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: [email protected] Mari Kangasniemi PhD RN Adjunct Professor/University Lecturer Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Piiku Pakkanen BNSc RN MNSc-Student Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Anne Korhonen PhD RN Specialist in Clinical Nursing Science Department of Pediatrics and Adolescence, Oulu University Hospital, Finland
K A N G A S N I E M I M . , P A K K A N E N P . & K O R H O N E N A . ( 2 0 1 5 ) Professional ethics in nursing: an integrative review. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.12619
Abstract Aim. To conduct an integrative review and synthesize current primary studies of professional ethics in nursing. Background. Professional ethics is a familiar concept in nursing and provides an ethical code for nursing practice. However, little is known about how professional ethics has been defined and studied in nursing science. Design and data sources. Systematic literature searches from 1948–February 2013, using the CINAHL, PubMed and Scopus electronic databases to look at previously published peer-reviewed studies. Review method. A modified version of Cooper’s five-stage integrative review was used to review and synthesize current knowledge. Results. Fourteen papers were included in this research. According to our synthesis, professional ethics is described as an intra-professional approach to care ethics and professionals commit to it voluntarily. Professional ethics consist of values, duties, rights and responsibilities, regulated by national legislation and international agreements and detailed in professional codes. Professional ethics is well established in nursing, but is constantly changing due to internal and external factors affecting the profession. Conclusion. Despite the obvious importance of professional ethics, it has not been studied much in nursing science. Greater knowledge of professional ethics is needed to understand and support nurses’ moral decision-making and to respond to the challenges of current changes in health care and society. Keywords: ethics, integrative review, nurse roles, nursing, profession
Introduction Ethics have been internationally recognized as a fundamental 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 © 2015 John Wiley & Sons Ltd
about their collaboration with colleagues (Ulrich et al. 2010) and other professions (Engel & Prentice 2013, Ewashen et al. 2013). Several studies have highlighted ethical questions that have arisen as a result of the high moral distress 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 1
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 ethics in nursing.
What are the key findings? ● There has been very little research focused into professional 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 contribute 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 discussion 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 ethical 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 2
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, Carney 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 concerning 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 intraprofessional by nature and it is this enforcement of formal ethics that creates visibility and, therefore, confidence between professionals and, in particular, between professionals and the public (Abbott 1983). Professional ethics usually appear in formal codes, including references to corporate norms (Frankel 1989), obligations and perceptions of relationships 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), virtues (Begley 2010) or their etiquette and correct manner (Aikens 1916/1943, Johnstone 1987, Freitas 1990, Bradshaw 2000). In addition to individual behaviour, professional ethics currently focus on groups of professionals guided by shared ethical codes (Liaschenko & Peter 2004, Meulenbergs et al. 2004, Milton 2007, Begley 2010, Kangasniemi & Haho 2012, Brecher 2014). In this sense, professional ethics is linked to the organizational and institutional ethics guiding nurses’ everyday work (Thompson 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© 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.
to the professional ethics that require them to take care of patients and protect their human dignity. Thus, the awareness of the nature of values of professional ethics provides an opportunity to evaluate, influence and develop professional ethics in a conscious way. The second question is, what are the changes in the profession and in health care, that influence professional ethics? 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), values 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 professional 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 profession 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 barriers 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 multiprofessional goal, instead of individual professional interests. It could help to avoid hierarchical comparison between tasks and professions (Liaschenko & Peter 2004, Thylefors 2012). Joint working by different professions is very topical, as health problems have been seen as multi-dimensional in western countries and globally. This means that professionals 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 professional ethics? Traditionally, nurses have taken responsibility for acquiring professional ethics during education and 10
clinical practice and following these ethics throughout their work (Verpeet et al. 2003, Liaschenko & Peter 2004, Dobrowolska 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 forcing, professional ethics as part of their role and responsibilities. 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 (Liaschenko & 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, Meulenbergs et al. 2004). The nursing profession is pressured to adapt to external expectations and the content of professional ethics needs to be frequently evaluated. However, there needs to be a balance between the core and static values and principles and those that are changing. For example, 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 professional ethics. The fourth question is why we found such an unexpectedly low number of previous primary studies on professional ethics in nursing, as we only identified 14 studies? Although it is well-established concept, research on the context of professional ethics is missing (Kasher 2005). Understandably, the most frequently used methodological approach has been theoretical examination. There is an obvious need for increased and advanced knowledge of professional ethics, in the field of ethics and empirical knowledge 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 © 2015 John Wiley & Sons Ltd
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): 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)
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
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 4
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 © 2015 John Wiley & Sons Ltd
Purpose 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.
Author(s) year, Country
Altun (2002), Turkey
Chadwick and Thompson (2000), United Kingdom
Crout et al. (2005), Australia 2005
Dobrowolska et al. (2007), Poland
Fowler (1993), Canada
Table 1 The description of 14 eligible studies.
© 2015 John Wiley & Sons Ltd Theoretical, literature
Theoretical, comparative study and analysis, literature
Qualitative, individual interviews (an unstructured, in-depth interview technique), Colaizzimethod 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 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
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
Quantitative questionnaire (developed based on literature and the Maslach Burnout Inventory scale)
Theoretical discussion, literature
Sample size and characteristics
Design and tools
(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
(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
(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
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
JAN: REVIEW PAPER Professional ethics in nursing
5
6 To discuss limitations of the concept of professional ethics and the contribution of ethics of work. To identify the factors influencing clinical competency in nursing.
Liaschenko and Peter (2004), United States
Memarian et al. (2007), Iran
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%)
Literature, 41 references, published between 1900–2003
To examine and structure nurses’ rights.
Kangasniemi et al. (2010), Finland
Theoretical discussion, literature
Literature, 16 references, published between 1953–1989
Theoretical discussion, literature
Examine the failure of professional ethics to prevent patients’ rights’ abuses in health care contexts.
Johnstone (1989), Australia
Literature, 35 references, published between 1998–2009
Literature, 49 references, published between 1957–1986
Theoretical discussion, philosophical analysis, literature
To focus on the phenomenon of professional ethics.
Johnstone (1987), Australia
Theoretical discussion, literature
Sample size and characteristics
Design and tools
Purpose
Author(s) year, Country
Table 1 (Continued).
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
M. Kangasniemi et al.
© 2015 John Wiley & Sons Ltd
Purpose Measure professional and personal values among nurses.
To highlight nurse’s clinical competency and to explain the process which clinical competency was acquired.
To prove and illustrate legal and professional documents reflection of professional ethics.
To describe the Nursing Professional Values Scale (NPVS) and its development.
Author(s) year, Country
Rassin (2008), Israel
Vanaki and Memarian (2009), Iran
Verpeet et al. (2003), Belgium
Weis and Schank (2000), United States
Table 1 (Continued).
© 2015 John Wiley & Sons Ltd 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%) 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%) Literature, 30 references, published between 1980–2002
Nurses (n = 599) -Education: including Baccalaureate and Masters0 students and practicing nurses
Quantitative, two questionnaires (The Rokeach Values Survey and questionnaire relied on values expressed in the Israeli nurses0 code of ethics 1996–2004
Quantitative, Nurses Professional Values Scale questionnaire
Theoretical discussion, content analysis, literature
Qualitative, grounded theory, individual semi-structured openended interviews
Sample size and characteristics
Design and tools
Aims and objectives clearly described Study design adequately described Research methods appropriate Explicit theoretical framework Limitations presented Implications discussed
(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 (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
(y) (y) (y) (y) (y) (y)
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
JAN: REVIEW PAPER Professional ethics in nursing
7
M. Kangasniemi et al.
looked at the relationship between professional ethics and clinical competency (Memarian et al. 2007, Vanaki & Memarian 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 & Memarian 2009), two in the USA (Weis & Schank 2000, Liaschenko & 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 professional ethics: the aims, values and professional ethics of regulation, 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 commitment and accountability in the nurse’s role. They involve self respect and self-evaluation and help to form nurses’ respective 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 & Memarian 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 accountability 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). 8
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 personal 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 experience, a nurse’s position in the unit, the working environment (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 legislation, 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 (Kangasniemi 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 © 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER
provide guidance for ethical nursing practice and professional identity. (Verpeet et al. 2003.) Professional ethics is formulated and condensed in professional codes (Verpeet et al. 2003), that focus on individual professions. These codes combine the contents of professional 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 professional ethics and the way that is implemented (Rassin 2008), but society also creates an environment where professional ethics can be maintained and fulfilled (Liaschenko & Peter 2004, Verpeet et al. 2003, Vanaki & Memarian 2009). Variations in values emerge when it comes to different 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). Professional 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 environment (Rassin 2008).
Discussion Based on our results, professional ethics in nursing is a well-known, but relatively unstudied, area of nursing science. Professional ethics is based on professional and personal 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 societal context. In this discussion, we will focus on four topical scientific questions. The first question is what is the purpose of professional ethics in nursing? According to our results, this purpose can be divided into the internal and external needs © 2015 John Wiley & Sons Ltd
Professional ethics in nursing
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 (Chadwick & Thompson 2000, Liaschenko & Peter 2004, Verpeet et al. 2003, Dobrowolska et al. 2007, Memarian et al. 2007, Rassin 2008, Vanaki & Memarian 2009) and combining 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 treated 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, Kangasniemi 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 requirements 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 differentiate 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 9
M. Kangasniemi et al.
to the professional ethics that require them to take care of patients and protect their human dignity. Thus, the awareness of the nature of values of professional ethics provides an opportunity to evaluate, influence and develop professional ethics in a conscious way. The second question is, what are the changes in the profession and in health care, that influence professional ethics? 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), values 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 professional 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 profession 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 barriers 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 multiprofessional goal, instead of individual professional interests. It could help to avoid hierarchical comparison between tasks and professions (Liaschenko & Peter 2004, Thylefors 2012). Joint working by different professions is very topical, as health problems have been seen as multi-dimensional in western countries and globally. This means that professionals 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 professional ethics? Traditionally, nurses have taken responsibility for acquiring professional ethics during education and 10
clinical practice and following these ethics throughout their work (Verpeet et al. 2003, Liaschenko & Peter 2004, Dobrowolska 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 forcing, professional ethics as part of their role and responsibilities. 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 (Liaschenko & 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, Meulenbergs et al. 2004). The nursing profession is pressured to adapt to external expectations and the content of professional ethics needs to be frequently evaluated. However, there needs to be a balance between the core and static values and principles and those that are changing. For example, 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 professional ethics. The fourth question is why we found such an unexpectedly low number of previous primary studies on professional ethics in nursing, as we only identified 14 studies? Although it is well-established concept, research on the context of professional ethics is missing (Kasher 2005). Understandably, the most frequently used methodological approach has been theoretical examination. There is an obvious need for increased and advanced knowledge of professional ethics, in the field of ethics and empirical knowledge 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 © 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER
inter-professional ethics, are needed to deepen our understanding 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 evaluate quality in articles from different decades. It is particularly 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, electronic search on databases are effective, but they may only identify about half of the eligible studies, because of inconsistent 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 strategies 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 publication 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 recognising earlier publications. However, this historical sensitivity is not taken into account by quality criteria, as they tend to focus on their current requirements. In this review, quality criteria with general methodological aspects were used, which mainly aimed to describe and evaluate selected articles. For this reason, all the studies © 2015 John Wiley & Sons Ltd
Professional ethics in nursing
featured in this review were selected because of their contribution to the knowledge of the professional ethics.
Conclusions Professional ethics in nursing is rarely studied and the problems 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 organization. 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 profession, 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 supporting 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 contribute 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 ICMJE (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.
References Abbott A. (1983) Professional ethics. American Journal of Sociology 88, 855–885. Aikens C.A. (1916/1943) Studies in Ethics for Nurses, 5th edn. W.B. Saunders Company, Philadelphia, PA. 11
M. Kangasniemi et al. Altun I. (2002) Burnout and nurses0 personal and professional values. Nursing Ethics 9, 269–278. Beauchamp T.L. & Childress J.F. (2009) Principles of Biomedical Ethics, 6th edn. Oxford University Press, New York. Begley A.M. (2010) On being a good nurse: reflections on the past and preparing for the future. International Journal of Nursing Practice 16, 525–532. Bertoluzzi G. & Palese A. (2010) The Italian economic crisis and its impacts on nursing services and education: hard and challenging times. Journal of Nursing Management 18, 515–519. Booth A. (2006) ‘Brimful of STARLITE’: toward standards for reporting literature searches. Journal of Medical Library Association 94, 421–429. Bowling A. (2002) Research Methods in Health: Investigating Health and Health Services, 2nd edn. Open University Press, Buckingham. Bradshaw A. (2000) Competence and British nursing: a view from history. Journal of Clinical Nursing 9, 321–329. Bradshaw A.E. (2013) Gadamer’s two horizons: listening to the voices in nursing history. Nursing Inquiry 20, 82–92. Brecher B. (2014) What is professional ethics? Nursing Ethics 21, 239–244. Canadian Nurses Association (CNA) (2008) Code of ethics for registered nurses. Retrieved from https://cna-aiic.ca/~/media/cna/ files/en/codeofethics.pdf on 14 September 2014. Carney M. (2010) Challenges in health care delivery in an economic downturn, in the republic of Ireland. Journal of Nursing Management 18, 509–514. Chadwick R. & Thompson A. (2000) Professional ethics and labor disputes: medicine and nursing in the United Kingdom. Cambridge Quarterly of Healthcare Ethics 9, 483–498. Cooper H.M. (1982) Scientific guidelines for conducting integrative research reviews. Review of Educational Research 52, 291–302. Cooper HM (1984) The Integrative Research Review: A Systematic Approach. Applied Social Research Methods Series, Volume 2. Sage Publications, California. Crout L.A., Chang E. & Cioffi J. (2005) Why do registered nurses work when ill? Journal of Advanced Nursing 35, 23–28. Dekeyser Ganz T. & Berkovitz K. (2012) Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nurses 68, 1516–1525. Dobrowolska B., Wronska I., Wiestaw F. & Wysonkinski M. (2007) Moral obligations of nurses based on the ICN, UK, Irish and Polish codes of ethics for nurses. Nursing Ethics 14, 171–180. Engel J. & Prentice D. (2013) The ethics of interprofessional collaboration. Nursing Ethics 20, 426–435. Evans D. & Kowanko I. (2000) Literature reviews: evolution of research methodology. Australian Journal of Advanced Nursing 18, 33–38. Ewashen C., McInnis-Perry G. & Murphy N. (2013) Interprofessional collaboration-in-practice: the contested place for ethics. Nursing Ethics 20, 325–335. Fowler M.D. (1993) Professional associations, ethics and society. Oncology Nursing Forum 20, 13–19. Frankel M.S. (1989) Professional codes: why, how and with what impact? Journal of Business Ethics 8, 109–115. Freitas L. (1990) Historical roots and future perspectives related to nursing ethics. Journal of Professional Nursing 6, 197–205.
12
Gazarian P.K. (2013) Use of the critical decision method in nursing research. An integrative review. Advances in Nursing Science 36, 106–117. Goethals S., Gastmans C. & Dierckx de Casterle B. (2010) Nurses’ ethical reasoning and behavior: a literature review. International Journal of Nursing Studies 47, 635–650. Gonza´lez-de Paz L., Kostov B., Siso´-Almirall A. & ZabaleguiYa´rnoz A. (2012) A Rasch analysis of nurses’ ethical sensitivity to the norms of the code of conduct. Journal of Clinical Nursing 19(20), 2747–2760. Graneheim U.H. & Lundman B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Helmstadter C. (2009) Shifting boundaries: religion, medicine, nursing and domestic service in mid-nineteen-century Britain. Nursing Inquiry 16, 133–134. Hunter D. (2007) Am I my brother’s gatekeeper? Professional ethics and prioritisation in healthcare. Journal of Medical Ethics 33, 522–526. International Council of Nurses (ICN) (2012) Code of ethics for nurses. Retrieved from http://www.icn.ch/images/stories/ documents/about/icncode_english.pdf on 14 September 2014. Jirwe M., Gerrish K., Keeney S. & Emami A. (2009) Identifying the core components of cultural competence: findings from a Delphi study. Journal of Clinical Nursing 18, 2622–2634. Johnstone M.J. (1987) Professional ethics in nursing: a philosophical analysis. Australian Journal of Advanced Nursing 4, 12–21. Johnstone M.J. (1989) Professional ethics and patients0 rights0 : past realities, future imperatives. Nursing Forum 24, 29–34. Kangasniemi M. & Haho A. (2012) Human love – inner essence of nursing ethics according to Estrid Rodhe. A study using the approach of history of ideas. Scandinavian Journal of Nursing Sciences 26, 803–810. Kangasniemi M., Viital€ahde K. & Porkka S. (2010) A theoretical examination of the rights of nurses. Nursing Ethics 17, 628–635. Kasher A. (2005) Professional ethics and collective professional autonomy: a conceptual analysis. Ethical Perspectives: Journal of the European Ethics Network 11, 67–98. Kristiansen L., Hellzen O. & Asplund K. (2010) Left alone – Swedish nurses’ and mental health workers’ experiences of being care providers in a social psychiatric dwelling context in the post-health-care-restructuring era. A focus-group interview study. Scandinavian Journal of Caring Sciences 24, 427–435. Langeland K. & Sørlie V. (2011) Ethical challenges in nursing emergency practice. Journal of Clinical Nursing 20, 2064–2070. Liaschenko J. & Peter E. (2004) Nursing ethics and conceptualization of nursing: profession, practice and work. Journal of Advanced Nursing 46, 488–495. McCurry M.K., Revell S.M. & Roy S.C. (2009) Knowledge for the good of the individual and society: linking philosophy, disciplinary goals, theory and practice. Nursing Philosophy 11, 42–52. Memarian R., Salsali M., Vanaki Z., Ahmadi F. & Hajizadeh E. (2007) Professional ethics as an important factor in clinical competence in nursing. Nursing Ethics 14, 203–214. Meulenbergs T., Verpeet E., Schotsmans P. & Gastmans C. (2004) Professional codes in changing nursing context: literature review. Journal of Advanced Nursing 46, 331–336.
© 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER Milton C.L. (2007) Professional values in nursing ethics: essential or optional in the global universe? Nursing Science Quarterly 20, 212–215. Nightingale F. (1952) Notes on Nursing. (First published in 1859). Duckworth, London. Nursing & Midwifery Council (2008) The Code: Standards, Conduct, Performance Ethics for Nurses and Midwives. Retrieved from http://www.nmc-uk.org/Documents/Standards/ nmcTheCodeStandardsofConductPerformanceAndEthicsForNurses AndMidwives_LargePrintVersion.PDF on 14 September 2014. Oh Y. & Gastmans C. (2013) Moral distress experienced by nurses: a quantitative literature review. Nursing Ethics. doi:10.1177/0969733013502803. Palese A., Vianelli C., De Maino R. & Bortoluzzi G. (2012) Measures of cost containment, impact of the economical crisis and the effects perceived in nursing daily practice: an Italian crossover study. Nursing Economics 30, 86–93. Pavlish C., Brown-Saltzman K., Jakel P. & Rounkle A.-M. (2012) Nurses’ responses to ethical challenges in oncology practice: an ethnographic study. Clinical Journal of Oncology Nursing 16, 592–600. Petticrew M. (2001) Systematic reviews from astronomy to zoology: myths and misconceptions. British Medical Journal 322, 98–101. Poikkeus T., Numminen O., Suhonen R. & Leino-Kilpi H. (2014) A mixed-method systematic review: support for ethical competence of nurses. Journal of Advanced Nursing 70, 256– 271. Radsma J. (1994) Caring and nursing: a dilemma. Journal of Advanced Nursing 20, 444–449. Rassin M. (2008) Nurses0 professional and personal values. Nursing Ethics 15, 614–630. Schank M.J., Weis D. & Ancona J. (1996) Reflecting professional values in the philosophy of nursing. Journal of Nursing Administration 26, 55–60. Sellman D. (1997) The virtues in moral education of nurses: Florence Nightingale revisited. Nursing Ethics 4, 3–11. Sherman R.O. (2006) Leading a multigenerational nursing workforce: issues, challenges and strategies. Online Journal of Issues in Nursing 11, 13. South African Nursing Council (SANC) (2005) Code of ethics for nursing practitioners in South-Africa. Retrieved from http:// www.sanc.co.za/pdf/SANC%20Code%20of%20Ethics%20for% 20Nursing%20in%20South%20Africa.pdf on 14 September 2014.
© 2015 John Wiley & Sons Ltd
Professional ethics in nursing Tadd W., Clarke A., Lloyd L., Leino-Kilpi H., Strandell C., Lemonidou C., Petsios K., Sala R., Barazzetti G., Radaelli S., Zalewski Z., Bialecka A., van der Arend A. & Heymans R. (2006) Value of nurses’ codes: European nurses’ views. Nursing Ethics 13, 376–393. Thompson D.F. (1999) The institutional turn in professional ethics. Ethics Behavior 9, 109–118. Thylefors I. (2012) All professionals are equal but some professionals are more equal than other? Dominance, status and efficiency in Swedish interprofessional teams. Scandinavian Journal of Caring Sciences 26, 505–512. Ulrich C.M., Taylor C., Soeken K., O’Donnell P., Farrar A., Danis M. & Grady C. (2010) Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing 66, 2510– 2519. Vanaki Z. & Memarian R. (2009) Professional ethics: beyond the clinical competency. Journal of Professional Nursing 25, 285– 291. Verpeet E., Meulenbergs T. & Gastmans C. (2003) Professional values and norms for nurses in Belgium. Nursing Ethics 10, 654– 665. Viens D.C. (1989) A history of nursing code of ethics. Nursing Outlook 37, 45–49. Wang L., Tao H., Ellenbecker C.H. & Liu X. (2012) Job satisfaction, occupational commitment and intent to stay among Chinese nurses: a cross-sectional questionnaire survey. Journal of Advanced Nursing 68, 539–549. Weis D. & Schank M.J. (2000) An instrument to measure professional values. Journal of Nursing Scholarship 32, 201–204. Whittemore J.E. & Knalf K. (2005) The integrative review: updated methodology. Journal of Advanced Nursing 52, 546–553. Winterstein T.-B. (2012) Nurses’ experiences of the encounter with elder neglect. Journal of Nursing Scholarship 44, 55–62. Wocial L.D. & Weaver M.T. (2013) Development a psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer. Journal of Advanced Nursing 69, 167– 174. World Health Organization (2011) Strategic directions for strengthening nursing and midwifery services. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.1_eng. pdf?ua=1 on 20 May 2014. Xiao L.D., Wills E. & Jeffers L. (2013) Factors affecting the integration of immigrant nurses into the nursing workforce: a double hermeneutic study. International Journal of Nursing Studies 51, 640–653.
13
M. Kangasniemi et al.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Journal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access).
• • • •
14
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan. Positive publishing experience: rapid double-blind peer review with constructive feedback. Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication. Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).
© 2015 John Wiley & Sons Ltd
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: [email protected] Mari Kangasniemi PhD RN Adjunct Professor/University Lecturer Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Piiku Pakkanen BNSc RN MNSc-Student Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Anne Korhonen PhD RN Specialist in Clinical Nursing Science Department of Pediatrics and Adolescence, Oulu University Hospital, Finland
K A N G A S N I E M I M . , P A K K A N E N P . & K O R H O N E N A . ( 2 0 1 5 ) Professional ethics in nursing: an integrative review. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.12619
Abstract Aim. To conduct an integrative review and synthesize current primary studies of professional ethics in nursing. Background. Professional ethics is a familiar concept in nursing and provides an ethical code for nursing practice. However, little is known about how professional ethics has been defined and studied in nursing science. Design and data sources. Systematic literature searches from 1948–February 2013, using the CINAHL, PubMed and Scopus electronic databases to look at previously published peer-reviewed studies. Review method. A modified version of Cooper’s five-stage integrative review was used to review and synthesize current knowledge. Results. Fourteen papers were included in this research. According to our synthesis, professional ethics is described as an intra-professional approach to care ethics and professionals commit to it voluntarily. Professional ethics consist of values, duties, rights and responsibilities, regulated by national legislation and international agreements and detailed in professional codes. Professional ethics is well established in nursing, but is constantly changing due to internal and external factors affecting the profession. Conclusion. Despite the obvious importance of professional ethics, it has not been studied much in nursing science. Greater knowledge of professional ethics is needed to understand and support nurses’ moral decision-making and to respond to the challenges of current changes in health care and society. Keywords: ethics, integrative review, nurse roles, nursing, profession
Introduction Ethics have been internationally recognized as a fundamental 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 © 2015 John Wiley & Sons Ltd
about their collaboration with colleagues (Ulrich et al. 2010) and other professions (Engel & Prentice 2013, Ewashen et al. 2013). Several studies have highlighted ethical questions that have arisen as a result of the high moral distress 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 1
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 ethics in nursing.
What are the key findings? ● There has been very little research focused into professional 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 contribute 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 discussion 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 ethical 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 2
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, Carney 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 concerning 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 intraprofessional by nature and it is this enforcement of formal ethics that creates visibility and, therefore, confidence between professionals and, in particular, between professionals and the public (Abbott 1983). Professional ethics usually appear in formal codes, including references to corporate norms (Frankel 1989), obligations and perceptions of relationships 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), virtues (Begley 2010) or their etiquette and correct manner (Aikens 1916/1943, Johnstone 1987, Freitas 1990, Bradshaw 2000). In addition to individual behaviour, professional ethics currently focus on groups of professionals guided by shared ethical codes (Liaschenko & Peter 2004, Meulenbergs et al. 2004, Milton 2007, Begley 2010, Kangasniemi & Haho 2012, Brecher 2014). In this sense, professional ethics is linked to the organizational and institutional ethics guiding nurses’ everyday work (Thompson 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© 2015 John Wiley & Sons Ltd
M. Kangasniemi et al.
to the professional ethics that require them to take care of patients and protect their human dignity. Thus, the awareness of the nature of values of professional ethics provides an opportunity to evaluate, influence and develop professional ethics in a conscious way. The second question is, what are the changes in the profession and in health care, that influence professional ethics? 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), values 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 professional 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 profession 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 barriers 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 multiprofessional goal, instead of individual professional interests. It could help to avoid hierarchical comparison between tasks and professions (Liaschenko & Peter 2004, Thylefors 2012). Joint working by different professions is very topical, as health problems have been seen as multi-dimensional in western countries and globally. This means that professionals 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 professional ethics? Traditionally, nurses have taken responsibility for acquiring professional ethics during education and 10
clinical practice and following these ethics throughout their work (Verpeet et al. 2003, Liaschenko & Peter 2004, Dobrowolska 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 forcing, professional ethics as part of their role and responsibilities. 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 (Liaschenko & 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, Meulenbergs et al. 2004). The nursing profession is pressured to adapt to external expectations and the content of professional ethics needs to be frequently evaluated. However, there needs to be a balance between the core and static values and principles and those that are changing. For example, 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 professional ethics. The fourth question is why we found such an unexpectedly low number of previous primary studies on professional ethics in nursing, as we only identified 14 studies? Although it is well-established concept, research on the context of professional ethics is missing (Kasher 2005). Understandably, the most frequently used methodological approach has been theoretical examination. There is an obvious need for increased and advanced knowledge of professional ethics, in the field of ethics and empirical knowledge 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 © 2015 John Wiley & Sons Ltd
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): 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)
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
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 4
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 © 2015 John Wiley & Sons Ltd
Purpose 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.
Author(s) year, Country
Altun (2002), Turkey
Chadwick and Thompson (2000), United Kingdom
Crout et al. (2005), Australia 2005
Dobrowolska et al. (2007), Poland
Fowler (1993), Canada
Table 1 The description of 14 eligible studies.
© 2015 John Wiley & Sons Ltd Theoretical, literature
Theoretical, comparative study and analysis, literature
Qualitative, individual interviews (an unstructured, in-depth interview technique), Colaizzimethod 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 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
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
Quantitative questionnaire (developed based on literature and the Maslach Burnout Inventory scale)
Theoretical discussion, literature
Sample size and characteristics
Design and tools
(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
(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
(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
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
JAN: REVIEW PAPER Professional ethics in nursing
5
6 To discuss limitations of the concept of professional ethics and the contribution of ethics of work. To identify the factors influencing clinical competency in nursing.
Liaschenko and Peter (2004), United States
Memarian et al. (2007), Iran
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%)
Literature, 41 references, published between 1900–2003
To examine and structure nurses’ rights.
Kangasniemi et al. (2010), Finland
Theoretical discussion, literature
Literature, 16 references, published between 1953–1989
Theoretical discussion, literature
Examine the failure of professional ethics to prevent patients’ rights’ abuses in health care contexts.
Johnstone (1989), Australia
Literature, 35 references, published between 1998–2009
Literature, 49 references, published between 1957–1986
Theoretical discussion, philosophical analysis, literature
To focus on the phenomenon of professional ethics.
Johnstone (1987), Australia
Theoretical discussion, literature
Sample size and characteristics
Design and tools
Purpose
Author(s) year, Country
Table 1 (Continued).
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
M. Kangasniemi et al.
© 2015 John Wiley & Sons Ltd
Purpose Measure professional and personal values among nurses.
To highlight nurse’s clinical competency and to explain the process which clinical competency was acquired.
To prove and illustrate legal and professional documents reflection of professional ethics.
To describe the Nursing Professional Values Scale (NPVS) and its development.
Author(s) year, Country
Rassin (2008), Israel
Vanaki and Memarian (2009), Iran
Verpeet et al. (2003), Belgium
Weis and Schank (2000), United States
Table 1 (Continued).
© 2015 John Wiley & Sons Ltd 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%) 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%) Literature, 30 references, published between 1980–2002
Nurses (n = 599) -Education: including Baccalaureate and Masters0 students and practicing nurses
Quantitative, two questionnaires (The Rokeach Values Survey and questionnaire relied on values expressed in the Israeli nurses0 code of ethics 1996–2004
Quantitative, Nurses Professional Values Scale questionnaire
Theoretical discussion, content analysis, literature
Qualitative, grounded theory, individual semi-structured openended interviews
Sample size and characteristics
Design and tools
Aims and objectives clearly described Study design adequately described Research methods appropriate Explicit theoretical framework Limitations presented Implications discussed
(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 (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
(y) (y) (y) (y) (y) (y)
(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
Quality appraisal criteria (scale: y = yes, p = poor, nr = not reported)
JAN: REVIEW PAPER Professional ethics in nursing
7
M. Kangasniemi et al.
looked at the relationship between professional ethics and clinical competency (Memarian et al. 2007, Vanaki & Memarian 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 & Memarian 2009), two in the USA (Weis & Schank 2000, Liaschenko & 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 professional ethics: the aims, values and professional ethics of regulation, 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 commitment and accountability in the nurse’s role. They involve self respect and self-evaluation and help to form nurses’ respective 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 & Memarian 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 accountability 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). 8
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 personal 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 experience, a nurse’s position in the unit, the working environment (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 legislation, 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 (Kangasniemi 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 © 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER
provide guidance for ethical nursing practice and professional identity. (Verpeet et al. 2003.) Professional ethics is formulated and condensed in professional codes (Verpeet et al. 2003), that focus on individual professions. These codes combine the contents of professional 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 professional ethics and the way that is implemented (Rassin 2008), but society also creates an environment where professional ethics can be maintained and fulfilled (Liaschenko & Peter 2004, Verpeet et al. 2003, Vanaki & Memarian 2009). Variations in values emerge when it comes to different 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). Professional 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 environment (Rassin 2008).
Discussion Based on our results, professional ethics in nursing is a well-known, but relatively unstudied, area of nursing science. Professional ethics is based on professional and personal 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 societal context. In this discussion, we will focus on four topical scientific questions. The first question is what is the purpose of professional ethics in nursing? According to our results, this purpose can be divided into the internal and external needs © 2015 John Wiley & Sons Ltd
Professional ethics in nursing
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 (Chadwick & Thompson 2000, Liaschenko & Peter 2004, Verpeet et al. 2003, Dobrowolska et al. 2007, Memarian et al. 2007, Rassin 2008, Vanaki & Memarian 2009) and combining 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 treated 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, Kangasniemi 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 requirements 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 differentiate 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 9
M. Kangasniemi et al.
to the professional ethics that require them to take care of patients and protect their human dignity. Thus, the awareness of the nature of values of professional ethics provides an opportunity to evaluate, influence and develop professional ethics in a conscious way. The second question is, what are the changes in the profession and in health care, that influence professional ethics? 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), values 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 professional 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 profession 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 barriers 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 multiprofessional goal, instead of individual professional interests. It could help to avoid hierarchical comparison between tasks and professions (Liaschenko & Peter 2004, Thylefors 2012). Joint working by different professions is very topical, as health problems have been seen as multi-dimensional in western countries and globally. This means that professionals 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 professional ethics? Traditionally, nurses have taken responsibility for acquiring professional ethics during education and 10
clinical practice and following these ethics throughout their work (Verpeet et al. 2003, Liaschenko & Peter 2004, Dobrowolska 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 forcing, professional ethics as part of their role and responsibilities. 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 (Liaschenko & 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, Meulenbergs et al. 2004). The nursing profession is pressured to adapt to external expectations and the content of professional ethics needs to be frequently evaluated. However, there needs to be a balance between the core and static values and principles and those that are changing. For example, 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 professional ethics. The fourth question is why we found such an unexpectedly low number of previous primary studies on professional ethics in nursing, as we only identified 14 studies? Although it is well-established concept, research on the context of professional ethics is missing (Kasher 2005). Understandably, the most frequently used methodological approach has been theoretical examination. There is an obvious need for increased and advanced knowledge of professional ethics, in the field of ethics and empirical knowledge 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 © 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER
inter-professional ethics, are needed to deepen our understanding 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 evaluate quality in articles from different decades. It is particularly 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, electronic search on databases are effective, but they may only identify about half of the eligible studies, because of inconsistent 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 strategies 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 publication 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 recognising earlier publications. However, this historical sensitivity is not taken into account by quality criteria, as they tend to focus on their current requirements. In this review, quality criteria with general methodological aspects were used, which mainly aimed to describe and evaluate selected articles. For this reason, all the studies © 2015 John Wiley & Sons Ltd
Professional ethics in nursing
featured in this review were selected because of their contribution to the knowledge of the professional ethics.
Conclusions Professional ethics in nursing is rarely studied and the problems 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 organization. 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 profession, 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 supporting 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 contribute 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 ICMJE (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.
References Abbott A. (1983) Professional ethics. American Journal of Sociology 88, 855–885. Aikens C.A. (1916/1943) Studies in Ethics for Nurses, 5th edn. W.B. Saunders Company, Philadelphia, PA. 11
M. Kangasniemi et al. Altun I. (2002) Burnout and nurses0 personal and professional values. Nursing Ethics 9, 269–278. Beauchamp T.L. & Childress J.F. (2009) Principles of Biomedical Ethics, 6th edn. Oxford University Press, New York. Begley A.M. (2010) On being a good nurse: reflections on the past and preparing for the future. International Journal of Nursing Practice 16, 525–532. Bertoluzzi G. & Palese A. (2010) The Italian economic crisis and its impacts on nursing services and education: hard and challenging times. Journal of Nursing Management 18, 515–519. Booth A. (2006) ‘Brimful of STARLITE’: toward standards for reporting literature searches. Journal of Medical Library Association 94, 421–429. Bowling A. (2002) Research Methods in Health: Investigating Health and Health Services, 2nd edn. Open University Press, Buckingham. Bradshaw A. (2000) Competence and British nursing: a view from history. Journal of Clinical Nursing 9, 321–329. Bradshaw A.E. (2013) Gadamer’s two horizons: listening to the voices in nursing history. Nursing Inquiry 20, 82–92. Brecher B. (2014) What is professional ethics? Nursing Ethics 21, 239–244. Canadian Nurses Association (CNA) (2008) Code of ethics for registered nurses. Retrieved from https://cna-aiic.ca/~/media/cna/ files/en/codeofethics.pdf on 14 September 2014. Carney M. (2010) Challenges in health care delivery in an economic downturn, in the republic of Ireland. Journal of Nursing Management 18, 509–514. Chadwick R. & Thompson A. (2000) Professional ethics and labor disputes: medicine and nursing in the United Kingdom. Cambridge Quarterly of Healthcare Ethics 9, 483–498. Cooper H.M. (1982) Scientific guidelines for conducting integrative research reviews. Review of Educational Research 52, 291–302. Cooper HM (1984) The Integrative Research Review: A Systematic Approach. Applied Social Research Methods Series, Volume 2. Sage Publications, California. Crout L.A., Chang E. & Cioffi J. (2005) Why do registered nurses work when ill? Journal of Advanced Nursing 35, 23–28. Dekeyser Ganz T. & Berkovitz K. (2012) Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nurses 68, 1516–1525. Dobrowolska B., Wronska I., Wiestaw F. & Wysonkinski M. (2007) Moral obligations of nurses based on the ICN, UK, Irish and Polish codes of ethics for nurses. Nursing Ethics 14, 171–180. Engel J. & Prentice D. (2013) The ethics of interprofessional collaboration. Nursing Ethics 20, 426–435. Evans D. & Kowanko I. (2000) Literature reviews: evolution of research methodology. Australian Journal of Advanced Nursing 18, 33–38. Ewashen C., McInnis-Perry G. & Murphy N. (2013) Interprofessional collaboration-in-practice: the contested place for ethics. Nursing Ethics 20, 325–335. Fowler M.D. (1993) Professional associations, ethics and society. Oncology Nursing Forum 20, 13–19. Frankel M.S. (1989) Professional codes: why, how and with what impact? Journal of Business Ethics 8, 109–115. Freitas L. (1990) Historical roots and future perspectives related to nursing ethics. Journal of Professional Nursing 6, 197–205.
12
Gazarian P.K. (2013) Use of the critical decision method in nursing research. An integrative review. Advances in Nursing Science 36, 106–117. Goethals S., Gastmans C. & Dierckx de Casterle B. (2010) Nurses’ ethical reasoning and behavior: a literature review. International Journal of Nursing Studies 47, 635–650. Gonza´lez-de Paz L., Kostov B., Siso´-Almirall A. & ZabaleguiYa´rnoz A. (2012) A Rasch analysis of nurses’ ethical sensitivity to the norms of the code of conduct. Journal of Clinical Nursing 19(20), 2747–2760. Graneheim U.H. & Lundman B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Helmstadter C. (2009) Shifting boundaries: religion, medicine, nursing and domestic service in mid-nineteen-century Britain. Nursing Inquiry 16, 133–134. Hunter D. (2007) Am I my brother’s gatekeeper? Professional ethics and prioritisation in healthcare. Journal of Medical Ethics 33, 522–526. International Council of Nurses (ICN) (2012) Code of ethics for nurses. Retrieved from http://www.icn.ch/images/stories/ documents/about/icncode_english.pdf on 14 September 2014. Jirwe M., Gerrish K., Keeney S. & Emami A. (2009) Identifying the core components of cultural competence: findings from a Delphi study. Journal of Clinical Nursing 18, 2622–2634. Johnstone M.J. (1987) Professional ethics in nursing: a philosophical analysis. Australian Journal of Advanced Nursing 4, 12–21. Johnstone M.J. (1989) Professional ethics and patients0 rights0 : past realities, future imperatives. Nursing Forum 24, 29–34. Kangasniemi M. & Haho A. (2012) Human love – inner essence of nursing ethics according to Estrid Rodhe. A study using the approach of history of ideas. Scandinavian Journal of Nursing Sciences 26, 803–810. Kangasniemi M., Viital€ahde K. & Porkka S. (2010) A theoretical examination of the rights of nurses. Nursing Ethics 17, 628–635. Kasher A. (2005) Professional ethics and collective professional autonomy: a conceptual analysis. Ethical Perspectives: Journal of the European Ethics Network 11, 67–98. Kristiansen L., Hellzen O. & Asplund K. (2010) Left alone – Swedish nurses’ and mental health workers’ experiences of being care providers in a social psychiatric dwelling context in the post-health-care-restructuring era. A focus-group interview study. Scandinavian Journal of Caring Sciences 24, 427–435. Langeland K. & Sørlie V. (2011) Ethical challenges in nursing emergency practice. Journal of Clinical Nursing 20, 2064–2070. Liaschenko J. & Peter E. (2004) Nursing ethics and conceptualization of nursing: profession, practice and work. Journal of Advanced Nursing 46, 488–495. McCurry M.K., Revell S.M. & Roy S.C. (2009) Knowledge for the good of the individual and society: linking philosophy, disciplinary goals, theory and practice. Nursing Philosophy 11, 42–52. Memarian R., Salsali M., Vanaki Z., Ahmadi F. & Hajizadeh E. (2007) Professional ethics as an important factor in clinical competence in nursing. Nursing Ethics 14, 203–214. Meulenbergs T., Verpeet E., Schotsmans P. & Gastmans C. (2004) Professional codes in changing nursing context: literature review. Journal of Advanced Nursing 46, 331–336.
© 2015 John Wiley & Sons Ltd
JAN: REVIEW PAPER Milton C.L. (2007) Professional values in nursing ethics: essential or optional in the global universe? Nursing Science Quarterly 20, 212–215. Nightingale F. (1952) Notes on Nursing. (First published in 1859). Duckworth, London. Nursing & Midwifery Council (2008) The Code: Standards, Conduct, Performance Ethics for Nurses and Midwives. Retrieved from http://www.nmc-uk.org/Documents/Standards/ nmcTheCodeStandardsofConductPerformanceAndEthicsForNurses AndMidwives_LargePrintVersion.PDF on 14 September 2014. Oh Y. & Gastmans C. (2013) Moral distress experienced by nurses: a quantitative literature review. Nursing Ethics. doi:10.1177/0969733013502803. Palese A., Vianelli C., De Maino R. & Bortoluzzi G. (2012) Measures of cost containment, impact of the economical crisis and the effects perceived in nursing daily practice: an Italian crossover study. Nursing Economics 30, 86–93. Pavlish C., Brown-Saltzman K., Jakel P. & Rounkle A.-M. (2012) Nurses’ responses to ethical challenges in oncology practice: an ethnographic study. Clinical Journal of Oncology Nursing 16, 592–600. Petticrew M. (2001) Systematic reviews from astronomy to zoology: myths and misconceptions. British Medical Journal 322, 98–101. Poikkeus T., Numminen O., Suhonen R. & Leino-Kilpi H. (2014) A mixed-method systematic review: support for ethical competence of nurses. Journal of Advanced Nursing 70, 256– 271. Radsma J. (1994) Caring and nursing: a dilemma. Journal of Advanced Nursing 20, 444–449. Rassin M. (2008) Nurses0 professional and personal values. Nursing Ethics 15, 614–630. Schank M.J., Weis D. & Ancona J. (1996) Reflecting professional values in the philosophy of nursing. Journal of Nursing Administration 26, 55–60. Sellman D. (1997) The virtues in moral education of nurses: Florence Nightingale revisited. Nursing Ethics 4, 3–11. Sherman R.O. (2006) Leading a multigenerational nursing workforce: issues, challenges and strategies. Online Journal of Issues in Nursing 11, 13. South African Nursing Council (SANC) (2005) Code of ethics for nursing practitioners in South-Africa. Retrieved from http:// www.sanc.co.za/pdf/SANC%20Code%20of%20Ethics%20for% 20Nursing%20in%20South%20Africa.pdf on 14 September 2014.
© 2015 John Wiley & Sons Ltd
Professional ethics in nursing Tadd W., Clarke A., Lloyd L., Leino-Kilpi H., Strandell C., Lemonidou C., Petsios K., Sala R., Barazzetti G., Radaelli S., Zalewski Z., Bialecka A., van der Arend A. & Heymans R. (2006) Value of nurses’ codes: European nurses’ views. Nursing Ethics 13, 376–393. Thompson D.F. (1999) The institutional turn in professional ethics. Ethics Behavior 9, 109–118. Thylefors I. (2012) All professionals are equal but some professionals are more equal than other? Dominance, status and efficiency in Swedish interprofessional teams. Scandinavian Journal of Caring Sciences 26, 505–512. Ulrich C.M., Taylor C., Soeken K., O’Donnell P., Farrar A., Danis M. & Grady C. (2010) Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing 66, 2510– 2519. Vanaki Z. & Memarian R. (2009) Professional ethics: beyond the clinical competency. Journal of Professional Nursing 25, 285– 291. Verpeet E., Meulenbergs T. & Gastmans C. (2003) Professional values and norms for nurses in Belgium. Nursing Ethics 10, 654– 665. Viens D.C. (1989) A history of nursing code of ethics. Nursing Outlook 37, 45–49. Wang L., Tao H., Ellenbecker C.H. & Liu X. (2012) Job satisfaction, occupational commitment and intent to stay among Chinese nurses: a cross-sectional questionnaire survey. Journal of Advanced Nursing 68, 539–549. Weis D. & Schank M.J. (2000) An instrument to measure professional values. Journal of Nursing Scholarship 32, 201–204. Whittemore J.E. & Knalf K. (2005) The integrative review: updated methodology. Journal of Advanced Nursing 52, 546–553. Winterstein T.-B. (2012) Nurses’ experiences of the encounter with elder neglect. Journal of Nursing Scholarship 44, 55–62. Wocial L.D. & Weaver M.T. (2013) Development a psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer. Journal of Advanced Nursing 69, 167– 174. World Health Organization (2011) Strategic directions for strengthening nursing and midwifery services. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.1_eng. pdf?ua=1 on 20 May 2014. Xiao L.D., Wills E. & Jeffers L. (2013) Factors affecting the integration of immigrant nurses into the nursing workforce: a double hermeneutic study. International Journal of Nursing Studies 51, 640–653.
13
M. Kangasniemi et al.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Journal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access).
• • • •
14
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan. Positive publishing experience: rapid double-blind peer review with constructive feedback. Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication. Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).
© 2015 John Wiley & Sons Ltd
