Ethical problems in nursing management: The role of

codes of ethics
AUTHORS: Elina Aitamaa, Helena Leino-Kilpi, Pauli Puukka and Riitta Suhonen
Abstract
The aim of this study was to identify the ethical problems that nurse managers encounter in their
work and the role of codes of ethics in the solutions to these difficulties. The data were collected
using a structured questionnaire and analysed statistically. The target sample included all nurse
managers in 21 specialized health care or primary health care organizations in two hospital
districts in Finland (N 501; response rate 41%). The most common ethical problems concerned
resource allocation as well as providing and developing high quality care. This was the case in
different managerial positions as well as in types of organization. Professional codes of ethics
were used more often for problems related to patients care compared with issues of resource
allocation. Nurse managers at middle or strategic management levels used codes of ethics more
often than those in charge of a ward. More research is required to investigate ethical decision
making in nursing management, especially with regard to problem solving. In addition, new
guidelines and continuing education in ethics are important for management personnel.
Discussion
The purpose of this study was to identify the ethical problems encountered by Finnish nurse
managers and the role of codes of ethics used for their solution. The findings indicate that nurse
managers perceive many kinds of ethical problems in their work, the most common of which are
related to the allocation of scarce personnel resources and ensuring the quality of care, as seen
also in previous studies carried out since the 1980s.3,4,7 These results were regardless of
different managerial positions as well as organization type. Questions concerning resources and
quality issues are of current interest in health care in many countries. At present in Finland, there
is a greater demand for than supply of health care services, and economic issues are more
relevant than before.22,36 Quality issues are also under examination and development. Good
care and quality issues are dependent on many factors, such as organizational culture, attitudes
and competencies. Sufficiency of human resources is also a very significant factor.37 Because of
the descriptive and general nature of this study, a possible interdependence of resource problems
and quality of care was not investigated. However, the literature indicates that this could be so.
For example, the theme of how to spend the money in the study by Gaudine and Beaton17
includes problems such as how to meet the needs of patients while staying on budget. The lack of
financial and personnel resources as a reason for inadequate care has also been reported in
studies concerning the care of older people.11 The frequency of these ethical problems measured
in this study needs serious attention, especially because there is no reason to assume that the
bases of these problems are temporary in nature. The results appear to show that codes of ethics
are used most with patient-related and least with organization-related problems. This could

support the suggestion of Meulenbergs et al.22 that codes of ethics should accommodate the
changing context of nursing. Codes of ethics emphasize the professionalpatient relationship and
the ideal state of patient care, and ignore the importance of the economic side of health care.27
Nevertheless, codes of ethics appear to be useful in many kinds of problems in spite of the
findingsofpreviousstudies7,33,34showingthatnursemanagersmostlymakedecisionsandchoicesbas
edontheirown values and discussion with colleagues. Ethical problems are most certainly varied,
complicated and unique matters, and there is a need for multiform guidance for resolving them.
Without recourse to any other means, personal values and discussion are too unstable and
uncertain to serve as guidelines in solving ethical problems. It is important for nurse managers to
be able to have closely argued, clear and transparent solutions because they should be role
models and teachers to their subordinates in ethical decision making. Codes of ethics are one
possible resource open to them. Ethical problems and the use of codes of ethics in nursing
management seem to be associated with different background factors. In this study, nurse
managers in strategic or middle management appeared to use codes of ethics more than those
who are in charge of a ward. This result can even be seen as unexpected because codes of ethics
are mainly aimed at nurses who are actually working with patients. Nurses in charge of a ward
are closer to daily practice and could thus be expected to make more use of codes of ethics.
However, there is also a code for nurse managers in Finland, which may be one reason for this
result. Second, previous studies of nurse managers resources used in ethical decision making
show that administrative colleagues are used much more frequently than codes of ethics.33,34 It
is not known how much ward nurse managers use discussion with their own superiors and
whether this could have an effect on the results. Third, differences may be associated with higher
levels of education achieved by middle- or strategic-level nurse managers and the different tasks
and duties involvedat various management levels. On the basis of this study we cannot draw firm
conclusions about the reasons for this difference. Participation in ethics training also seems to
increase both the ability to perceive ethical problems and the use of codes of ethics in resolving
them. However, this reasoning is not very clear. It is possible that nurse managers who are
interested in ethical issues and are able to perceive ethical problems, and use the available codes
of ethics, are also more inclined to take courses in ethics. The younger nurse managers perceived
ethical problems more often than their older counterparts. It can be assumed that the younger
managers ethics education would be more recent, which may be a reason for this result. All
these findings may support the idea that education and training strengthen readiness to be aware
of ethical problems and preparedness to resolve them. However, it could also be assumed that
nurses should be selected more on the basis of their genuine ethical awareness and attitudes. The
similarities of the ethical problems regardless of job position or organization type can be
considered to indicate that the problems revealed are the same throughout the Finnish health care
system, which makes the findings surrounding the most common ethical problems more
significant.
Some limitations need to be taken into account in interpreting the results. These have to
do with the instrument, the nature of the concepts in the questionnaire and the response rate.
First, a suitable established questionnaire was not found, which is why one was developed

especially for this study and there was of course no previous information about its reliability and
validity. However, the items are based on the literature and expert analysis. The internal
consistencies of the sum variables for the ethical problems and the use of codes of ethics in their
solution were satisfactory (Table 4; also see Burns and Grove38). Second, some of the questions
may have been ambiguous and could have caused some response bias. Previous literature shows
that the concept of an ethical problem can be understood in different ways. The frequencies of
ethical issues are thus only suggestive in nature, but the resulting order of the ethical problems is
more valuable. Each participant may understand the concept of an ethical problem rather
differently, but when ranking problems they use their own ideas in the same way with each one.
The use of codes of ethics as a concept is also problematic. The Finnish codes of ethics for
different nursing professionals were mentioned in the questionnaire and were thus not open to
interpretation, but ways of using them could vary and be understood in different ways.
Respondents may think only of using the codes in a concrete manner, or they could also realize
that they use them unconsciously. The latter means that the values and advice contained in the
codes are already internalized and there is no need to think about their content.26 Thus, the order
of the problems in which the codes of ethics were used is more significant than exact frequencies
of use. Third, the relatively low response rate may also decrease the validity and generalizability
of the results. However, the sample was large enough (n205) and it represented nurse managers
at all levels and from different types of organizations with no systematic under- or overrepresentation of specific groups.
Conclusion and recommendations
This study provided an overview of the ethical problems encountered in nursing management,
but more qualitative studies are needed for shaping the features and nature of these issues. The
findings indicate the importance of resource allocation and issues of quality of care as sources of
ethical problems in nurse managers work. Further qualitative study could provide a more exact
description of ethical problems related to resource and care quality as well as other issues.
Second, the basis and mechanisms of ethical decision making in nursing management are not
well known. More research is needed to find out the values, principles or codes that guide
solutions to ethical problems. More information is required about the concrete mechanisms of
how decisions are made in ethically problematic situations. Furthermore, the concrete choices for
and solutions of ethical problems should be studied to investigate the types of choices that are
made and the nature of the argumentation used. There is also a need for wide discussion about
values in health care, which should be conducted in both health care organizations and society.
Nurse managers should be involved in this discussion and also be capable of stating arguments
for solutions for themselves, their subordinates, stakeholders and the public. This is extremely
important, especially in situations where structures and resources of health care are re-evaluated
because of societal changes.
Summary:

As nurse managers, we face many kinds of ethical problems in our work. Based on the study,
most common of which are related to the allocation of scarce personnel resources and ensuring
the quality of care. The study was done in Finland, but the same problems are actually also
happening in the Philippines. Nurse professionals codes of ethics seem to have limited value
when it comes to resource allocation. Thus, clear guidelines should be drawn up for nursing
management personnel to serve as an aid in ethical decision making for resource allocation
issues and, moreover, to combine economically effective activities and a high quality of care.
Education is important when aspiring to better ethical competence and the creation of a strong
and common basis for ethical thinking in all nursing practice and management.
Reference: nej.sagepub.com