Professional Ethics in Nursing: An Integrative Review

R E V I E W P A P E R
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 I M . , 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. Professional ethics 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. Systematic literature searches from 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. Fourteen papers were included in this research. According to our
synthesis, professional ethics is described as an intra-professional approach to
care ethics and professionals commit to it voluntarily. Professional ethics consist
of values, duties, rights and responsibilities, regulated by national legislation and
international agreements and detailed in professional codes. Professional ethics is
well established in nursing, but is constantly changing due to internal and
external factors affecting the profession.
Conclusion. Despite the obvious importance of professional ethics, it has not
been studied much in nursing science. Greater knowledge of professional ethics is
needed to understand and support nurses’ moral decision-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 ethical questions 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, ethical questions are raised
about their collaboration with colleagues (Ulrich et al.
2010) and other professions (Engel & Prentice 2013, Ewa-
shen et al. 2013). Several studies have 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 ethical nursing values of good and
© 2015 John Wiley & Sons Ltd 1

individualized care with the external practical values of
effective, productive and economical practices (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 issues on an individual level, 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 development of a
healthy society (Aikens 1916/1943, Abbott 1983, Kasher
2005, McCurry et al. 2009). A profession refers to an
occupational group that posses specialized skills that are
based in some way on esoteric knowledge (Abbott 1983).
The group responds autonomously, but, at the same time, it
needs to meet the demands of the public it serves (Frankel
1989). The current, overall aim 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 educational influences (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). All of 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 general moral norms that are acceptable in a certain
occupational group (Beauchamp & Childress 2009) to deal
with morally ambiguous situation (Frankel 1989) and thus
prevent and avoid, ethical harm (Brecher 2014). It is intra-
professional by nature and it is this enforcement of formal
ethics that creates visibility and, therefore, confidence
between professionals and, in particular, between profession-
als and the public (Abbott 1983). Professional ethics usually
appear in formal codes, including references to corporate
norms (Frankel 1989), obligations and perceptions of rela-
tionships between colleagues and with the public (Abbott
1983, Frankel 1989, Beauchamp & Childress 2009).
In the field of nursing, professional ethics may have had
a different meaning in years gone by, perhaps referring to
nurses’ personal characteristics (Sellman 1997, Dekeyser
Ganz & Berkovitz 2012, Kangasniemi & Haho 2012), vir-
tues (Begley 2010) or their etiquette and correct manner
(Aikens 1916/1943, Johnstone 1987, Freitas 1990, Brad-
shaw 2000). In addition to individual behaviour, profes-
sional ethics currently focus on groups of professionals
guided by shared ethical codes (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 organizational and
institutional ethics guiding nurses’ everyday work (Thomp-
son 1999, Poikkeus et al. 2014), and being linked to other
healthcare professions (Liaschenko & Peter 2004, Milton
2007, Kangasniemi & Haho 2012). Thus, nursing ethics is
not different from other health professions, as it includes
the same rules of ethical values and norms, but the empha-
Why this review is needed?
● The history of nursing shows that professional ethics has
been an inherent part of the profession since the very early
days.
● Professional ethics is changing and is affected by internal
and external factors.
● Despite the fact that professional ethics is well established
in nursing, there is no real synthesis understanding of eth-
ics in nursing.
What are the key findings?
● There has been very little research focused into profes-
sional ethics in nursing science.
● In nursing, professional ethics consists of 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.
● Professional ethics is an integral part 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 professional ethics is highly topical in
nursing science and the fact that it is constantly evolving
reflects changes in the profession, different codes of ethics
in different countries and in societies in general. Therefore,
it is important to be aware of the constant values of the
profession to develop professional ethics in conscious way.
● The development of professional ethics in nursing could
help to create and maintain the sustainable bridge between
representatives of the same profession, both locally and
globally.
● To support nurses professional ethics, more scientific dis-
cussion and nursing science studies is needed, together
with educational support for nurses in everyday practice.
2 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.

sis on ethical issues in nursing profession and the way that
they have emerged over the years may be different.
Although ethics is central to the nursing profession and a
lot of scientific attention has been paid to the ethical ques-
tions affecting nurses, few studies have focused on profes-
sional ethics in nursing but a synthesis of findings is
lacking.
The review
Aim
The aim of this study was to conduct an integrative review
and synthesize primary studies of professional ethics in
nursing, to deepen and clarify our discussions on the sub-
ject. Two research questions were addressed: how has pro-
fessional ethics 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 of data
(quality appraisal), analysis and interpretation of data (data
abstraction) and presentation of 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 professional ethics in nursing
was clearly needed. Because previous knowledge was sparse
and of different types, 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 stage was data collection included literature
search. Purposive sampling with specific databases and
years was used, limited to professional ethics in nursing
(Booth 2006). Information was retrieved using electronic
database searches (Cooper 1982) and conducted using the
CINAHL, PubMed and Scopus databases (Figure 1). To
avoid any possible bias, previous studies in all languages
were looked at. Years were not restricted and all original
articles since the beginning of databases, earliest 1948, until
February 2013 were included. Search terms linked to the
profession were used (professional ethic, work ethic and
ethic of work) and ethical terms (code, value, duty, right,
norm and responsibility).
Search outcome
The original 4,377 articles were selected in five stages,
based on their titles (n = 245), abstracts (n = 90), full-texts
(n = 46), removal due 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 papers that focused on education,
students or research, ethical dilemmas, decision-making
and codes or other disciplines such 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 methodological pluralism, low numbers of publications
and long publishing periods. However, six descriptive criteria
concerning methodological structure (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 that all the individual articles 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
professional ethics by following the principles of inductive
content analysis (Graneheim & Lundman 2004).
Data synthesis
The fifth stage was presenting the results on all the elements
of professional ethics (Cooper 1984, 113, Whittemore &
Knalf 2005). Because only three qualitative and three quanti-
tative methods were used and there were eight theoretical
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 until categoriz-
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 published between 1987–2010 (Table 1). The
quantitative studies used standardized instruments, such as
the Nursing Professional Value Scale (NPVS) (Weis &
Schank 2000), The Rokeach Values Survey (Rassin 2008)
and two different questionnaires developed by the authors
of the studies (Altun 2002, Rassin 2008). The qualitative
studies used grounded theory (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-structured interviews
(Memarian et al. 2007, Vanaki & Memarian 2009).
Professional ethics in nursing was the main focus of five
studies (Johnstone 1987, 1989, Fowler 1993, Chadwick &
Thompson 2000, Verpeet et al. 2003), while the othersLimitations: YearsCINAHL 1981–2013PubMed 1948–2013Scopus 1960–2013Search words(and combinations):professional ethic, work ethicand ethic of work combinedwith code, value, duty, right,norm and responsibilityExcluded basedon titles(n = 4135)Accepted based on titles(n = 245)CINAHL n = 71PubMed n = 98Scopus n = 76Exclusion criteria:- Focused oneducation;students;researchers,ethicaldilemmas;decisionmaking; codesor otherInclusion criteria:- Peer-reviewed,scientific paper- Search term orsynonymmentioned intitleAccepted based on abstracts(n = 90)CINAHL n = 27PubMed n = 25Scopus n = 38Accepted based on full texts(n = 46)CINAHL n = 13PubMed n = 9Scopus n = 24Excluded basedon abstracts(n = 155)Inclusion criteria:- Peer-reviewed,scientific paper- Focused onnurses’professionalethicsDuplicateremoved (n = 32)Selected fulltextsn = 14Electronic searches(N = 4377)CINAHL = 434PubMed = 1908Scopus = 2035Excluded basedon full texts(n = 44)disciplines
Figure 1 Flow diagram of literature searches and selection.
4 © 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.