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Etika keperawatan

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Pemecahan masalah etika yang berhubungan ª Penulis (s) 2015 Cetak ulang
dan izin:
sagepub.co.uk/journalsPermissions.nav
dengan pekerjaan: Kegiatan manajer perawat 10,1177 / 0969733015584966
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Laura Laukkanen dan Riitta Suhonen


University of Turku, Finlandia

Helena Leino-Kilpi
University of Turku, Finlandia; Rumah Sakit Universitas Turku, Finlandia

Latar belakang abstrak: manajer perawat bertanggung jawab untuk memecahkan masalah etika yang berhubungan dengan pekerjaan untuk mempromosikan

budaya etis positif dalam organisasi kesehatan.

tujuan: Tujuan dari penelitian ini adalah untuk menggambarkan kegiatan yang manajer perawat digunakan untuk memecahkan masalah etika
workrelated. Tujuan utama adalah untuk meningkatkan kesadaran etis dari semua manajer perawat.
Desain penelitian: Data untuk survei cross-sectional deskriptif ini dianalisis melalui analisis isi induktif dan kuantifikasi.

Peserta dan konteks penelitian: Data dikumpulkan pada tahun 2011 menggunakan kuesioner yang termasuk pertanyaan dan latar
belakang faktor terbuka. Peserta manajer perawat yang bekerja di organisasi kesehatan Finnish (n ¼ 122).

pertimbangan etis: Izin untuk studi ini diberikan oleh Finlandia Asosiasi Manajer Akademik dan Ahli Ilmu Kesehatan.

temuan: manajer perawat mengidentifikasi berbagai kegiatan yang mereka gunakan untuk memecahkan masalah yang berhubungan dengan
pekerjaan etis: diskusi (30%), kerja sama (25%), organisasi kerja (17%), intervensi (10%), nilai-nilai pribadi (9%), operasional model (4%),
statistik dan umpan balik (4%), dan contoh-contoh pribadi (1%). Namun, kegiatan ini tidak mengikuti model umum atau sistematis.

Diskusi dan kesimpulan: Di masa depan, manajer perawat membutuhkan pendekatan yang lebih sistematis untuk memecahkan masalah etika. Hal ini
penting untuk membangun jenis baru dari struktur etika dalam organisasi, seperti biasa, sistematis pembuatan keputusan etis model dan klub etika untuk
masalah perawat manajer, untuk mendukung manajer perawat dalam memecahkan masalah etika yang berhubungan dengan pekerjaan.

Kata kunci
masalah etika, struktur etika, manajer perawat, memecahkan masalah etika, masalah etika yang terkait dengan pekerjaan

pengantar
manajer perawat memiliki tanggung jawab untuk memecahkan masalah etika yang berhubungan dengan pekerjaan, 1,2 melakukan pengambilan keputusan
etis, 3 dan mendukung perawat dalam memecahkan masalah etika. 4 Masalah etika yang benar diselesaikan mempromosikan pertimbangan etis yang lebih
besar di antara manajer perawat dan meningkatkan budaya etis

Penulis yang sesuai: Laura Laukkanen, Departemen Ilmu Keperawatan, Universitas Turku, 20.014 Turku, Finlandia. Email: lslauk@utu.fi

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2 Etika keperawatan

organisasi. 5 budaya etis kuat dikaitkan dengan prevalensi lebih rendah dari masalah etika serta keterlibatan kerja yang lebih tinggi. 6 Selain itu,
keputusan etis dibuat dan kegiatan yang diambil sebagai akibat dari keputusan tersebut menjadi penting karena berdampak langsung terhadap
kualitas keseluruhan perawatan. 7 kualitas baik perawatan secara luas diterima sebagai nilai yang menyeluruh di Uni Eropa (UE) tingkat dan
dibagi di seluruh Eropa. 8 Ada kekhawatiran yang berkembang untuk seberapa baik manajer perawat mampu memecahkan masalah etika yang
berhubungan dengan pekerjaan ketika mereka menghadapi cepat, perubahan prosedur yang berkelanjutan, restrukturisasi, pembatasan
anggaran, reformasi untuk meningkatkan produktivitas, 9,10 dan tuntutan pertumbuhan dan harapan baik dari segi kualitas perawatan dan nilai
uang. 3 Pemecahan masalah etika tidak boleh diabaikan karena tekanan ini. Dalam penelitian ini, istilah perawat manajer mengacu pada
pemimpin perawat dan manajer pada tingkat yang berbeda dalam organisasi kesehatan. Meskipun masalah etika dapat bervariasi pada
berbagai tingkat manajemen, kegiatan serupa dapat digunakan untuk memecahkan masalah ini.

masalah etika dipahami sebagai masalah yang sulit yang membutuhkan solusi moral, dan solusi harus didasarkan pada prinsip-prinsip moral
atau nilai-nilai dan apa dasarnya baik atau benar. masalah etika mungkin baru dan asing, atau mereka dapat berulang masalah sehari-hari. Syarat dilema
etika digunakan ketika pilihan harus dibuat antara dua alternatif sama-sama memuaskan dan ada konflik yang jelas antara prinsip-prinsip moral
bersaing dan nilai-nilai. Situasi menjadi tak terpecahkan dan sering menyebabkan perselisihan tak berujung dan perselisihan. Jika mungkin untuk
membingkai ulang dilema sebagai masalah, namun, dimungkinkan untuk menerapkan metode pemecahan masalah dan menemukan solusi yang
layak. 11 Dalam studi ini, dilema etika yang terkait dengan pekerjaan demikian dilihat sebagai masalah etika, terjadi dalam pekerjaan dan yang
berkaitan dengan bekerja tugas.

manajer perawat menempati peran kunci kepemimpinan dalam organisasi kesehatan di seluruh dunia, 3 dan mereka membuat keputusan etis
secara teratur. 7,12 Ada beberapa etika pengambilan keputusan model yang dapat mendukung manajer perawat di sebenarnya pembuatan keputusan
etis mereka, 5,7,13-15 memahami perspektif yang berbeda dari masalah, mengatur dan memprioritaskan pemikiran, dan menghargai implikasi dari
berbagai pilihan. 7 Semua mengikuti proses sangat mirip: memperjelas dan menentukan sifat dari masalah; mengidentifikasi fakta-fakta kunci, nilai-nilai,
dan pemangku kepentingan; daftar suatu tindakan; mengidentifikasi hasil dari setiap tindakan pada masing-masing stakeholder sekarang dan di masa
depan; memutuskan tindakan tertentu; dan mengevaluasi hasilnya. 5,7,13-15

Namun, semua manajer perawat etis yang kompeten yang membuat keputusan rutin dapat melintasi langkah-langkah sangat cepat sehingga mereka
tidak sadar menyadari mereka. Untuk tantangan kurang umum, manajer perlu mendedikasikan waktu sadar dan usaha ketika mencari keputusan etis.
manajer perawat dan organisasi seharusnya sudah ditentukan pedoman mereka sendiri untuk mengidentifikasi dan memecahkan masalah etika mereka, 16 etis
pengambilan keputusan aturan, model yang jelas, 14 dan pendekatan sistematis mereka sendiri dengan etika. 12 Hal ini tidak dapat diasumsikan bahwa
pemimpin '' dari hati nurani yang baik '' secara otomatis akan mencari tahu tindakan yang paling etis untuk mengambil, bahkan mereka tidak keputusan
frommaking kekebalan tubuh yang belum diperiksa secara menyeluruh untuk konten etis mereka. 14

Menurut studi sebelumnya, manajer perawat menggunakan nilai-nilai pribadi mereka 1,17-20 dan rekan-rekan mereka untuk
memecahkan masalah etika. 1,17-21 Mereka juga menggunakan diskusi, 21,22 etika komite, 1,18 pertemuan profesional, kebijakan
organisasi, 20 Pasien Bill of Rights, 1,17-19 dan kode etik. 1,17,18,20,23 Proto-kode dari Asosiasi Direksi Perawat Eropa 24 dan kode etik dari
kedua Dewan Perawat Internasional 25 dan Asosiasi Manajer Akademik dan Ahli Ilmu Kesehatan di Finlandia 26 menawarkan
bimbingan etis dan menginformasikan manajer tentang bagaimana mereka harus bertindak. 24 Kegunaan kode tersebut etik telah
terbukti menjadi positif untuk berbagai jenis masalah, 23 meskipun kegunaan kode etik untuk aktual pengambilan keputusan juga telah
dikritik. 27 Untuk kode ini menjadi berarti, mereka harus diketahui dengan jelas, dipahami, dan, tentu saja, dapat digunakan. 28

Komponen penting untuk yang terbaik pembuatan keputusan etis juga tidak adanya tekanan yang tidak semestinya yang akan kompromi
standar etika sendiri. Selain itu, penting untuk memastikan bahwa manajer perawat dilengkapi dengan baik dan berpendidikan dalam hal
bagaimana menangani mereka sendiri dan masalah staf mereka. pelatihan etika, 20 etika komite, 29 klub etika, 30 dan berbagai jenis pertemuan
etika harus mudah tersedia. Etika putaran dan pengalaman pendidikan membantu untuk mengidentifikasi dan menganalisis masalah etika,
merangsang

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Laukkanen et al. 3

refleksi kritis, dan dukungan pembuatan keputusan etis. 31 Dukungan dari para pemimpin senior dan organisasi juga diperlukan. 4,32 Mendukung
sekitarnya organisasi dipandang sebagai prasyarat untuk kompetensi etis. 30

Selanjutnya, etika percakapan atau putaran dipimpin oleh ahli etika dapat bertindak sebagai forum untuk pengolahan dan mendiskusikan isu-isu etika, 33 korban
memperluas berpikir dan memperkuat kepercayaan diri untuk bertindak. 34

Meskipun ada beberapa studi tentang kegiatan pemecahan masalah perawat manajer, ada kebutuhan untuk mempelajari proses pembuatan
keputusan etis mereka. 35 Khususnya, lebih etis deskripsi pemecahan masalah yang diperlukan serta pengetahuan lebih lanjut tentang kegiatan tertentu
yang manajer perawat digunakan untuk memecahkan masalah etika yang berhubungan dengan pekerjaan dan proses manajer ini secara sadar
mengadopsi untuk membuat keputusan etis mereka sendiri. Penelitian sebelumnya havemainly melihat kegiatan perawat manajer sendiri. Kegiatan yang
didukung oleh struktur organisasi jarang dipelajari. 20

Tujuan dari penelitian ini

Tujuan dari penelitian ini adalah untuk menggambarkan kegiatan yang manajer perawat digunakan untuk memecahkan masalah etika yang berhubungan dengan pekerjaan.

Pengetahuan ini dapat menyediakan sumber daya yang mendukung bagi manajer perawat dalam memecahkan masalah etika masa depan. Tujuan utama dari penelitian ini

adalah untuk meningkatkan kesadaran perawat manajer tentang pentingnya etika dan kegiatan etis mereka. pertanyaan utama studi ini adalah sebagai berikut: '' Kegiatan

apa yang manajer perawat digunakan untuk memecahkan masalah etika yang terkait dengan pekerjaan mereka? ''

metode

desain penelitian, sampel, dan pengumpulan data

Data untuk survei ini deskriptif, cross-sectional dikumpulkan pada tahun 2011 dari manajer perawat yang bekerja di organisasi
kesehatan Finlandia. Ada hampir 5800 manajer perawat di Finlandia bekerja di lingkungan atau tingkat menengah organisasi. 36 Untuk
mencapai deskripsi yang luas dan beragam kegiatan manajer perawat dalam memecahkan masalah etika yang berhubungan dengan
pekerjaan, data yang dikumpulkan dari sekitar 1170-anggota Asosiasi Manajer Akademik dan Ahli Ilmu Kesehatan. serikat adalah
kelompok kepentingan nasional untuk manajer dan canggih konsultan / spesialis di sektor sosial dan kesehatan. Anggota memegang
gelar master dalam ilmu keperawatan atau disiplin yang terkait. Kelompok sasaran termasuk semua manajer perawat terdaftar serikat
yang memegang ward-, menengah, dan posting strategis tingkat (N ¼ 326). Dikecualikan (N ¼ 1170 326 ¼ 844) adalah berbagai jenis
ahli yang tidak bekerja dalam peran manajemen. Sampel adalah kelompok besar manajer perawat Countrywide dari posisi
manajemen yang berbeda dan dengan usia yang sesuai mean (50 tahun) dan jenis kelamin (perempuan 94%) dalam hal seluruh
penduduk manajer perawat di Finlandia. 36

Data dikumpulkan dengan menggunakan kuesioner yang termasuk pertanyaan dan latar belakang faktor terbuka. Pertama, ada
satu pertanyaan terbuka di mana responden diminta untuk menggambarkan, tanpa ada pembatasan, setidaknya satu kegiatan mereka
digunakan untuk memecahkan masalah etika yang terkait dengan pekerjaan di tempat kerja: menjelaskan bagaimana Anda
memecahkan masalah etis yang Anda hadapi di tempat kerja, yang berkaitan dengan kerjamu. Kedua, ada pertanyaan terstruktur yang
termasuk faktor latar belakang (jenis kelamin, usia, pendidikan, pekerjaan saat ini, dan panjang pengalaman kerja). Kuesioner adalah
pilot diuji dalam sampel sembilan manajer perawat untuk menguji kelayakan studi dan kejelasan pertanyaan. Asosiasi Manajer
Akademik dan Ahli Ilmu Kesehatan memberikan label alamat, dan kuesioner dikirim ke alamat rumah manajer perawat dengan amplop
prabayar untuk mengembalikan kuesioner selesai. Selama waktu respon 2 minggu, 122 tanggapan diterima (tingkat respon dari 37%),
dan mayoritas responden (n ¼ 104) juga menjawab pertanyaan terbuka.

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4 Etika keperawatan

pertimbangan etis
Izin untuk studi ini diberikan oleh Asosiasi Manajer Akademik dan Ahli Ilmu Kesehatan pada tahun 2011. Karena studi ini tidak
melibatkan pasien atau intervensi dalam integritas seseorang, etika kelembagaan persetujuan komite tidak diperlukan. 37 Namun,
pertimbangan cermat dari etika penelitian dilakukan. Potensi peserta diberitahu via surat lamaran tentang tujuan penelitian, prinsip
sukarela, dan anonimitas responden, serta kesempatan untuk mendapatkan informasi tambahan atau menarik diri dari penelitian. 38 Kuesioner
selesai dianggap persetujuan untuk berpartisipasi dalam penelitian ini.

Analisis data

analisis isi induktif 39 dan kuantifikasi digunakan untuk menganalisis pertanyaan terbuka. Versi ditranskripsikan dari bahan sumber
(A4) diketik dalam 1,5 spasi baris untuk menghasilkan 79 halaman A4. Fokus analisis adalah pada isi manifest untuk meniadakan
kemungkinan palsu menafsirkan materi. Unit analisis adalah tanggapan terhadap tugas belajar. Untuk lingkup penelitian ini, unit
makna yang cocok digunakan, yaitu, konstelasi kata. Berarti unit kental, disarikan, dan diberi label dengan kode. Kemudian, berbagai
kode dibandingkan dan diurutkan ke dalam delapan kategori, dinamai sesuai dengan konten utama mereka.

Setelah analisis isi, jumlah kegiatan yang digunakan untuk memecahkan masalah etika yang berhubungan dengan pekerjaan (n1 ¼ jumlah total dari
kegiatan yang digunakan untuk memecahkan masalah etika) dan jumlah responden (n2 ¼ jumlah orang yang melahirkan kegiatan untuk memecahkan
masalah etika kategori tertentu) dihitung. Setiap responden dijelaskan setidaknya satu kegiatan untuk memecahkan masalah etika yang terkait dengan
pekerjaan.
Microsoft Excel digunakan untuk menganalisis pertanyaan terstruktur. Frekuensi, persentase, dan sarana yang digunakan untuk menggambarkan
latar belakang responden.

temuan

responden
Mayoritas (98%, n ¼ 120) responden adalah perempuan dengan gelar master (83%, n ¼ 102) dan usia rata-rata 51 tahun. Sebagian besar
responden manajer perawat yang bekerja baik pada tingkat strategis tengah atau (73%, n ¼ 89), dan sebagian besar (86%) memiliki 5 atau
lebih tahun pengalaman dalam manajemen kesehatan.

Kegiatan untuk memecahkan masalah etika yang berhubungan dengan pekerjaan

Manajer perawat dijelaskan berbagai kegiatan untuk memecahkan masalah etika yang berhubungan dengan pekerjaan (n1 ¼ 193
solusi). Selama analisis isi, kegiatan pemecahan masalah etika dibagi menjadi delapan kategori (lihat Gambar 1). masalah etika
diselesaikan dengan menggunakan diskusi (30%), kerja sama (25%), organisasi kerja (17%), intervensi (10%), nilai-nilai pribadi (9%),
model operasional (4%), statistik dan umpan balik ( 4%), dan contoh-contoh pribadi (1%). Dalam paragraf berikut, kegiatan
problemsolving etis utama untuk setiap kategori dijelaskan dengan dukungan dari kutipan responden asli.

menggunakan diskusi

Dalam kebanyakan kasus, masalah etika diselesaikan melalui diskusi (30%, n1 ¼ 59). manajer perawat melakukan diskusi dengan para
peserta yang terlibat dalam masalah ini dan pada pembenaran dan nilai-nilai yang berkaitan dengan situasi (lihat Tabel 1).

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Laukkanen et al. 5

Figure 1. Activities of nurse managers to solve work-related ethical problems. n1 ¼ number of ethical problem solvings, expressed also in percents;
n2 ¼ number of respondents in this category.

menggunakan kerjasama

Nurse managers also worked to solve ethical problems using cooperation with others (25% of solutions, n1 ¼ 49). They cooperated
with staff, other operators, and higher authorities (see Table 2).

Using work organization

Ethical problems were also solved using work organization (17%, n1 ¼ 32). Work was organized by arranging work tasks, resourcing
the staff, agreeing on work-related matters, dividing

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6 Nursing Ethics

Table 1. Solutions to ethical problems using discussion.

Using discussion

With different participants ‘‘ . . . discussed and contemplated with personnel . . . ’’ V12 ‘‘ . . . offered the chance to discuss . . . openly within the
involved in the issue work community . . . ’’ V13 ‘‘ . . . discussion session with the closest supervisor and relevant personnel . . . ’’ V37

Discussion of justifications ‘‘I always try to justify my decision, and I also accept this in others; it is the foundation of
of solutions righteousness.’’ V81 ‘‘The situation is
justified . . . ’’ V90
Discussion on values ‘‘Shared discussion . . . jointly we agreed on values and how they are reflected in our
work . . . ’’ V79
‘‘I try to remind her of the ‘golden rule’ . . . ’’ V45

Table 2. Solutions to ethical problems using cooperation.

Using cooperation

With staff ‘‘ . . . I would handle similar situations on a public level with the staff and reiterate the ‘game rules’
with them . . . ’’ V15 ‘‘ . . . it is necessary to deal ethically in department meetings . . . ’’ V30 ‘‘ . . .
development days . . . ’’ V54 ‘‘ . . . the breakdown of work, for example on workability-days . . . ’’
V69 ‘‘ . . . regular performance reviews.’’ V60

With other ‘‘Along with occupational safety and health organization . . . professional knowledge of specialist
operators medical care . . . . By cooperating we agreed on a solution beneficial to the whole.’’ V72
‘‘ . . . luckily there is work supervision available to dissolve these processes . . . ’’ V96
With a higher ‘‘ . . . I took it to be negotiated with management . . . ’’ V29 ‘‘ . . . info for
authority employers and politicians . . . ’’ V70
‘‘I proposed that the reduction of sickbeds and the transformation of structures focused also on
other profit centres . . . ’’ V44

and changing the workload, using an additional workforce, and directing the flow of patients (see Table 3).

Using intervention

Ethical problems were also solved using interventions (10%, n1 ¼ 19). Nurse managers were taking up matters, giving warnings,
breaking situations, and directing staff to the occupational health center (see Table 4).

Using personal values

Nurse managers solved ethical problems by using their own personal values (9%, n1 ¼ 18). They strive to work according to their
values with righteousness, equality, transparency, respectful, humane behavior, and good care. They also try to use their values to
direct them to their own best solutions (see Table 5).

Using an operational model

Nurse managers solved ethical problems using operational models (4%, n1 ¼ 7) with the use of shared operational models, rules,
and instructions (see Table 6).

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Laukkanen et al. 7

Table 3. Solutions to ethical problems using work organization.

Using work
organization

Arranging work tasks ‘‘ . . . a worker rarely understands leaving, and it is, of course, one solution . . . retirement . . . moving to another task in
the organization . . . redirection process . . . ’’ V67 ‘‘ . . . all six nurses . . . into work cycling one at a time’’ V56

Resourcing staff ‘‘Staff’s joint use . . . ’’ V24 ‘‘ . . . surveyed my other departments to see if I could find a replacement for my sick nurses.’’

V80 ‘‘ . . . we acquired some free time on our day off . . . ’’ V110

Agreeing on ‘‘Agreeing on division of labour . . . ’’ V107 ‘‘ . . . shared agreements . . . .We discussed for example, what does
work-related patient/customer centred nursing mean to us and how is it put into practice. -> common lines and agreements’’ V87
matters ‘‘We have agreed on the cycling of summer holiday months . . . chance to agree amongst

themselves [on] the exchange of holiday months . . . ’’ V78


Dividing and changing ‘‘ . . . reorganization of work, more equal division of the workload . . . ’’ V16 ‘‘ . . . what could be moved for the next shift to
the workload take care of.’’ V115 ‘‘ . . . staff is doing double shifts . . . moving from the teamwork model to the old office model

. . . ’’ V70
Using an additional ‘‘One function of nursing is based on reserve staff . . . ’’ V33 ‘‘ . . . Utilisation of
workforce reserve staff . . . ’’ V24 ‘‘Doctors are bought from private clinics . . . ’’ V33

Directing the flow of ‘‘Assigning patients . . . the limitation of the inflow of elective patients . . . ’’ V24
patients

Table 4. Solutions to ethical problems using intervention.

Using intervention

Taking up matters ‘‘ . . . I took up the issue in a conversation . . . . . . ’’ V116


Giving warnings ‘‘ . . . nurse received a written warning for the inappropriate altering of a document.’’
V108
Breaking up situations ‘‘I broke up the situation . . . ’’ V23
Directing to occupational ‘‘ . . . we decided that he/she should apply to the occupational safety and health
health center department to assess her ability to work . . . ’’ V6

Table 5. Solutions to ethical problems using personal values.

Using personal values

Striving to work according to ‘‘ . . . Equality and righteousness is important to me, in other words that leading can
one’s own values be equal and righteous . . . ’’ V111 ‘‘ . . . I made an ethically
correct decision . . . ’’ V61

Table 6. Solutions to ethical problems using an operational model.

Using an operational model

Shared operational model, ‘‘ . . . there are clear rules and operational models to follow when initiating a
rules, and instructions discussion on the use of intoxicating substances . . . ’’ V98

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8 Nursing Ethics

Table 7. Solutions to ethical problems using statistics and feedback.

Using statistics and feedback

Feedback from students and patients ‘‘ . . . by gathering feedback from students and patients . . . ’’ V117
Different statistics ‘‘ . . . the use of statistics for help . . . ’’ V52

Table 8. Solutions to ethical problems using personal examples.

Using personal examples

Being an example for ‘‘ . . . setting an example . . . ’’ V17 ‘‘ . . . a head nurse’s visibly good and beautiful grip on his/her department is a
the staff remarkable
help!’’ V45

Using statistics and feedback

Ethical problems were also solved using statistics and feedback (4%, n1 ¼ 7). Feedback came from clients, staff, or students. The
utilization of statistics meant the use of different clinical monitoring forms and statistics to help solve these ethical problems (see
Table 7).

Using personal examples

Ethical problems were also solved using personal examples (1%, n1 ¼ 2). Nurse managers were considered to act as examples for
other staff (see Table 8).

Discussion
Ethical problems are diverse, complicated, and unique, and when solving them, there is a need to have multiform solution methods. In
this study, nurse managers described various activities that they use to solve work-related ethical problems. Activities were their own
(using work organization, personal values, intervention, and personal examples), realized together with someone else (using
discussion, cooperation) and with the support of the organizational structures (using operational model, statistics, and feedback).
Nurse managers solved work-related ethical problems most often by discussing them. It is an important part of nurse managers’ work
to discuss the ethical premises, aspects, and solutions on which they build their practice at different levels of their organizations.
Based on these data, nurse managers worked to solve ethical problems, made conscious ethical decisions, and worked together at
different levels to solve problems guided by their own values and operational models. Nurse managers also sought support for
situations and found different ways to take ways to deal with these problems into shared meetings, theme-days, and performance
reviews.

However, the actual used activities seemed to be quite unstable and uncertain as precise guidelines when solving work-related
ethical problems. Nurse managers’ activities to solve ethical problems did not follow any common or systematic model. Meslin et al. 40 found
that different organizations manage the same ethical issues differently. In this study, there was a described use of operational
models. No one described ethical decision-making models, although the use of models was recommended decades ago. 2 Furthermore,
ethics committees were not described as solving ethical problems at all. In the1980s, Sietsema and Spradley 17 found that nurse
managers working in hospitals without ethics committees reported ethical conflict more often than managers in hospitals with ethics
committees did. A

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Laukkanen et al. 9

formalized ethical problem solution mechanism, however, did decrease the level of ethical conflict for nurse managers. It is important
for nurse managers to have closely argued, clear, and transparent solutions because these managers should be professional role
models, 41 modeling ethical decision-making to nurses 3 and thus overall ensuring that nursing remains ethically at the highest level. 25

It is also noteworthy that nurse managers used their own values for solving ethical problems. However, none indicated that
organizational or professional values supported them in problem-solving, not codes of ethics. It is possible that nurse managers had
adopted certain organizational and professional values so deeply that they did not mention those separately although we expected
that a code of ethics would be mentioned. Codes of ethics should serve, support, and guide nurse managers 32 in ethical
decision-making. The fact that none of the nurse managers indicated the use of ethics experts may describe the situation in Finland.
Ethics experts are not employed in clinical settings, although there are examples of their valuable use in other countries. 33,34

Strengths and limitations


Certain limitations need to be taken into account when interpreting the results of this study. First, the goal of the study was to collect
representative descriptions about the activities of nurse managers when they were solving work-related ethical problems. The
response rate of 37% was relatively low and weakened the trustworthiness of the study overall. A reminder letter might have increased
the response rate, but because the survey was anonymous, sending one was not possible. However, that trustworthiness was
strengthened by broad and positive material in the study: Written answers to the open-ended question were rich and diverse and
were organized into categories according to similarities. The resulting categories from the content analysis were also quantified to
highlight the commonness of the ethical problem-solving activities being used. A focus group interview may have produced even
more multidimensional data; however, collecting nurse managers from different parts of the nation for a focus group would have been
too challenging. The questionnaire was also considered to be easier for nurse managers to respond to challenging and even sensitive
ethical issues in private and peace at work or at home. Second, to improve the trustworthiness of the research, the analysis was
described in such minute detail that another researcher could easily follow the exact steps used in the analysis of this research
material. 42 Furthermore, there were direct quotations from the nurse managers included, so readers will be able to evaluate the
findings easily. 39

Conclusion and recommendations


The ethical problems that nurse managers face are diverse and will continue to be so in the future. Problems will stay the same to a
certain degree, but new types of problems will also surface. It is important to establish, support, and use new kinds of ethics
structures in organizations and to better support nurse managers in their ethical problem-solving. These ethics structures can include
implementing a common, systematic, ethical decision-making model, based on the results of this study, as such tools seem currently
to be missing from most nurse manager activities. A systematic ethical decision-making model would support nurse managers and
help them deal with immediate problems 11 and likely will improve the process and the outcomes of ethical decisions. 15 It would also
better equip nurse managers to deal more effectively with new problems in the future. 11 Furthermore, essential nurse leader
competency in 2020 is predicted to require expert decision-making that is clearly rooted in empirical science. Using systematic,
scientific approaches in ethical decision-making will increase the likelihood of making quality decisions that work well for all
concerned. 43

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10 Nursing Ethics

It also appears that nurse managers are not aware of ethics committees or, at the very least, are not using those that do exist.
Two dominant types of ethics committees exists in organizations: (1) research ethics committees (RECs), which focus on a reviewof
research practices involving human subjects and (2) clinical ethics committees (CECs), which focus onmoral issues related to patient
care. 44,45 In Finland, there are nine RECs, and they are centralized in university hospital regions 46 and regulated by the Medical
Research Act. 37 REC regulatory structures have been developed at both international and national levels, while CECs have remained
much less regulated. 44,45 In Europe, a number of countries have established CECs to provide support to health professionals when
they solve ethical problems, 45,47 whereas in Finland CECs have developed more slowly. For example, in Norway, in every hospital
trust, there is at least one CEC that uses a structured ethical decision-making model to ensure a good decision-making process and
the best possible foundation for any decisions its healthcare personnel must make. These CECs arrange seminars for hospital
employees, elaborate and develop ethical guidelines, discuss general and individual patient cases, and encourage multi-professional
cooperation to view and address ethical problems from different points of view. 48

The ethics structures of each organization must include a CEC. It is also important to consider using an ethics committee or an
ethics club for nurse manager problems. In such nurse manager clubs, nurse managers can discuss not only ethics but also their
work-related ethical problems and can analyze or solve these problems with the support of a common ethical decision-making model.
Nurse managers have several other ethical responsibilities in addition to solving individual ethical problems. These responsibilities
include developing their own ethics knowledge and conducting and/or implementing ethics research. Nurse manager ethics clubs can
also offer support to help nurse managers meet any of these responsibilities. If it is correct that value consciousness and an
increased ability to solve ethical problems can save resources without reducing quality of treatment and care 49 and that the ethical
management of nursing can have a positive impact on the commitment and well-being of staff and consequently on the care of
patients 50,51 and higher patient satisfaction, 52 then there is no reason to leave these ethical structures without effective organizational
support.

This study offers an overview of nurse manager activities to solve work-related ethical problems. More detailed information is still
needed. In the future, it would be interesting to test different systematic ways to solve ethical problems and to identify which can best
enhance the quality of ethical decisions and advance the overall ethical culture of each organization.

Acknowledgements

The authors would like to thank all the nurse managers who kindly participated in the study and reflected on the aspect of ethical
problem-solving activities that they have encountered in nursing management.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

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

Research Ethics Board Approvals

Permission for the study was given by the Association of Academic Managers and Experts of Health Sciences (2011-05-02). The
completed questionnaire was considered to be consent and a willingness to participate in the study.

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Laukkanen et al. 11

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