Professional ethics in nursing: An integrative review

Abstract

To conduct an integrative review and synthesize current primary studies of professional ethics in nursing.
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.
Systematic literature searches from 1948-February 2013, using the CINAHL, PubMed and Scopus electronic databases to look at previously published peer-reviewed studies.
A modified version of Cooper's five-stage integrative review was used to review and synthesize current knowledge.
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.
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.
© 2015 John Wiley & Sons Ltd.

Full text

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. & KORHONEN 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
©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
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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 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 1 Flow 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
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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 Masters0students 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
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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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M. Kangasniemi et al.

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
JAN: REVIEW PAPER Professional ethics in nursing
©2015 John Wiley & Sons Ltd 9

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
M. Kangasniemi et al.
10 ©2015 John Wiley & Sons Ltd

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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