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Professional ethics in nursing: An integrative review

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 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: mari.kangasniemi@uef.fi

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
KANGASNIEMI M . , PAKKANEN P. & K ORHONEN A. ( 2015) 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

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M. Kangasniemi et al.

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.

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-
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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

M. Kangasniemi et al.

Electronic searches (N = 4377) CINAHL = 434

PubMed = 1908
Scopus = 2035
Limitations: Years
CINAHL 1981–2013
PubMed 1948–2013
Scopus 1960–2013
Search words
(and combinations):
Inclusion criteria:
- Peer-reviewed,
scientific paper
- Search term or
synonym
mentioned in
title

Exclusion criteria:
- Focused on
education;
students;
researchers,
ethical
dilemmas;
decision
making; codes
or other
disciplines

Inclusion criteria:
- Peer-reviewed,
scientific paper
- Focused on
nurses’
professional
ethics

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

Excluded based on abstracts

(n = 155)

Accepted based on abstracts

(n = 90) CINAHL n = 27
PubMed n = 25
Scopus n = 38
Excluded based on full texts
(n = 44)

Accepted based on full texts

(n = 46) CINAHL n = 13
PubMed n = 9
Scopus n = 24

Duplicate removed (n = 32)

Selected full
texts
n = 14

Figure 1 Flow diagram of literature searches and selection.

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 others

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Table 1 The description of 14 eligible studies.

Quality appraisal criteria
(scale: y = yes, p = poor, nr = not
Author(s) year, Country Purpose Design and tools Sample size and characteristics reported)

Altun (2002), Turkey
Chadwick and Thompson
(2000), United Kingdom
Crout et al. (2005),
Australia 2005
Dobrowolska et al. (2007),
Poland
Fowler (1993), Canada
Determine the relationship
between the degree of
burnout experienced by
nurses and their
professional values.
Describe professional
ethics by nurses and
physicians from industrial
point of view.
To explore and describe
nurses’ experiences of
coming to work when ill.
To present a comparative
analyses of codes of ethics
for nurses.
Examine the role of
professional association in
relation to professional
ethics.
Quantitative questionnaire
(developed based on literature
and the Maslach Burnout
Inventory scale)
Theoretical discussion, literature
Qualitative, individual interviews
(an unstructured, in-depth
interview technique), Colaizzi-
method as modified by Beck for
analyse
Theoretical, comparative study
and analysis, literature
Theoretical, literature
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)
Literature, 41 references, published
between 1971–1998
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
Codes of ethics (4):
-The ICN0 s Code of Ethics for Nurses
-The UK0 s Code of Professional
Conduct
-The Irish Code of Conduct for each
Nurse and Midwife
-The Polish Code of Professional Ethics
for Nurses and Midwives
Literature, 26 references, published
between 1896–1993
(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
(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
(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
(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
(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
Table 1 (Continued).
Author(s) year, Country Purpose
Johnstone (1987), To focus on the
Australia phenomenon of
professional ethics.
Johnstone (1989), Examine the failure of
Australia professional ethics to
prevent patients’ rights’
abuses in health care
contexts.
Kangasniemi et al. (2010), To examine and structure
Finland nurses’ rights.
Liaschenko and Peter To discuss limitations of
(2004), United States the concept of
professional ethics and
the contribution of ethics
of work.
Memarian et al. (2007), To identify the factors
Iran influencing clinical
competency in nursing.
6
Design and tools
Theoretical discussion,
philosophical analysis, literature
Theoretical discussion, literature
Theoretical discussion, literature
Theoretical discussion, literature
Qualitative, Grounded Theory,
semi-structured individual
interviews
Sample size and characteristics
Literature, 49 references, published
between 1957–1986
Literature, 16 references, published
between 1953–1989
Literature, 35 references, published
between 1998–2009
Literature, 41 references, published
between 1900–2003
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
Quality appraisal criteria
(scale: y = yes, p = poor, nr = not
reported)
(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
(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
(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
(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
(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
M.2015
© Kangasniemi
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et al.
& Sons Ltd

(n = 11.31%), PhDs (n = 10.28%)

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Table 1 (Continued).

Quality appraisal criteria

(scale: y = yes, p = poor, nr = not
Author(s) year, Country Purpose Design and tools Sample size and characteristics reported)

Rassin (2008), Israel Measure professional and Quantitative, two questionnaires Nurses (n = 323): 82% women and (y) Aims and objectives clearly described
personal values among (The Rokeach Values Survey and 18% men (y) Study design adequately described
nurses. questionnaire relied on values -Average age 39 years (y) Research methods appropriate
expressed in the Israeli nurses0 -Education: RN with Bachelor degree (p) Explicit theoretical framework
code of ethics 1996–2004 (42.5%), Master degree (13.3%), no (y) Limitations presented
further qualifications (33%), licensed (p) Implications discussed
vocational nurses (11.3%)
Vanaki and Memarian To highlight nurse’s Qualitative, grounded theory, Nurses (n = 36), (including clinical (y) Aims and objectives clearly described
(2009), Iran clinical competency and individual semi-structured open- nurses, nurse educators, hospital (y) Study design adequately described
to explain the process ended interviews managers and members of Nursing (y) Research methods appropriate
which clinical competency Council in Tehran 2005 (y) Explicit theoretical framework
was acquired. -Age 38–65 years (y) Limitations presented
-Clinical experience 8–24 years (y) Implications discussed
-Nursing experience 8–35 years
-Education: Bachelor degree (n = 15,
42%), Master level (n = 11.31%),
PhDs (n = 10.28%)
Verpeet et al. (2003), To prove and illustrate Theoretical discussion, content Literature, 30 references, published (p) Aims and objectives clearly described
Belgium legal and professional analysis, literature between 1980–2002 (p) Study design adequately described
documents reflection of (y) Research methods appropriate
professional ethics. (y) Explicit theoretical framework
(p) Limitations presented
 (p) Implications discussed
Weis and Schank (2000), To describe the Nursing Quantitative, Nurses Professional Nurses (n = 599) (y) Aims and objectives clearly described
United States Professional Values Scale Values Scale questionnaire -Education: including Baccalaureate (y) Study design adequately described
(NPVS) and its and Masters0 students and practicing (y) Research methods appropriate
development. nurses (y) Explicit theoretical framework
(y) Limitations presented
(y) Implications discussed
 M. Kangasniemi et al.
looked at the relationship between professional ethics and clinical competency (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 studies focused on the values of professional ethics in nursing (Weis & Schank 2000, Altun 2002, Rassin
2008, Kangasniemi et al. 2010). Three of the 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 analysis revealed five categories relating to profes- sional ethics: the aims, values and professional ethics of reg- ulation,
the role that codes play in professional ethics 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 professional rules 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).
Professional ethics in nursing includes the description of professional responsibilities and duties that support and
maintain the societal purpose of 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 cause avoidable harm to the patient (Johnstone 1989).
The relationship between professional ethics and clinical competence has been recognized (Chadwick & Thompson
2000, Weis & Schank 2000, Liaschenko & Peter 2004, Dobrowolska et al. 2007, Memarian et al. 2007, Vanaki & Memarian
2009). Professional ethics, in terms of account- ability and responsibility, influence clinical competence (Memarian et al. 2007,
Vanaki & Memarian 2009) and result in nurses observing rules, regulations and patient rights (Memarian et al. 2007).
They also require continual
learning (Vanaki & Memarian 2009).

Values in professional ethics

Professional ethics is based on professional (Chadwick & Thompson 2000, Weis & Schank 2000, Liaschenko & Peter
2004, Dobrowolska et al. 2007, Memarian et al.
2007, Rassin 2008) and personal values (Rassin 2008). Professional nursing values are human dignity, equality (Altun 2002,
Rassin 2008), preventing suffering (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 achieve the goals of the profession (Dobrowolska et al.
2007, Kangasniemi et al. 2010). Nurses have professional duties (Chadwick & Thompson 2000, Weis & Schank
2000, Liaschenko & Peter 2004, Dobrowolska et al. 2007, Memarian et al. 2007) and obligations (Liaschenko & Peter
2004) towards the patient, the nursing profession, their colleagues, other health professionals and society (Liaschenko & Peter
2004, Verpeet et al. 2003). Nurses’ professional rights (Dobrowolska et al. 2007, Kangasniemi et al. 2010) are based on
legislation and professional values, and so-called earned rights based on particular education or experience
(Kangasniemi et al. 2010). Nurses have the professional right to be respected by society, act as an advocate for patients
and refuse to take part in-patient care if it is against their own values (Chadwick
& Thompson 2000, Weis & Schank 2000, Liaschenko & Peter 2004, Dobrowolska et al. 2007, Memarian et al.
2007, Kangasniemi et al. 2010).
Professional ethics is also related to an individual’s per- sonal experience of values (Rassin 2008) and is influenced by
many factors, including individual issues, 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

Professional ethics 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). General legislation defines the aim of the
profession on a national and societal level (Kan- gasniemi et al. 2010), but there are also laws focused on nursing and health
care (Verpeet et al. 2003).
 In many countries, national or international advisory documents help to inform policies, provide a professional identity and
regulate the nursing profession. Professional
ethics is also covered in nursing ethics text-books, which

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provide guidance for ethical nursing practice and profes- sional identity. (Verpeet et al. 2003.)
Professional ethics is formulated and condensed in profes- sional codes (Verpeet et al. 2003), that focus on individual
professions. These codes combine the contents of 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
(Verpeet et 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 environment where pro- fessional ethics can be maintained and fulfilled (Liaschenko
& Peter 2004, Verpeet et al. 2003, Vanaki & Memarian
2009). Variations in values emerge when it comes to differ- ent generations of nurses, their position in the workplace and
the type of unit they work in. Culture, education, age, length of work experience, professional position and field of
expertise also affects nurses’ values (Rassin 2008). Pro- fessional ethics has to be taught in an educational setting, not just
as ethical theories and how they should be applied (Johnstone 1989), together with contextual issues relating to the
surrounding culture, education and professional envi- ronment (Rassin 2008).

Discussion
Based on our results, professional ethics in nursing is a well-known, but relatively unstudied, area of nursing sci- ence.
Professional ethics is based on professional and per- sonal commitment, including rights, duties and responsibilities. They
lay down the values and principles that regulate the conduct of professionals in relation to their patients and clients,
colleagues, other professions and organization. The aim of professional ethics is to protect patients and give nurses guidance
they need to contribute to the development of a healthy society. Professional ethics in nursing is often formulated in codes
of ethics. They are related not only to international nursing values but 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 topical scientific questions. The first question is what is the purpose of pro-
fessional ethics in nursing? According to our results, this
purpose can be divided into the internal and external needs
of the profession. Internally, the main role of professional ethics is to define ethical ideology 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 professional rights (Dobrowolska et al.
2007, Kangasniemi et al. 2010).
The external requirement for professional ethics must be recognized (Liaschenko & Peter 2004, Kasher 2005). The main
purpose of this is to provide a ‘trade description’ for general public, which describes nurses’ rights, duties and 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 professional ethics 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 professional ethics can be seen throughout its 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- ments have varied from the religious (Nightingale 1952, Bradshaw
2013) to the biological (Aikens 1916/1943) and society’s expectations of the nurses’ role (Radsma 1994, Helmstadter 2009).
However, the key focus has been on nurses’ choices and characteristics (Freitas 1990).
The external expectations of the nursing profession are topical and obvious and these include pressure from the
ethically and legally improved position of patients and increases organizational and economical pressures. The role of the
nurse is also changing, with the move towards advanced nursing practices and 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 (Kangasniemi et al. 2010) and those between professions and the ethical responsibilities of the profession need
to be clarified.
It is noteworthy that nurses’ should remain constant, even through their responsibilities in society may change and
their values and principles may be affected by changes in individualization or globalization. Being aware of the content of
professional ethics gives us an opportunity to dif- ferentiate the stable elements from the changing ones, so that nurses can
put the constant elements into practice. For example, under the current economical pressures, nurses’ are required to
prioritize care in practice (Hunter 2007,
Langeland & Sørlie 2011), but they still have to conform

© 2015 John Wiley & Sons Ltd 9

M. Kangasniemi et al.
to the professional ethics that require them to take care of patients and protect their human dignity. Thus, the aware- ness
of the nature of values of professional ethics 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 professional eth- ics?
The nursing profession is shaped by professional ethics that is based on current and shared international values (International
Council of Nurses (ICN) 2012). Those values are reflected in ethical codes at national level, such as in South Africa
(South African Nursing Council (SANC)
2005), Canada (Canadian Nurses Association (CNA) 2008) and Great Britain (Nursing & Midwifery Council 2008), that
represent variations between countries and influence professional ethics. These include the description of the degree of
autonomy (Tadd et al. 2006) and the weight of such values as responsibility and beneficence. In addition, professional ethics is
also affected by changes with nursing, such as increased multiculturalism (Xiao et al. 2013), val- ues held by different
generations (Sherman 2006) and the variation in nursing philosophies around the world. Ethics can also be affected by an
individual nurse commitment to their career (Wang et al. 2012), which could threaten their adherence to professional ethics.
However, these all provide opportunities to highlight the importance of shared values beyond time-related challenges. The
development of profes- sional ethics in nursing could help to create and maintain the bridge between representatives of the
same profession, both locally and globally.
The inter-professional approach to professional ethics needs to be highlighted, in relation to the changes in profes- sion
and health care (Engel & Prentice 2013, Ewashen et al. 2013). Inter-professional working is required to achieve
high-quality patient care, but the risk is that barri- ers to multi-professional collaboration in ethical issues might be
ignored (Poikkeus et al. 2014). Work ethics have been presented as a way of focusing on the shared multi- professional goal,
instead of individual professional inter- ests. It could help to avoid hierarchical comparison between tasks and professions
(Liaschenko & Peter 2004, Thylefors
2012). Joint working by different professions is very topi- cal, as health problems have been seen as multi-dimensional in
western countries and globally. This means that profes- sionals need to take a wider view about ethics in health care and
social services.
The third question is how well do nurses understand their own role and responsibilities in relation to their profes- sional
ethics? Traditionally, nurses have taken responsibility
for acquiring professional ethics during education and
clinical practice and following these ethics throughout their work (Verpeet et al. 2003, Liaschenko & Peter 2004, Do-
browolska et al. 2007). In addition, nurses have reported that they feel morally distressed, due to major challenges in current
healthcare 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 requires more scientific discussion and nursing science studies, together
with educational support for nurses in everyday practice.
As a result, professional ethics are not static, but are influenced by several changes during any given era (Lias- chenko
& Peter 2004, Meulenbergs et al. 2004, Milton
2007, Begley 2010, Kangasniemi & Haho 2012). Nurses’ scientific, evidence-based knowledge influences not only their
work but it is also affected by changes in society and global sense (Viens 1989, Liaschenko & Peter 2004, Meu- lenbergs et
al. 2004). The nursing profession is pressured to adapt to external expectations and the content of profes- sional ethics
needs to 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’s wishes have to be taken into account, while ensuring
that the profession’s high 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 number of previous primary studies on profes- sional
ethics in nursing, as we only identified 14 studies? Although it is well-established concept, research on the con- text of professional
ethics is missing (Kasher 2005). Under- standably, the most frequently used methodological approach has been
theoretical examination. There is an obvious need for increased and advanced knowledge of pro- fessional ethics, in the field
of ethics and empirical knowl- edge is needed. However, the current requirement for producing evidence-based knowledge
about effectiveness is often inappropriate. More conceptual and philosophical research is needed to update professional ethics
and gain and deeper understanding of the patient (Dobrowolska et al. 2007, Kangasniemi et al. 2010, Brecher 2014).
In addition, awareness of professional ethics is reported to be inadequate in practice (Schank et al. 1996, Liaschenko &
 Peter 2004, Gonzalez-de Paz et al. 2012), implying that there is a need for improved empirical research and
education. In future, literature reviews that cover the basic
values of nursing and other healthcare professions, and

10 © 2015 John Wiley & Sons Ltd

JAN: REVIEW PAPER Professional ethics in nursing
inter-professional ethics, 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 methodological rigour and evaluation
of theoretical studies in 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 methodological
rigour of search strate- gies was improved by consulting an informatician and the studies were selected with the
collaboration 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 several decades could imply that there
was not sufficient consideration given to their quality. Scientific writing and academic journal requirements have changed
radically during that period. Early articles were less structured, research questions were fragmented and methodology was
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, ethical questions are contextual by nature and synthesis of
previous knowledge requires rec- ognising earlier publications. However, this historical sensi- tivity is not taken into account
by quality criteria, as they tend to focus on their current requirements.
In this review, quality criteria with general methodologi- 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. Professional ethics create a basis for
the nursing profession. It comprises the values, rights, duties and responsibilities of nurses 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 development of healthy society. Professional ethics 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 ethical decision-making in an environment of continuously changing
health 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 grant from 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 final version and meet at least one of the following criteria [recommended by the IC- MJE
(http://www.icmje.org/ethical_1author.html)]:
 • substantial contributions to conception and design, acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important intellectual content.

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