
W.B. Saunders Company, Philadelphia, PA.
JAN: REVIEW PAPER Professional ethics in nursing
© 2015 John Wiley & Sons Ltd 11

Altun I. (2002) Burnout and nurses0 personaland professional
values. Nursing Ethics 9, 269–278.
Beauchamp T.L.& Childress J.F. (2009)Principles ofBiomedical
Ethics, 6th edn. Oxford University Press, New York.
Begley A.M.(2010) On being a good nurse:reflections on the past
and preparing forthe future.InternationalJournal of Nursing
Practice 16, 525–532.
BertoluzziG. & Palese A. (2010)The Italian economic crisis and
its impacts on nursing servicesand education: hard and
challenging times. Journal of Nursing Management 18, 515–519.
Booth A. (2006) ‘Brimful of STARLITE’: toward standardsfor
reporting literature searches.Journal of Medical Library
Association 94, 421–429.
Bowling A. (2002) Research Methodsin Health: Investigating
Health and Health Services,2nd edn. Open University Press,
Buckingham.
Bradshaw A.(2000) Competence and British nursing:a view from
history. Journal of Clinical Nursing 9, 321–329.
Bradshaw A.E. (2013) Gadamer’stwo horizons: listening to the
voices in nursing history. Nursing Inquiry 20, 82–92.
Brecher B.(2014) What is professionalethics? Nursing Ethics 21,
239–244.
Canadian NursesAssociation (CNA) (2008) Code of ethicsfor
registered nurses.Retrieved from https://cna-aiic.ca/~/media/cna/
files/en/codeofethics.pdf on 14 September 2014.
Carney M. (2010) Challengesin health care delivery in an
economicdownturn, in the republic of Ireland. Journal of
Nursing Management 18, 509–514.
Chadwick R. & Thompson A. (2000) Professional ethics and labor
disputes: medicine and nursing in the United Kingdom.
Cambridge Quarterly of Healthcare Ethics 9, 483–498.
Cooper H.M. (1982) Scientific guidelines for conducting integrative
research reviews. Review of Educational Research 52, 291–302.
Cooper HM (1984) The Integrative Research Review: A Systematic
Approach.Applied SocialResearch Methods Series,Volume 2.
Sage Publications, California.
Crout L.A., Chang E.& Cioffi J. (2005) Why do registered nurses
work when ill? Journal of Advanced Nursing 35, 23–28.
Dekeyser Ganz T. & Berkovitz K. (2012) Surgical nurses’
perceptionsof ethicaldilemmas,moral distressand quality of
care. Journal of Advanced Nurses68, 1516–1525.
Dobrowolska B., Wronska I., Wiestaw F. & Wysonkinski M. (2007)
Moral obligationsof nursesbased on the ICN, UK, Irish and
Polish codes of ethics for nurses. Nursing Ethics 14, 171–180.
Engel J. & Prentice D. (2013) The ethics of interprofessional
collaboration. Nursing Ethics 20, 426–435.
Evans D. & Kowanko I. (2000)Literature reviews:evolution of
research methodology.Australian Journalof Advanced Nursing
18, 33–38.
Ewashen C., McInnis-Perry G. & Murphy N. (2013)
Interprofessionalcollaboration-in-practice:the contested place
for ethics. Nursing Ethics 20, 325–335.
Fowler M.D. (1993)Professionalassociations,ethics and society.
Oncology Nursing Forum 20, 13–19.
FrankelM.S. (1989) Professionalcodes:why, how and with what
impact? Journal of Business Ethics 8, 109–115.
Freitas L.(1990) Historical roots and future perspectives related to
nursing ethics. Journal of Professional Nursing 6, 197–205.
Gazarian P.K. (2013) Use of the critical decision method in nursing
research.An integrative review. Advances in Nursing Science 36,
106–117.
Goethals S., Gastmans C. & Dierckx de Casterle B. (2010) Nurses’
ethicalreasoning and behavior:a literature review.International
Journal of Nursing Studies 47, 635–650.
Gonza´lez-de Paz L., Kostov B., Siso´-Almirall A. & Zabalegui-
Ya´rnoz A. (2012)A Rasch analysis ofnurses’ethicalsensitivity
to the norms of the code of conduct. Journal of Clinical Nursing
19(20), 2747–2760.
Graneheim U.H. & Lundman B. (2004) Qualitative content
analysis in nursing research:concepts,procedures and measures
to achieve trustworthiness. Nurse Education Today 24, 105–112.
HelmstadterC. (2009) Shifting boundaries:religion, medicine,
nursing and domesticservicein mid-nineteen-century Britain.
Nursing Inquiry 16, 133–134.
Hunter D. (2007) Am I my brother’sgatekeeper?Professional
ethics and prioritisation in healthcare.Journal of MedicalEthics
33, 522–526.
InternationalCouncil of Nurses (ICN) (2012)Code of ethics for
nurses. Retrieved from http://www.icn.ch/images/stories/
documents/about/icncode_english.pdf on 14 September 2014.
Jirwe M., Gerrish K., Keeney S.& Emami A. (2009)Identifying
the core componentsof cultural competence:findingsfrom a
Delphi study. Journal of Clinical Nursing 18, 2622–2634.
Johnstone M.J. (1987) Professional ethics in nursing: a
philosophicalanalysis.Australian Journalof Advanced Nursing
4, 12–21.
Johnstone M.J. (1989) Professional ethics and patients0 rights0: past
realities, future imperatives. Nursing Forum 24, 29–34.
Kangasniemi M. & Haho A. (2012) Human love – inner essence of
nursing ethicsaccording to Estrid Rodhe.A study using the
approach ofhistory of ideas.Scandinavian Journalof Nursing
Sciences 26, 803–810.
KangasniemiM., Viital€ahde K. & Porkka S. (2010)A theoretical
examination of the rights of nurses. Nursing Ethics 17, 628–635.
Kasher A. (2005) Professionalethicsand collectiveprofessional
autonomy: a conceptual analysis. Ethical Perspectives: Journal of
the European Ethics Network 11, 67–98.
Kristiansen L., Hellzen O. & Asplund K. (2010) Left alone –
Swedish nurses’and mentalhealth workers’experiences of being
care providersin a social psychiatricdwelling contextin the
post-health-care-restructuring era. A focus-group interview study.
Scandinavian Journal of Caring Sciences 24, 427–435.
Langeland K. & Sørlie V. (2011) Ethical challengesin nursing
emergency practice. Journal of Clinical Nursing 20, 2064–2070.
Liaschenko J. & Peter E. (2004) Nursing ethics and
conceptualizationof nursing: profession,practice and work.
Journal of Advanced Nursing 46, 488–495.
McCurry M.K., RevellS.M. & Roy S.C. (2009) Knowledge for the
good of the individual and society: linking philosophy, disciplinary
goals, theory and practice. Nursing Philosophy 11, 42–52.
Memarian R., SalsaliM., Vanaki Z., Ahmadi F. & Hajizadeh E.
(2007) Professionalethics as an important factor in clinical
competence in nursing. Nursing Ethics 14, 203–214.
Meulenbergs T.,Verpeet E.,Schotsmans P.& Gastmans C.(2004)
Professionalcodes in changing nursing context:literature review.
Journal of Advanced Nursing 46, 331–336.
M. Kangasniemi et al.
12 © 2015 John Wiley & Sons Ltd

Milton C.L. (2007)Professionalvalues in nursing ethics:essential
or optional in the global universe? Nursing Science Quarterly 20,
212–215.
Nightingale F.(1952) Notes on Nursing.(First published in 1859).
Duckworth, London.
Nursing & Midwifery Council (2008) The Code: Standards,
Conduct, Performance Ethics for Nurses and Midwives.
Retrieved from http://www.nmc-uk.org/Documents/Standards/
nmcTheCodeStandardsofConductPerformanceAndEthicsForNurses
AndMidwives_LargePrintVersion.PDF on 14 September 2014.
Oh Y. & Gastmans C. (2013) Moral distressexperienced by
nurses: a quantitative literature review. Nursing Ethics.
doi:10.1177/0969733013502803.
PaleseA., Vianelli C., De Maino R. & Bortoluzzi G. (2012)
Measuresof cost containment,impactof the economicalcrisis
and the effectsperceived in nursing daily practice:an Italian
crossover study. Nursing Economics 30, 86–93.
Pavlish C.,Brown-Saltzman K.,Jakel P. & Rounkle A.-M. (2012)
Nurses’responses to ethicalchallenges in oncology practice:an
ethnographic study.Clinical Journal of Oncology Nursing 16,
592–600.
Petticrew M. (2001) Systematicreviews from astronomy to
zoology: myths and misconceptions. British Medical Journal 322,
98–101.
Poikkeus T.,Numminen O.,Suhonen R.& Leino-Kilpi H. (2014)
A mixed-method systematic review: support for ethical
competence ofnurses.Journal of Advanced Nursing 70,256–
271.
Radsma J. (1994) Caring and nursing: a dilemma.Journal of
Advanced Nursing 20, 444–449.
Rassin M. (2008) Nurses0 professionaland personal values.
Nursing Ethics 15, 614–630.
Schank M.J., Weis D. & Ancona J. (1996) Reflecting professional
values in the philosophy of nursing. Journal of Nursing
Administration 26, 55–60.
Sellman D. (1997) The virtues in moral education of nurses:
Florence Nightingale revisited. Nursing Ethics 4, 3–11.
Sherman R.O. (2006) Leading a multigenerationalnursing
workforce:issues,challengesand strategies.Online Journal of
Issues in Nursing 11, 13.
South African Nursing Council(SANC) (2005) Code of ethics for
nursing practitionersin South-Africa. Retrievedfrom http://
www.sanc.co.za/pdf/SANC%20Code%20of%20Ethics%20for%
20Nursing%20in%20South%20Africa.pdfon 14 September
2014.
Tadd W., Clarke A., Lloyd L., Leino-Kilpi H., StrandellC.,
Lemonidou C., PetsiosK., Sala R., BarazzettiG., Radaelli S.,
Zalewski Z., Bialecka A., van der Arend A. & Heymans R.
(2006) Value of nurses’codes:European nurses’views.Nursing
Ethics 13, 376–393.
Thompson D.F. (1999) The institutional turn in professional ethics.
Ethics Behavior 9, 109–118.
Thylefors I. (2012) All professionalsare equal but some
professionals are more equalthan other? Dominance,status and
efficiency in Swedish interprofessionalteams. Scandinavian
Journal of Caring Sciences 26, 505–512.
Ulrich C.M., Taylor C., Soeken K.,O’DonnellP., Farrar A., Danis
M. & Grady C. (2010) Everyday ethics:ethicalissues and stress
in nursing practice.Journal of Advanced Nursing 66,2510–
2519.
Vanaki Z. & Memarian R. (2009) Professionalethics:beyond the
clinical competency.Journal of ProfessionalNursing 25, 285–
291.
VerpeetE., MeulenbergsT. & Gastmans C. (2003) Professional
values and norms for nurses in Belgium. Nursing Ethics 10, 654–
665.
Viens D.C. (1989) A history of nursing code ofethics.Nursing
Outlook 37, 45–49.
Wang L., Tao H., EllenbeckerC.H. & Liu X. (2012) Job
satisfaction,occupationalcommitment and intent to stay among
Chinese nurses: a cross-sectionalquestionnaire survey. Journal of
Advanced Nursing 68, 539–549.
Weis D. & Schank M.J. (2000) An instrumentto measure
professional values. Journal of Nursing Scholarship 32, 201–204.
Whittemore J.E. & Knalf K. (2005) The integrative review: updated
methodology. Journal of Advanced Nursing52, 546–553.
Winterstein T.-B. (2012) Nurses’ experiences of the encounter with
elder neglect. Journal of Nursing Scholarship 44, 55–62.
Wocial L.D. & Weaver M.T. (2013) Development a psychometric
testing of a new tool for detecting moraldistress:the Moral
DistressThermometer.Journal of Advanced Nursing 69,167–
174.
World Health Organization (2011) Strategic directions for
strengthening nursing and midwifery services.Retrieved from
http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.1_eng.
pdf?ua=1 on 20 May 2014.
Xiao L.D., Wills E. & Jeffers L. (2013) Factors affecting the
integration ofimmigrantnursesinto the nursing workforce:a
double hermeneuticstudy. InternationalJournal of Nursing
Studies 51, 640–653.
JAN: REVIEW PAPER Professional ethics in nursing
© 2015 John Wiley & Sons Ltd 13

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary releva
and with potentialto advance knowledge for practice,education,management or policy.JAN publishes research reviews,original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open:the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).
M. Kangasniemi et al.
14 © 2015 John Wiley & Sons Ltd