Ethical problems in nursing management

Abstract

Background:

Nurse managers have responsibilities relating to the quality of care, the welfare of the staff and running of the organization. Ethics plays significant role in these responsibilities. Ethical problems are part of daily management, but research in this area is limited.

Objective:

The aim of this study was to identify and describe ethical problems nurse managers encounter in their work to get more detailed and extensive view of these problems.

Methods:

The data consisted of nine interviews with nurse managers at different management levels in primary healthcare and specialized healthcare organizations, and it was analysed by inductive content analysis.

Ethical considerations:

Permission to conduct the interviews including ethical approval was given at all participating organizations according to national standards. The respondents were informed about the aim of the study, and voluntary participation, anonymous response and confidentiality were explained to them.

Findings:

Four main categories were found: conflicts in practical situations, lack of appreciation, disregard of problems and experienced inadequacy. Problems could also be divided to patient-related, staff-related, organization-related and other problems.

Discussion:

The findings correspond with results from earlier studies but add knowledge of the nature and details of nurse managers’ ethical problems. New information is produced related to the ethical problems with nurse managers’ own courage, motivation and values.

Conclusion:

Nurse managers identified a variety of different ethical problems in their work. This information is useful in the development of ethics in nursing management. Further research about the frequency and intensity of nurse managers’ ethical problems is needed as well as possible differences in different levels of management.

Keywords

Ethical problem ethics interview nurse manager nursing management

Introduction

Ethics is significant in healthcare administration, especially in a time of continuous changes of economical, technical and behavioural circumstances and development.¹ In the Global Competency Model of the World Health Organization (WHO),² professional behaviour in accordance of healthcare ethics and values is emphasized.

Nurse managers (NMs) are part of healthcare administration, managing nurses, who are the greatest number of health workers. NMs are working at different levels in healthcare organizations: ward, middle and strategic management. They have ethical responsibilities to the healthcare organization, to patients cared in this organization and to the nursing staff employed by this organization.³ NMs play a role in clarifying organizations’ mission, vision and values to their staff.⁴ They are ensuring continuous upholding of ethical standards among staff⁵ and supporting nurses’ ethical competence.⁶ NMs should influence nursing staff and act as arbiters between organizational and professional values.⁷ They also play a strategic role in patient safety that is sensitive to ethics and promoting nursing practice where the humanity and dignity of patients are respected.⁸ Ethical leadership in nursing has been found to be responsive to practitioners and the contextual system. It also requires receiving and providing support, so that capacity of practice and discussion about ethics in daily context may be increased.⁹

To maintain and develop good ethical management practice in healthcare, guidelines have been created. In the United Kingdom, Code of Conduct of National Health Service (NHS) managers¹⁰ sets out the core standards of conduct expected of NHS managers. The principles emphasized responsibilities to patients, so that their care and safety should be managers’ first concern. Other principles highlight the respect of all the interest parties in healthcare, including the patients, staff and public, accepting responsibilities and showing commitment to working as a team member. Manager’s own behaviour and personal development are also underlined: the manager should be honest and act with integrity and take responsibility for her own learning and development. The Code has been made to guide managers in the work they do and decisions and choices they have to make.¹⁰ Encountering ethical problems and seeking solutions to them are part of NMs’ work.¹¹

In the literature, the concept ‘ethical problem’ is defined in various ways. According to Thompson et al.,¹² an ethical problem can be understood as a difficult matter requiring a moral solution. Fundamentally it is a question of what is right or wrong or good or bad. The concept ‘ethical dilemma’ is used to denote a situation in which a choice has to be made between two alternatives that appear undesirable. The concepts ‘ethical’ and ‘moral’ are often used as synonyms, as are ‘ethical problems’ and ‘moral problems’.^12,13 Van der Arend and Remmers-van den Hurk¹⁴ have defined moral problem as ‘a situation in which a problem or a dilemma is experienced between our own values and norms and those of other people: a situation which by your own account is not correct or “should not occur”’. Concept ‘ethical conflict’ is also used. Gaudine and Beaton¹⁵ have defined it this way: ‘When an individual’s personal values clash with those of the employing organization, the result is ethical conflict’. Not all articles have a clear definition of what is meant by ethical problems in the study in question. In this study, the concept ‘ethical problem’ is used in the same meaning as in the study of Van der Arend and Remmers-van den Hurk.¹⁴

There are some studies of ethical problems in nursing management in 1990s.^16,17 Results were quite in common level, such as problems in staffing or maintaining good care. Research made in the 2000 concentrated on the consequences of ethical problems to different stakeholders. There are not only studies concerning ethical problems in nursing management in general^3,11,18 but also studies regarding ethical conflicts against organization,¹⁵ workplace stress,¹⁹ negative workplace behaviours,²⁰ case studies²¹ and nurse middle manager ethical dilemmas.²² Still, there is a need for qualitative research to get more detailed information of the nature of NMs’ ethical problems.

Ethical problems are part of daily management. In Camunas’¹⁶ study, among NMs, nearly all (94%, n = 315) respondents reported encountering ethical problems when making daily management decisions. In nursing management, ethical problems can be divided into three categories: organization-related, staff-related and patient-related problems.²³ Toren and Wagner²¹ describe divided loyalties in NMs’ work: employees (nurses) versus the organization, employees versus patients and employees versus the profession. In some surveys, the most frequently encountered ethical problems have concerned staffing, developing and maintaining good care and allocation of scarce resources.^11,16,17 An ethical conflict between the administrative role and nursing professional role has been identified in several studies.^16

–19 In Israeli study, among nurse middle managers, the most common and most distressing ethical dilemmas were in administrative situations, other categories being clinical situations such as inappropriate care and interpersonal situations.²² In the study of Gaudine and Beaton,¹⁵ NMs’ ethical conflicts in hospitals are divided into four categories: ‘voicelessness’, ‘where to spend the money’, ‘rights of the individual versus needs of the organization’ and ‘unjust practices on the part of senior administration and/or the organization’, all associated with distress and frustration.

In relation to staff, ethical problems have also been found in staff relations, hiring and termination and promoting employees,^16,17 but the nature and details of these problem areas were not described. Stress and guilt among the nursing staff in relation to patient care are also challenges to NMs.²³ Negative workplace behaviours have been identified as an ethical dilemma for NMs when trying to treat everyone fairly and respecting the individual dignity and integrity of professionals.²⁰

NMs mentioned bioethical issues such as right to die, quality of life and appropriate care as a source of role conflict in patient care, but the issues were not identified in detail.¹⁶ In a survey study of ethics and human right issues among nurses in leadership roles, the most frequently experienced issue was ‘protecting patient rights and human dignity’ (62.7%), one-third of the respondents working in the area of gerontology and long-term care. It also indicates that the advocate role is very important to nurses in leadership role.³

To conclude, ethical problems are perceived to appear in NMs’ work. However, the nature and variety of these problems have been rarely studied, and there is a need to know more in order to develop the ethics in nursing management and by that to improve the running of the organization, the quality of care and the welfare of the staff. Knowledge is also needed for developing instruments for the measurement of ethical problems in nursing management and to obtain generalizable results.

Aim and research questions

The aim of this study was to identify the ethical problems NMs encounter in their work and describe the nature of these problems from NMs’ point of view. The ultimate goal is to improve the ethics in nursing management. The following research question was addressed:

What kind of ethical problems NMs encounter in their work related to patients, staff and organization?

Methods

Design and participants

The data were collected using semi-structured interviews with NMs (n = 9). The qualitative method was selected because of the limited knowledge of the ethical problems in NMs’ work but the known existence of these problems. The interviewees were purposefully and continuously selected by the researcher during data collection. Purposeful sampling was used to get rich and diverse data. Interviewees represented varied and relevant experience of working in management and was aimed to represent the widest breadth of possible ethical problems they encounter in nursing management. They also had acquaintance with ethical questions by belonging ethical committees or teams, by doing ethical-related research or by writing about ethics. They represented strategic (n = 2), middle (n = 4) and ward management level (n = 3) both in specialized and primary healthcare organizations in different parts of Finland 2010 (Table 1). Managers in middle or ward management worked in different areas of healthcare such as older people care, paediatric, medical, surgical, emergency or psychiatric clinics. Strategic-level managers were in charge of the nursing practice of the whole organization. The participants were aged 43–61 years (mean 52 years), and they had been working as managers for 1–27 years (mean 14 years).

Table 1.

Organizations and job positions of interviewees.

	Primary healthcare	Specialized healthcare
Ward management	1	2
Middle management	2	2
Strategic management	1	1

Data collection

Data were collected by interviews. The broad interview framework, the research questions, was beforehand sent to respondents. This gives interviewees time to think those themes before, aim being to get a richer description during the interview.²⁴ NMs were asked to describe the ethical problems they had encountered in their work as concrete cases related to patients, staff, organization and other possible issues. Additional questions such as ‘what do you mean by that?’ or ‘what is the ethical problem here?’ were asked when necessary. The interviews were audio taped with the participants’ permission. The background information collected from the participants included age, current job position, level of education, length of managing experience and current unit. Special knowledge or experience of ethical issues was also asked. The interviewees chose the places where the interviews were carried out, and they lasted between 30 and 75 min (mean 61 min).

Analysis

Inductive content analysis was used because of the descriptive aim of the study and limited previous research literature.^25,26 First, the data were transcribed verbatim. Then, meaning units, that is, words, sentences or paragraphs answering the research question, were identified. The meaning units were marked and then the expressions were condensed and coded (Figure 1). Then, the coded expressions were grouped based on similarities first into subcategories and second into the larger main categories. The analysis focused on manifest contents, visible and obvious components in the text.²⁵ The meaning units were also grouped to patient-related, staff-related, organization-related and other problems (Table 2). Citations from the interviews are reported with the results. Minor revisions have been made to maintain confidentiality.

Figure 1.

Examples of meaning units, condensed meaning units and codes.

Table 2.

Ethical problems in nurse managers’ work.

	Patient-related problems	Staff-related problems	Organization-related problems	Other problems
Conflicts in practical situations	Disagreements in patient care	Conflicts between staff members; ambivalence about justice and fairness in personnel management	Conflicts with owners or persons elected to a position of trust; conflicts between own and organizational values
Lack of appreciation	Paternalistic culture; inequality of patients; indiscreet treatment of patients	Lack of collegial behaviour; problems with collaboration with other professionals	Lack of valuing nursing profession; negative public image
Disregard of problems	Not patient-oriented routines and habits	Not listening to staff; excessive collegiality of physicians	Protection of incompetent key persons; permitting unfair treatment; avoiding responsibilities	Lack of managers’ own motivation
Experienced inadequacy	Prioritization in patient care; limited power; limited circumstances	Fatigue of the staff; problems with evaluating and rewarding staff members	Scarce resources	Limitations caused by confidentiality

Ethical considerations

Permission to conduct the interviews, including ethical approval was given at all participating organizations according to national standards.²⁷ The respondents were informed about the aim of the study, and voluntary participation, anonymous response and confidentiality were explained to them. All the participants gave their written consent at the beginning of the interview.

Results

The main categories of ethical problems in NMs’ work that emerged from the data were conflicts in practical situations, lack of appreciation, disregard of problems and experienced inadequacy. Each of these categories contains patient-related, staff-related and organization-related problems; in addition, there were some other problems related to the managers themselves (Table 2).

Conflicts in practical situations

Conflicts in practical situations included situations where there were at least two different opinions as to what was the right way to act. Situations where conflicts exist are obvious and conflicting values are easily found, and there usually is open discussion between two or more parties.

Related to patient care, conflicts emerged between patients and staff, between nurses and physicians and between patient and their relatives. Values related to these issues were, on one hand, patient’s autonomy and self-determination and, on the other hand, professionals’ or relatives’ understanding of patient’s best. Between patient and staff, these conflicts included refusal of care, coercion and power. For some reason, staff’s understanding of necessary care differed from the patients’ opinion. Differences of opinion on patient care also appeared between nurses and physicians, especially when the patient was not strong enough to make his or her own decisions. Acting as an advocate to patients was thought to be nurses’ responsibility. Relatives may also disagree about patient care with staff or the patient. Sometimes disagreements were related to treatment, which the patient or relatives had perceived as unfair or inappropriate. In the case of complains on treatment, NMs’ problem is to find out what actually happened. As one NM put it,

We receive patient complaints, and the patient’s or relative’s side of the story is totally different from the nursing staff’s side; who should be believed? (Participant 3)

Related to staff, NMs named two types of problems linked to the value of justice. First, there were conflicts between staff members emerging when members of staff did not get along. There was negative behaviour, bullying and scapegoating, and staff members were typically not able to solve their problems in a constructive way. Problems of this kind impair the functionality of the whole unit. NMs considered these as ethical problems because it was difficult to know who was right and who should be believed. A second type of staff-related conflict was ambivalence as to justice and fairness in personnel management. Decisions need to be made about shifts, holidays, education and rewarding. Problems appear if employees’ and organizations’ needs are opposed or if employees’ needs and hopes are in conflict with each other. Employee selection may be difficult, as can all kind of evaluation, if the criteria used are insufficient. Nurses’ rights may be a problem; especially in situations where the patient is aggressive or violent, there is the question of how much abuse nurses should stand.

Related to organization, conflicts with owners or persons elected to a position of trust (politicians) are related to the Finnish system where public healthcare organizations are owned by municipalities. Especially, in primary healthcare, politicians have direct power over many kinds of decisions. NMs encountered conflicts between their professional expertise and politicians’ decisions which – according to NMs – may be influenced by short-term political goals. One NM explained,

In municipalities, political decision-makers are almost demanding that they should be given operational management … but after all, they are laymen. (Participant 9)

Conflicts between one’s own and organizational values were another organization-related conflict situation. NMs’ own values were based on their nursing professional values. In their management role, they were expected to act according to the organization’s values. Their management role presumed justifying organizational values to their staff even if they did not agree with them.

Lack of appreciation

This category contains descriptions of situations or issues where NMs have perceived some participants being undervalued or not taken into account when making decisions. The values included here are equality, respect and – regarding to patients – human dignity. The lack of appreciation is more NM’s experience than open disagreement, so there are no public defence of opposing values.

Related to patients, lack of appreciation finds expression in paternalistic culture, inequality of patients and indiscreet treatment of patients. The culture of paternalism was still more or less in evidence in hospitals. Nurses and physicians thought that they knew what was best for patients better than the patients themselves. As one ward manager put it,

We in healthcare still somehow think that the patient is ours when he/she comes to hospital. (Participant 4)

Lack of appreciation may focus on some groups of patients, for example, alcoholics, so that they are not treated similar to others. Indiscreet treatment of patients may appear as heavy-handed treatment or rude talk. Sometimes, nurses tried to justify their behaviour by the patient’s behaviour or unrealistic expectations or by their own tiredness. NMs have a duty to advance the culture of caring, so that patients’ rights may come true.

Related to staff, lack of appreciation was expressed as lack of collegial behaviour and problems with collaboration with other professionals. Lack of collegial behaviour appeared as lack of collaboration, criticizing colleagues without good reason, denying help to a colleague, not trusting colleagues’ work and not committing to group decisions. Problems with collaboration with other professionals mean unsatisfactory multiprofessional teamwork. Especially, physicians were seen to be acting based on medicine, not taking account of nursing perspective.

Related to organization, lack of appreciation was mentioned in two kinds of problems: lack of valuing the nursing profession and negative public image of the organization. Lack of valuing the nursing profession was expressed in that NMs were not taken into account in decision-making, and they were obligated to implement decisions, even if the decisions involved nursing professionals. NMs felt that organizations are led on physicians’ terms, and the professions are not equal. Lack of valuing was also experienced by nursing staff because not enough resources are given to nursing. NMs felt that their authority and influence was limited as described by one NM working in middle management:

… different professions are not equal in our organization … and it is very deep-rooted that physicians are the primary and most valuable group on whose terms the whole organization runs. (Participant 3)

Organizations were described to have a negative public image as consequence of some individual cases or broader issues in media. NMs felt that as a result, every single nurse is branded, and this has an effect on work motivation among nurses.

Disregard of problems

Disregard of problems consisted of matters that NMs considered wrong but somehow accepted as existing in the organization culture, or at least there was nothing active going on to correct them. According to NMs, these problems are perceived commonly in the organization also by other professionals.

Related to patients, there were accounts of not patient-oriented routines and habits as an expression of a caring culture that has developed for historical reasons, so that routines are more inclined to serve professionals or organization than patients. There are not necessarily any conflicts, but the patient’s role is not as participative as it should be.

Related to staff, there are two problems in this category: not listening to staff and excessive collegiality on the part of physicians. According to NMs, they get messages from the staff that they are not sufficiently listened to. This could have to do with organization culture where management is more about giving orders than interacting. One strategic-level NM thought that

… staff, is it that there is no time to listen to them, or is there something in the attitudes, is the management more like giving orders … (Participant 8)

Another problem was that from NMs’ point of view physicians’ collegiality goes too far. Physicians interfere very rarely with each other’s actions, including patient care and professional behaviour. There were accounts of excessive collegiality related to patient care, multiprofessional co-operation and staff conflicts.

Related to organizations, disregard of problems was manifested in three forms. First, there was protection of incompetent key persons. They were described as persons who were just ‘waiting for retirement’ or who had lost their competence and/or their motivation for some other reason. A person of that kind in a key position has a wide effect, usually resisting changes and development. One NM told that

… characters near retirement age in responsible position as managers, and I mean characters in a bad way … not capable of supervising that the work in the ward or in the clinic is still going on properly. (Participant 6)

Second, permitting unfair treatment was described. When the person responsible for the unfair treatment is at high level in the hierarchy, it is possible that nothing may be done about the problem. One reason mentioned here was that the unfair person is indispensable to the organization. Third, avoiding responsibilities was reported. NMs explained that there were problems that were recognized, but nothing was done to resolve them, or resolving was inefficient and slow. Management overlooked its responsibilities and ‘let them be’, so that nursing staff were forced to face them without support from managerial level.

As other problems, NMs described lack of motivation on their part if they only got little support for their actions. In difficult situations, courage to be under fire is also needed. One NM told that in a difficult situation:

I also think … there will later be some consequences for myself. (Participant 1)

Experienced inadequacy

NMs described situations where they did not have enough ways to do the best possible thing. There were many kinds of obstacles which are very difficult to impact: legislative, financial and cultural. NMs experienced inadequacy in these situations.

Patient-related problems in the category of experienced inadequacy were prioritization of patient care, limited power and limited circumstances. Prioritization in patient care was described as situations where it was not possible to care for all the patients as well as they should be cared for. One NM from a long-term care clinic told that

patients cannot necessary have a wash as often as they should and staff cannot take patients outdoors as much as they should and problems occur with eating as well. (Participant 8)

Another problem, limited power, was described as situations where legislation sets limits to care. Especially, with children, there are situations where parents have a right to make decisions which nursing professionals do not think are in the child’s best interest. Third, limited circumstances in patient care were described especially with long-term or dying patients. The hospital culture or physical circumstances set limitations to a natural death in a peaceful environment with one’s own familiar belongings.

Related to staff, experienced inadequacy related was reported by NMs as fatigue on the part of staff. Multiple and rapid changes in the healthcare system were described as being more or less exhausting for staff. Managers feel that so much is demanded of the professionals, and they cannot do enough for staff’s welfare in midst of all the changes.

Related to organization, scarce resources, either financial or personnel related, were mentioned as an ethical problem. If there are not enough nurses for all patients, choices must be made about what kind of functions, patients and units need them most. The problem may be lack of financial resources, or there are not enough nurses available. Choices must also be made between patient care, staff education and development projects.

As other problems causing experienced inadequacy, NMs described limitations caused by confidentiality placing them in a difficult position. One NM told,

A manager gets a lot of information about staff’s private affairs which influence a person’s work and behaviour, but the manager cannot tell anything to others. (Participant 7)

Managers use the information when making decisions but cannot explain the reasons to other employees. This may weaken staff’s trust in manager. Confidentiality may also cause situations where NM does not get necessary information and feels inadequacy.

Discussion

NMs identified a variety of different ethical problems in their work. The existence of these ethical problems was known.¹¹ However, this study provided new and more detailed knowledge about content of NMs’ ethical problems which are here grouped into four categories: conflicts in practical situations, lack of appreciation, disregard of problems and experienced inadequacy. Findings also enlighten the context of the problems with more detailed information. Problems were also divided to patient-related, staff-related, organization-related and other issues. However, in the future, it would also be interesting to explore the problems in different levels: micro, meso and macro. As other issues, NMs described ethical problems with their own courage, motivation and values, which seem not to have been reported before. Results highlight NMs’ own descriptions of the ethical problems.

Conflicts in practical situations related to patients are often linked to patients’ rights as autonomy, self-determination and right to good care, which in many countries have regulated by law. Problems appear if healthcare professionals think themselves as experts who have the best knowledge for patient’s best and patient’s own opinions are understated. The culture in healthcare is continuously chancing, and the patient’s role in decisions concerning his own care is increased and still increasing. In Finland, for example, there are new regulations for patient’s right to choose their place of care²⁸ and for electronic pages for citizens where they may read their own documents entered in the Prescription Centre or electronic Patient Data Archive.²⁹ Protection of patients’ rights is reported to be nurses’ most frequent ethical issue in nursing practice in a study made in the United States.³⁰ Ethical issues in patient care have been indicated to also belong to NMs’ role.³ Redman and Fry³ concluded that the main issue is protecting patient rights and human dignity and that being an advocate for patients’ rights is very important in NMs’ role. New regulations and changes in healthcare culture may not only cause new ethical problems but also give some help when trying to solve problems. NMs should actively follow these changes when acting as an advocate for patients’ rights and supporting nursing staff in their patient care.

In conflicts in practical situations, related to staff, NMs underlined justice as a very important value in their work. Besides conflicts between staff members, they described normal tasks in personnel management such as planning work shifts and holidays, hiring employees, rewarding or punishing personnel as ethical problems, when trying to treat everyone fairly. However, there is no unambiguous description of justice in personnel management in healthcare. NMs and nurses may have different views on justice, for example, in planning work shifts and holidays. For example, some may think that every nurse should have equal amount of different shifts, others thinking that nurse’s wishes and situation in life should be taken account. NMs seem to be aware of their ethical responsibilities for nursing staff as well in supporting their work in patient care as in personnel management forwarding nurses well-being and coping at work. Nurses encounter daily ethical challenges in their work, and there is an urgent need for strategies to retain nurses at work. Ethics support and ethics-related interventions are needed for that.³⁰ More information is needed about nurses’ experiences of the support they are getting. Results of Canadian studies have indicated that nurses in practice were lacking the support needed to provide ethical care.³¹ Education and work experience in nursing help NMs to understand nurses’ values and their ethical problems, but there may still be insufficient understanding of needs of clinical nurses as one nurse claims in Gaudine et al.’s³² study.

In conflicts in practical situations, related to organization, problems in administrative level seem to be common and significant in NMs’ work in different countries.^11,15,16,22 Especially, conflict between organizational values and NMs’ professional values has been described in many studies.^16

–19 In Israeli study among nurse middle managers, the highest intensity and frequency of moral distress were found for administrative issues.²² In our study, having originally been trained as nurses and still identifying themselves as nurses, the interviewees’ personal values seemed to be the same as the nursing profession’s. Their role as managers requires that they emphasize the administrative goals and values often related to economical effectiveness. However, the quality of care and effective use of recourses should not be conflicting, and economically effective actions are also ethical.

Lack of appreciation was described from many perspectives: related to patients, related to staff and related to organization. In a Canadian descriptive study of ethical conflicts in the workplace as experienced by NMs, Gaudine and Beaton¹⁵ described one theme as ‘voicelessness’ including expressions such as ‘nursing not valued’ and ‘nurse managers not present during decision-making on issues that affect nursing’. This is very similar to ‘lack of valuing nursing profession’ in our study. There may be reasons related to the history of medicine as a much older science than nursing and longer education and better social status of physicians. Political supervision of the interests may uphold also this kind of attitudes. But Gaudine et al.³² have reported ethical conflicts with organizations shared by nurses and physicians, and both groups described lack of respect. They had told about feelings being not respected, valued and supported by the organization as individuals and as well as their professional group. Lack of respect was indicated also between nurses and NMs.³² Appreciation is very subjective feeling and the reasons causing feelings of lack of appreciation may also vary. However, it could be argued that appreciation should be earned by the professionals’ own actions and merits. NMs should consider what they can do to increase the appreciation of themselves and the whole profession.

Disregard of problems was also encountered related to patients, related to staff and related to organization. Very serious problems were described related to organization meaning that administration at the highest level allows even unfair treatment to take place. Gaudine and Beaton¹⁵ had a theme close to this: ‘unjust practices on the part of senior administration and/or the organization’. Quite the same theme, ‘administration turning a blind eye’, was reported in the study where nurses and physicians have experienced very troublesome issues where administration know about the problem but ‘turn a blind eye’.³² NMs seem to be quite powerless with problems of this kind, when there is a question of the highest administration, but they should mind of their own actions, so that they are not ‘turning a blind eye’. NMs also described lack of motivation and courage of their own, which may lead disregarding of problems and cause ethical problems to their nursing staff.

Experienced inadequacy was described with many issues, including expressions of lack of power, resources and knowledge. Nursing staff is critical resource in hospitals and staffs fatigue needs serious attention. Employer has no right to risk employees’ health by demanding too much from them. Insufficient or scarce resources are mentioned as ethical problem also by nurses^22,32 and physicians.³² Interesting is that NMs themselves experience same kind of problems in which they should support their nursing staff. NMs are criticizing administration and in the same time they are part of it and at the receiving end of nurses’ criticism and demands. Obviously, NMs also need support in their duties to solve ethical problems and supporting their staff.

Validity of the study

The trustworthiness of this study may be assessed by the concepts of credibility, dependability and transferability.²⁵ The NMs in this study represented different organizations and different clinics, which is why the variation of the data was rich, and a variety of description was provided by NMs, strengthening its credibility. The sample remains small (n = 9). However, the main categories appeared very early, after a few interviews, and were repeated almost in all of the interviews. However, more interviews might have produced a wider range of examples. Credibility is also increased by using quotations in the text. All the interviewees were given written information and the interview themes in advance, so there was no risk of inconsistency during data collection, which strengthened the dependability of the study. The aim of descriptions of the interviewees and the process is to make it easier for the reader to assess transferability, which is the third aspect of trustworthiness.

Conclusion

Ethical problems impair the running of the healthcare organization, and they should be made visible. Therefore, new tools and methods need to be developed or adapted into healthcare organizations to bring up these situations. The results found in this study could help to formulate the content of such tool. There is a need for open discussion of ethical problems and ethics in patient care within healthcare organizations. When ethical problems are perceived and solutions found to them, it has improving impact to the main responsibilities of healthcare organizations – responsibilities to patients care and safety.

The nursing profession and the status of NMs also need to be discussed. NMs themselves are in key position in this discussion, and they should make their actions for patient care and organizational functions more clear and visible. Nurses are greatest number of health workers. They need to be supported in their work to perceive and discuss ethical issues in daily practice and make ethically decisions, so that they can provide high-quality nursing practice.

There is also a need for further research on ethics in management. More information is needed of the reasons for ethical problems and frequency and severity of the problems. Very little is known about the values, resources and mechanisms adopted when resolving ethical problems. The information assists to develop ethically high-level management, which improves the quality of patient care, staff welfare and effective running of the organization.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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