Managerial ethical principles and behaviours for nurse managers: A Delphi method

Abstract

Background

Managerial ethical principles and behaviours guide the roles, duties, responsibilities, behaviours, and relationships of nurse managers in healthcare institutions.

Research objectives

The aim of this study was to establish the managerial ethical principles and behaviours for nurse managers.

Research question

What are the managerial ethical principles and behaviours for nurse managers?

Research design

The Delphi method, one of the qualitative research methods, was used in this study. The Delphi process consisted of two rounds. Data were collected by e-Delphi technique.

Participations

42 experts were included in the first Delphi round and 39 in the second Delphi round. These experts consisted of nurse managers, academicians studying in the field of ethics and nursing management.

Ethical considerations

Participation in the study was voluntary and informed consent of the experts was obtained before the study. Approval was obtained from the ethics committee of the university at which the researcher worked (Approval date: 24.07.2020, Decision No: 2020/12-16).

Findings

At the end of the Delphi rounds, eight managerial ethical principles and 29 ethical behaviours of these principles were identified. The distribution of these behaviours and principles were: justice (six behaviours), equality (two behaviours), honesty (two behaviours), fairness (two behaviours), responsibility (eight behaviours), confidentiality (two behaviours), clarity (two behaviours), and humanity (five behaviours).

Conclusion

These managerial ethical principles and behaviours are intended to guide nurse managers when providing nursing services but should be updated accordingly in line with changing conditions and developments.

Keywords

Delphi method ethical behaviours ethical principles nursing management

Introduction

Factors such as changes and developments in health, an increase in epidemic diseases, change in generations of health personnel, and the development of technology increase the importance of ethical behaviour in health services management.^1,2 For this reason, ethical principles and behaviours should guide the roles, duties, responsibilities, behaviours, and relationships of nurses who provide the effective organization and delivery of healthcare so that they may effectively fulfill their professional obligations.^3,4 Nursing services managers are expected to comply with ethical principles appropriate⁵ to both professional and managerial roles⁶ and address unethical behaviours in accordance with ethical principles in the moral challenges they face.⁷

Background

Ethical principles transmit the values, views, and ideology of a profession⁸ while ethical behaviour abides by what is right.⁹ Ethical principles and behaviours have been determined for many professions worldwide;^10,11 for the nursing profession, they have been determined by both national and international professional associations.^4,12,13 Management ethics is defined as the principles of behaviour that guide managers in their actions; such behaviour ensures consistency, impartiality, and fact-based management processes; respect of the existence and integrity of individuals; choice of actions that benefit everyone; and choice of actions based on universal values such as justice, equality, impartiality, honesty, responsibility, respect, openness, love, democracy, and tolerance.¹⁴

Ethical principles and behaviours in nursing services management aim to achieve institutional goals and create/support an environment appropriate for the provision of high quality and cost-effective patient care^1,15,16 Previous studies have outlined ethical principles for nurse managers at national and international levels^4,12,13,17 (Table 1). Some of these studies have identified ethical behaviours for “nurses and patients or other people requiring care or services,” “nurses and practice,” “nurses and the profession,” and “nurses and global health,”⁴ as well as for the sake of “competence,” “care,” “safety,” “information,” “staff,” “life-long learning,” and “multi-sectorial working.”¹³ With the emergence of ethical behaviours, nursing services managers who act in line with ethical principles will contribute to the formation of an ethical climate in the work environment^18–20 and create positive results for patients, employees, leaders, the profession, and society.^1,21

Table 1.

Ethical principles.

References		Ethical principles
(ICN, 2021)	The International Council of Nurses (ICN) code of ethics for nurses	Respect, privacy, confidentiality, advocacy, safety, competence, trust, leadership, skill, judgment, service, expertise, integrity, knowledge, public good, acountability, fairness, responsibility, justice, collaboration, solidarity, equity, responsiveness, compassion, dignity, care, empathy, inclusivity
(ENDA, 2017)	The European nurse directors’ proto-code of ethics and conduct	Responsibility, equality, commitment, respect, integrity, honesty, justice, autonomy, beneficence, and non-harm
(ANA, 2015)	View the code of ethics for nurses	Usefulness, do no harm, loyalty, accountability, integrity, accuracy, and patient autonomy
(Curtin, 2000)	The first ten principles for the ethical administration of nursing services	Fugality and healing/therapeutic delicacy/grace, clinical reliability in organizational skills, provision of peace of mind, definition of ethical issues, commitment/loyalty, delegation of authority/delegation, improvement of responsibilities, responsibility, personal discipline, and continuing education

In order for managerial ethical principles to be reflected in behaviour conducive to an ethical working environment, they should be applied alongside the existing laws, regulations, and professional standards governing the nursing practices of different countries.⁴ To current knowledge, previous studies have not identified managerial ethical principles and behaviours for nurse managers in our country, although one researcher²² established the “Administrative Ethical Behaviour Scale” with which nurses used to evaluate the ethical and unethical administrative behaviours of nurse managers in the categories of accuracy and honesty, responsibility and supremacy of law, rights and freedom, good human relations and humanity, and justice and equality. The current study aimed to identify the ethical principles and behaviours used to guide the roles, duties, responsibilities, behaviours, and relationships of all executive nurses at lower, middle, and upper levels.

Methodology

Objective

The aim of this study was to establish the managerial ethical principles and behaviours for nurse managers.

Research questions:

• What are the managerial ethical principles for nurse managers?

• What are the managerial ethical behaviours for nurse managers?

Design

This study used the Delphi method, a qualitative research method in which more than one consultation is conducted in order to systematically gather the opinions of experts and reach a consensus on the topic.^23,24 This process consisted of three steps: a) Identification of items for managerial ethics principles/behaviours and the experts who would participate in the Delphi rounds, b) Implementation and analysis of the first Delphi round, and c) Implementation and analysis of the second Delphi round and finalization of managerial ethics and behaviours (Figure 1). Guidance on Conducting and Reporting Delphi Studies (CREDES) was used to report the research process.²⁵

Figure 1.

Research proccess.

This study is based on a doctoral dissertation in which ethical principles for nurse managers were determined. The doctoral study was conducted in two stages; the first stage included the qualitative section and used the phenomenological research method, and the second stage used the Delphi method, one of the qualitative research methods. The current study also used the Delphi method.

Step 1

The data obtained after individual interviews with 27 participants in the first phase of the thesis study were analyzed by the research team (two experts in the field of management and members of nurses’ associations, including the association of executive nurses) using the inductive content analysis method.²⁶ The “I. Delphi Questionnaire Form” was created after data analysis.

The Delphi questionnaire form consisted of two parts. The first part included questions about socio-demographic data, and the second part included 17 managerial ethical principles and 77 ethical behaviours. These principles and behaviours were: justice (four behaviours), equality (three behaviours), honesty (three behaviours), fairness (four behaviours), clarity (four behaviours), human relationships (six behaviours), cooperation (five behaviours), human rights (four behaviours), humanity (four behaviours), responsibility (thirteen behaviours), democracy (four behaviours), labor justice (three behaviours), follow the law (six behaviours), frugality (four behaviours), confidentiality (two behaviours), trust (two behaviours), and commitment (three behaviours). The form also included a space under each principle and behaviours in which experts could add additional suggestions.

Although there is no universally accepted criterion for the selection of experts in the Delphi method, it is considered appropriate to select experts who are experienced in their field, follow current information, and can act impartially towards findings.²⁷ For this reason, this study used maximum diversity (nurses working in management positions in the clinical field, academicians in the department of management in nursing colleges/faculties, or academicians working in the field of ethics) and a snowball sampling method to access more experts on the subject.²⁸ Although there is no consensus in the literature on the sufficient number of experts for Delphi rounds,²⁹ it is recommended that each round should consist of 15–50 experts.²⁴ In this study, 45 experts were selected for the first Delphi round.

Step 2

In the first Delphi round, the “I. Delphi Questionnaire Form” and “I. Delphi Survey Invitation Text” containing information about the purpose and process of the Delphi rounds were sent to the email addresses of 45 experts. One month after the first email was sent, reminder e-mails were sent, and telephone calls were made to the experts. Some experts replied that they could not participate in the study due to their workloads or did not respond to the email at all, so invitation e-mails were sent to 10 more experts recommended by the experts who had already agreed to participate in the study. The first Delphi round was completed with a total of 42 experts, and the return rate was 76%. The 42 experts who participated in the rounds are indicated as (Respondent 1-Respondent 42).

In the first Delphi round, experts’ suggestions were recorded by the researcher (first author) using Word, and a report was created. Suggestions received were: “this item should be accepted,” “this item should be dropped,” “this item should be changed to….,” and “this item should be changed as….” The report obtained was read independently by the researchers, after which the research team met to reduce the 17 ethical principles formed before the I. Delphi round to eight ethical principles and the 77 ethical behaviours to 29. In Table 2, it was stated that the ethical behaviours were changed, accepted and dropped in line with the suggestions received. The eight ethical principles and 29 ethical behaviours were included in the “II. Delphi Questionnaire Form.”

Table 2.

Opinions on managerial ethical principles and behaviours after the first Delphi round (n: 42).

Ethical principles	Ethical behaviours	Result
Justice	1. The nurse manager ensures that healthcare is provided fairly to the individual, family, and community	Change
	2. The nurse manager ensures fair distribution of resources among departments, employees, healthy individuals, patients, and their relatives	Change
	3. The nurse manager acts in accordance with legal and institutional rules in human resources management processes such as recruitment-placement, training, career development, achievement evaluation, and promotion-raising	Change
	4. The nurse manager acts fairly in nurse task distribution, workload, and work schedules	Change
Equality	1. The nurse manager ensures equal distribution of resources among departments, employees, healthy individuals, patients, and their relatives	Drop
	2. The nurse manager does not discriminate against colleagues in terms of nationality, race, ethnic origin, gender, etc., and treats them equally in line with their duties and competencies	Change
	3. The nurse manager ensures that employees provide care services without discrimination; without prejudice; without discrimination of race, ethnic origin, gender, etc.; without prejudice; and with a focus on human rights, sensitive to traditions, values, and beliefs	Change
Honesty	1. The nurse manager exhibits behaviour and attitude based on truthfulness and honesty in all relationships in the work environment.	Change
	2. The nurse manager creates an environment of trust to ensure that her/his employees do not provide misleading information, explaining themselves accurately and completely	Change
	3. The nurse manager sets an example to her/his staff by telling the truth openly and by her/his attitudes and behaviours that do not deviate from the truth	Drop
Fairness	1. The nurse manager acts impartially towards her/his employees	Accept
	2. The nurse manager bases her/his decisions and actions on concrete data and evidence by maintaining objectivity	Change
	3. The nurse manager acts impartially towards the employees with whom she/he has a common background (same school, hometown, etc.) and a relationship of interest, and does not show favoritism	Drop
	4. The nurse manager maintains impartiality while evaluating the individual characteristics-competencies of her/his employees in the human resources management process	Drop
Clarity	1. The nurse manager demonstrates an open attitude and behaviour to employees, patients and their relatives, the institution, and the society in which she/he works in making decisions and taking action	Change
	2. The nurse manager openly shares all decisions and processes related to the management of the institution and nursing services	Drop
	3. The nurse manager clearly communicates the problems that are communicated to her/him to senior management when they cannot easily be solved	Drop
	4. The nurse manager is open to criticism and exhibits constructive attitude and behaviour	Drop
Human relationships	1. The nurse manager demonstrates an open attitude and behaviour to employees, patients and their relatives, the institution, and the society in which she/he works in making decisions and taking action	Drop
	2. The nurse manager openly shares all decisions and processes related to the management of the institution and nursing services	Drop
	3. The nurse manager clearly communicates the problems that are communicated to her/his to senior management when they cannot be easily solved	Drop
	4. The nurse manager is open to criticism and exhibits constructive attitude and behaviour	Drop
	5. The nurse manager maintains communication and human relations to reduce conflicts in the work environment	Drop
	6. The nurse manager acts tolerantly towards the unapproved attitudes and behaviours of her/his employees, unless they are contrary to the law and ethical rules	Drop
Cooperation	1. The nurse manager ensures cooperation with other institutions, department managers, subordinates, patients, and patient’s relatives in order to achieve organizational goals	Drop
	2. Maintains cooperation by effectively managing tension and conflict between health professional members and nurses	Drop
	3. Demonstrates a collaborative and supportive approach in the conduct of nursing and health-related research and the use of research results	Drop
	4. Collaborates with health and nursing education institutions on student education and research	Drop
	5. Carries out joint studies with local administrations, non-governmental organizations, nursing professional organizations, etc. in line with institutional and professional objectives	Drop
Human rights	1. The nurse manager exhibits behaviours that defend basic human rights	Drop
	2. The nurse manager does not remain silent in the case of offences against human rights and makes efforts to correct injustice	Drop
	3. Participates in the development of strategies and directives to protect human rights, patient rights, and vulnerable groups in the institution and unit	Drop
	4. Participates in external studies to protect human rights and vulnerable groups	Drop
Humanity	1. The nurse manager exhibits behaviours that defend basic human rights	Drop
	2. The nurse manager does not remain silent in the case of offences against human rights and makes efforts to correct injustice	Drop
	3. Participates in the development of strategies and directives to protect human rights, patient rights, and vulnerable groups in the institution and unit	Accept
	4. The nurse manager shows love for human beings and all living things in her/his attitudes and behaviours	Drop
Responsibility	1. The nurse manager exhibits the behaviours required by his/her responsibilities towards his/her employees, the institution, the patient and patient’s relatives, the profession, and society	Drop
	2. Accountable to superiors, colleagues, patients, patients’ relatives, and society within the scope of their authority and responsibilities	Accept
	3. The nurse manager acts with the awareness that her/his responsibility continues even when she/he delegates her/his authority to her/his subordinates	Change
Responsibility	4. Continues his/her personal, professional, and managerial development as a manager	Accept
	5. The nurse manager fulfills the requirements of her/his responsibility in order to be prepared for unexpected/extraordinary situations	Drop
	6. The nurse manager uses her/his duties, authorities, and responsibilities within legal limits	Drop
	7. The nurse manager accepts her/his mistakes regarding her/his decisions and actions	Drop
	8. Ensures that behaviours in accordance with professional ethical principles are exhibited in the institution	Drop
	9. Contributes to structures such as ethics committees, commissions, and consultancy where ethical problems and violations experienced in the institution are evaluated	Drop
	10. Works to create an ethical working climate in institutions and units	Change
	11. Takes measures to address all risks, inappropriate behaviour, or misuse of technologies that threaten the safety of people	Drop
	12. Takes initiatives to prevent all kinds of violence in working life	Drop
	13. Takes part in studies on local and global issues affecting health such as climate change, human rights, poverty, food safety, and environmental health.	Drop
Democracy	1. The nurse manager demonstrates a participatory and democratic management approach in order to realize the aims of the institution and to make employees feel valued	Drop
	2. The nurse manager demonstrates approaches that are sensitive to the rights of employees and protects them	Drop
	3. The nurse manager ensures the participation of employees in problem solving and decision-making processes by considering their opinions	Drop
	4. The nurse manager encourages nurses to claim their professional and trade union organizational rights	Drop
Labor justice	1. The nurse manager defends the right of the labor of the employees to be given materially and morally	Drop
	2. The nurse manager takes part in activities to ensure that her/his employees receive the rewards of their labor	Drop
	3. The nurse manager does not own the works/products of others and does not use them without permission	Drop
Follow the law	1. The nurse manager expresses her/his reservations by stating that the orders given by her/his superior in violation of the law are not in accordance with the law	Drop
	2. The nurse manager knows that she/he cannot give illegal orders to her/his staff and does not take such action	Drop
	3. The nurse manager does not employ her/his employees for jobs outside of their job descriptions	Drop
	4. The nurse manager does not use the resources of the institution for her/his own benefit, does not accept gifts, bribes, etc	Drop
	5. Does not turn a blind eye to gifts, bribes, corruption, etc., in his/her institution and unit	Drop
	6. The nurse manager does not exhibit silence or condone inappropriate behaviour for her/his individual interest	Drop
Frugality	1. The nurse manager avoids wastefulness by ensuring that the resources of the institution (material, human, etc.) are used in accordance with the aims of the institution	Drop
	2. The nurse manager foresees that institutional resources may be scarce in extraordinary disaster situations and takes the necessary precautions and prevents wastefulness	Drop
	3. The nurse manager does not use organizational resources for individual benefit and prevents them from being used inappropriately	Drop
	4. The nurse manager ensures that her/his time and the time of her/his staff is used effectively and efficiently	Drop
Confidentiality	1. The nurse manager shares information about the institution, employees, colleagues, patients, and relatives in accordance with legal and ethical rules	Change
Confidentiality	2. The nurse manager takes measures in accordance with the laws on the protection of personal data in health records, reporting systems, etc	Change
Trust	1. The nurse manager demonstrates reassuring attitudes and behaviours	Drop
Trust	2. Ensures the development of trust-based relationships between employees	Drop
Commitment	1. The nurse manager shows her/his commitment to the profession through her/his attitude and behaviours	Drop
	2. The nurse manager participates in national and international professional organizations for the development of the profession	Drop
	3. The nurse manager carries out activities to support the professional and organizational commitment of her/his employees	Drop

Drop: This behaviour was dropped after the suggestions from the first Delphi session. Change: This behaviour was changed after the suggestions from the first Delphi session. Accept: This behaviour was accepted after the suggestions from the first Delphi session.

Step 3

The “II. Delphi Questionnaire Form” and “II. Delphi Survey Invitation Text” were sent to the 42 experts who participated in the I. Delphi round. Three experts stated that they could not participate in the study due to health problems, so 39 experts participated in the round. The return rate was 93%. Experts were asked to o rate these managerial ethical principles and behaviours on a 5-point Likert scale, 1 (definitely should not be included), 2 (should not be included), 3 (un-decided), 4 (should be included), and 5 (definitely should be included). The form also included a line under each item where the experts could write their suggestions and reasons for their changes. The form also included a space under each item in which the experts could add additional suggestions and reasons for their changes. The data collection process was completed in approximately 1 month (May–June 2022).

The data obtained from the second Delphi round were recorded using Excel, and SPSS 26 (Statistical Package for the Social Sciences) was used for analysis. Descriptive statistics (number, percentage) were used in the analysis of demographic data, and descriptive statistics (percentage of agreement, standard deviation, mean, square, and quartile width) were used in the analysis of Likert data. Although there is no exact value and scientific reality for the percentage of consensus, the literature states that 75% is the lowest level.^30,31 The research team ranked the eight ethical principles and 29 ethical behaviours according to the degree of consensus, suggestions from the experts, and frequency of expression.

Findings

When the groups in which the experts who participated in the first Delphi round showed the highest distribution were examined, 13 experts (31%) were Assistant Professors according to academic title, 6 experts (14%) were charge nurses according to clinical title, 16 experts (38%) were between 41–50 years of age according to age distribution, 29 experts (69%) were PhD graduates according to educational status, 24 experts (57%) had 21 years or more experience according to professional experience, and 13 experts (31%) had 6–10 years of experience according to management experience. The sociodemographic characteristics of the 42 experts who participated in the first Delphi round are presented in Table 3.

Table 3.

Sociodemographic characteristics of the experts participating in the Delphi rounds.

		I. Delphi n (%)	II. Delphi n (%)
Age	20–30	4 (10)	4 (10)
	31–40	13 (31)	12 (31)
	41–50	16 (38)	16 (39)
	51–60	8 (19)	6 (15)
	61 and over	1 (2)	1 (3)
Level of education	Associate degree	1 (2)	1 (3)
	Bachelor’s degree	4 (10)	4 (10)
	Master’s degree	8 (19)	8 (21)
	Doctor’s degree	29 (69)	26 (67)
Position (clinical)	Nursing services manager	1 (2)	1 (3)
	Assistant director of nursing services	4 (10)	4 (10)
	Supervisory nurse	3 (7)	2 (5)
	Charge nurse	6 (14)	6 (15)
	Team leader nurse	1 (2)	1 (3)
	Other	2 (5)	2 (5)
Position (academic)	Professor doctor	6 (14)	5 (13)
	Associate doctor	3 (7)	2 (5)
	Assistant professor	13 (31)	13 (33)
	Research assistant doctor	1 (2)	1 (2)
	Lecturer	2 (5)	2 (5)
Duration of professional experience	0–5 years	2 (5)	2 (5)
	6–10 years	5 (12)	5 (13)
	11–15 years	5 (12)	4 (10)
	16–20 years	6 (14)	6 (15)
	21 years and over	24 (57)	22 (56)
Duration of management experience	No experience	8 (19)	8 (21)
	1–5 years	11 (26)	11 (28)
	6–10 years	13 (31)	11 (28)
	11–15 years	2 (5)	2 (5)
	16–20 years	3 (7)	2 (5)
	21 years	5 (12)	5 (13)

Some of the experts’ suggestions for the 17 managerial ethical principles and 77 ethical behaviours in the first Delphi round are shared below.

Equality principle 2nd behaviour in the I. Delphi questionnaire form:

“In line with her/his duties and competences, the nurse manager does not discriminate against her/his colleagues in terms of nationality, race, ethnic origin, gender, etc. and treats them equally.”

One of the suggestions received from the experts in the first Delphi round for the 2nd behaviour of the equality principle was: “This item should be revised, and the phrase ‘in line with his/her duties and competences’ should be removed, as he/she already has these as a manager.”

The equality principle 2nd behaviour after I. Delphi round was changed to: “The nurse manager shall act equally without discrimination among her/his employees,” (Respondent 23) as reflected in Table 2.

Fairness principle third behaviour in the I. Delphi questionnaire form:

“The nurse manager acts impartially towards the employees with whom she/he has a common background (same school, hometown, etc.) and a relationship of interest, and does not show favoritism.”

One of the suggestions received from the experts in the I. Delphi round for the 3rd behaviour of the fairness principle was: “This article should be removed, as it is similar to principle of neutrality 1.” (Respondent 7) This change is dropped in Table 2.

Humanity principle third behaviour in the I. Delphi questionnaire form: “As a nurse manager, she/he takes into consideration that her/his employees have a family-social life outside of work life.”

One of the suggestions received from the experts in the first Delphi round for the 3rd behaviour of the humanity principle was: “This behaviour can be accepted as is.” (Respondent 13) The accepted behaviour is reflected in Table 2.

When the drop decision was made for all behaviours under the managerial ethical principle after the first Delphi round, that managerial ethical principle was deleted. Afterward, the research team met to reduce the 17 ethical principles formed before the I Delphi round to eight ethical principles and the 77 ethical behaviours to 29.

A total of 39 experts participated in Delphi round II. When the most common groups of the experts participating in Delphi II were examined, 13 experts (33%) were Assistant Professors according to academic title, six experts (15%) were charge nurses according to clinical title, 16 experts (39%) were between 41–50 years of age according to age distribution, 26 experts (67%) were PhD graduates according to educational status, 22 experts (56%) had 21 years or more experience according to professional experience, and 11 experts (28%) had 6–10 years of management experience (Table 3).

Some experts’ suggestions for the eight managerial ethical principles and 29 ethical behaviours in the II. Delphi round are as follows:

“The principle of justice is the most important for a manager.” (Respondent 11)

“I expect a manager to be open after he/she complies with the principles of justice and equality.” (Respondent 35)

The results of the second Delphi round and the ranking of the statements of managerial ethical principles and behaviours are presented in Table 4.

Table 4.

Managerial ethical principles and behaviours in II Delphi round (n: 39).

Ethical principles	Ethical behaviours	Percentage consensus > 80	Standard deviation ≤ 1.5	Mean	Median ≥ 4	Interquartile range (IQR) ≤ 1
Justice	1. The nurse manager ensures that nursing services are provided fairly	92	0.95	4.69	5	0
	2. The nurse manager ensures fair distribution of resources	92	0.86	4.69	5	0
	3. The nurse manager implements and ensures the fair application of legal and institutional rules in human resources management processes	92	0.86	4.72	5	0
	4. The nurse manager defends the right of the labor of the employees to be given materially and morally	90	0.99	4.59	5	0
	5. The nurse manager treats the employees she/he is responsible for fairly	90	1.11	4.64	5	0
	6. The nurse manager does not own the work/products that others have labored for	85	1.02	4.54	5	0
Equality	1. The nurse manager acts equally without discrimination among employees	87	1.12	4.54	5	0
Equality	2. The manager ensures that nurse staff provide care services without discrimination, without prejudice, with a focus on human rights, and with sensitivity to values and beliefs	87	1.23	4.51	5	0
Honesty	1. The nurse manager exhibits attitudes and behaviours that uphold honesty in all relationships in the working environment	92	0.92	4.69	5	0
Honesty	2. The nurse manager creates a working environment in which employees can exhibit attitudes and behaviours based on integrity	90	1.05	4.51	5	1
Fairness	1. The nurse manager acts impartially towards her/his employees	92	0.84	4.77	5	0
Fairness	2. The nurse manager bases her/his decisions and actions on concrete data and evidence, and with objectivity	92	0.86	4.69	5	0
Responsibility	1. The nurse manager exhibits the behaviour required by her/his responsibilities towards her/his employees, the institution, the patient and patients’ relatives, the profession, and society	90	0.99	4.64	5	0
	2. The nurse manager ensures that resources are used in accordance with their purposes	92	1.01	4.67	5	0
	3. The nurse manager establishes contact with all stakeholders in line with their duties, authorities, and responsibilities in order to achieve organizational goals	87	0.94	4.51	5	1
	4. The nurse manager is accountable to her/his superiors, colleagues, patients, relatives and the community within the scope of her/his authority and responsibilities	85	0.97	4.56	5	0
Responsibility	5. The nurse manager acts with the awareness that her/his responsibility continues even when she/he delegates her/his authority to her/his subordinates	85	1.02	4.49	5	1
	6. The nurse manager creates an ethical working environment in which employees can exhibit behaviours in accordance with professional principles	95	0.91	4.74	5	0
	7. The nurse manager supports the development of the profession	82	1.16	4.41	5	1
	8. The nurse manager encourages nurses to claim their professional and trade union organizational rights	92	0.97	4.59	5	0
Confidentiality	1. The nurse manager acts in accordance with legal, ethical, and institutional rules in sharing information about the institution, its employees, colleagues, patients, and patients’ relatives	92	1	4.69	5	0
	2. The nurse manager ensures that her/his employees act in accordance with legal, ethical, and institutional rules in sharing information about the institution, colleagues, patients, and patients’ relatives	95	0.84	4.68	5	0
Clarity	1. The nurse manager is transparent in her/his decisions and actions	95	0.92	4.72	5	0
Clarity	2. The nurse manager completes self-assessments in line with feedback	90	0.89	4.69	5	0
Humanity	1. The nurse manager exhibits attitudes and behaviours sensitive to human rights and dignity in all personal, managerial, and professional relationships	95	0.82	4.74	5	0
	2. The nurse manager supports the creation of an organizational culture based on respect and value for all human beings	95	0.83	4.72	5	0
	3. The nurse manager demonstrates an approach that takes into account that her/his employees have a family-social life outside of work	90	1.05	4.51	5	1
	4. The nurse manager supports the development of strategies and directives to protect human rights, patient rights, and vulnerable groups	95	0.83	4.72	5	0
	5. The nurse manager does not remain silent in the case of offences against human rights and makes efforts to correct injustice	92	0.95	4.69	5	0

Ethical considerations

Approval was obtained from the ethics committee (Onay tarihi: 24.07.2020, Karar No: 2020/12-16) of the university in which the study was conducted. A link to the “I.-II. Delphi survey invitation text” was sent to the email addresses of the experts, including information on how the process will be followed during the Delphi rounds, that they can leave the study at any time and that participation in the study is voluntary. In addition, written informed consent of the experts was obtained through this link.

The information of the experts involved in the study has been anonymized. Confidentiality was ensured by assuring that personal identifying information (such as institutional information and position) would not be used directly in the study and that the data would be destroyed electronically after the study was completed.

Limitations

This study aimed to select a maximum diversity²⁸ academicians and clinical nurses, but because the study coincided with the COVID-19 pandemic, access to participants was affected by the increased work intensity of clinical nurses, resulting in a limited distribution. Another limitation of the study is that it was conducted in one specific region.

Discussion

This study identified eight managerial principles for nurse managers and 29 ethical behaviours related to these principles after two Delphi rounds. These principles were: “justice,” “equality,” “honesty,” “fairness,” “responsibility,” “confidentiality,” “clarity,” and “humanity.”

Under the principle of justice, nurse manager behaviour included: ensuring that nursing services are provided fairly, distributing resources fairly, applying and enforcing legal and institutional rules fairly in human resources management processes, treating the employees they are responsible for fairly, advocating that employee labor is assigned materially and morally, and not appropriating the work/products of others. According to the studies of national and international associations, ethical behaviours indicate that managers should work to prevent the occurrence of discriminatory practices that may occur in the institution for patients and other persons served,³² train their employees in fair service delivery to patients, identify populations receiving inadequate patient care and formulate strategies and policies,³³ and ensure that existing resources of the institution are used consistently and that limited resources are used within the framework of ethical values such as justice, fairness, and transparency.³² The results of the current study were similar to the results of a study on ethical behaviours that determined that managers should manage those in the management area (such as employees and resources) in line with the principle of justice.¹³ The current study’s results were also in line with another study indicating that a culture should be created in which employees are fairly compensated for their labor.³² Research studies show that managers should distribute the resources of the organization fairly because if not, ethical problems may occur.^15,34 Additional studies have also indicated that employees reported that their managers should be fair.^15,35

Another managerial ethical principle identified in this study was the principle of equality. The ethical behaviours under this principle indicate that managers should treat their employees equally without discrimination and that their employees should provide care services without discrimination/prejudice, with a focus on human rights, and with sensitivity to values and beliefs. The ethical behaviour guidelines published by nurse associations state that nurse managers should lead their employees regardless of nationality, race, ethnicity, language, culture, and country;⁴ without prejudice;³³ and in a culture where all kinds of discrimination (race, ethnicity, sexual orientation, etc.) are prevented.³² In addition, the International Council of Nurses⁴ stated that nurse leaders/managers should provide care that respects human rights, is non-discriminatory, and is sensitive to people’s values, traditions, and beliefs.

Another managerial ethical principle identified in this study was the principle of honesty. The ethical behaviours under this principle indicated that the manager should be truthful and honest in all relationships and should create a working environment in which employees can exhibit truthful and honest behaviours. According to the literature, nurse managers should comply with the principle of integrity¹³ for patient satisfaction, patient safety/public protection, and the principle of honesty³⁶ in order to guide their decisions and choices and to show that decisions taken are accountable and in line with certain standards. In addition, the latest report of the International Council of Nurses⁴ pointed out that in order to improve the quality of patient care and safety, organizations should eliminate the fear of punishment in working environments so that employees can exhibit honest behaviour.

Another managerial ethical principle identified in this study was the principle of fairness. The first ethical behaviour under this principle indicated that the manager should be fair to his/her employees and should base his/her decisions and actions on objective concrete data and evidence. Florence Nightingale’s “Notes on Nursing,” published in 1860, stated that nurse leaders should comply with the principle of fairness.³⁷ Likewise, ethical principles determined for many professions indicate that managers should be fair.^14,38 In addition, the International Council of Nurses⁴ states that the manager should not discriminate among employees.

Another managerial ethical principle identified in this study was the principle of responsibility. The first ethical behaviour under this principle concerned the behaviour of managers towards their employees, the institution, patients/patients’ relatives, the profession, and society. Ethical behaviours published by international organizations confirm that managers have ethical responsibilities towards the profession, patients and other healthcare providers, the institution, employees, and society,³² as well as that nurse managers should fulfill the ethical obligations and responsibilities of the profession.⁴

The second behaviour under the principle of responsibility concerned the appropriate use of resources. While the European Nurse Directors Association¹³ stated that resources should be used in line with the principle of effectiveness and efficiency, the International Council of Nurses⁴ drew attention to the insufficiency of resources during the COVID-19 pandemic, stating that managers should reserve resources for emergencies, disasters, conflicts, epidemics, and pandemics.

The third behaviour under the principle of responsibility indicated that the nurse manager should establish connections with all stakeholders in line with their duties, authorities, and responsibilities in order to achieve organizational goals. The European Nurse Directors Association¹³ (emphasized the importance of the collaboration of executive nurses with healthcare institutions and professional/multi-sectoral organizations, while the International Council of Nurses⁴ emphasized the importance of collaboration with colleagues for research on nursing and health. The fourth behaviour under the principle of accountability indicated that nurse managers were accountable to their superiors, colleagues, patients, relatives, and society within the scope of their authority and responsibilities. A guide on the role of executive nurses in patient safety, published by the American Executive Nurses Organization,³⁹ stated that managers should be accountable and create an accountable working environment.

Another behaviour under the principle of responsibility indicated that nurse managers should create an ethical working environment in which their employees would exhibit behaviours in accordance with professional principles. Related to this ethical behaviour, the European Nurse Directors’ Association¹³ draws attention to the need for nurse managers to provide appropriate working conditions in which employees can provide care in accordance with such principles, and the American Health Care Executives³² draws attention to the need for a working environment in which ethical problems are easily stated and discussed and in which there is no violence. In addition, the International Council of Nurses⁴ draws attention to the need for a working environment in which ethical values are shared. Another behaviour under the principle of responsibility indicated that nurse managers supported the development of the profession. Similarly, the literature points out that nurse managers should attach importance to continuing education,⁴ create organizational conditions that ensure the development of professional identity, carry out continuous professional development and accreditation practices,¹³ and maintain competence.³²

The last behaviour under the principle of responsibility indicated that nurse managers should provide support so that nurses may exercise their professional and union organization rights. In its recent report on ethics, the International Council of Nurses⁴ stated that nurses and nurse managers should participate in national nursing associations to ensure appropriate socioeconomic and working conditions, while the European Nurse Directors Association¹³ stated that managers should support their employees in active membership of professional organizations.

Another managerial ethical principle identified in this study was the principle of confidentiality. The ethical behaviours under this principle were that managers and employees should act in accordance with legal, ethical, and institutional rules in sharing information. Similar to these principles and behaviours, international organizations have also stated that nurse managers should respect the confidentiality and privacy of their employees' information, share this information only in accordance with the requirements of the law,¹³ and establish processes to protect patients’ confidentiality.³²

Another managerial ethical principle identified in this study was the principle of clarity. The ethical behaviours under this ethical principle were that the manager should be open in his/her decisions and actions and complete his/her own self-evaluation in line with feedback. Similarly, the International Council of Nurses⁴ states that managers should encourage open communication among all stakeholders and create an environment in which health-promoting conversations are openly shared. It is also stated that health institution managers should clearly convey information about available health services to patients.³²

The last managerial ethical principle identified in this study was the principle of humanism. The first ethical behaviour under this principle indicated that nurse managers should exhibit attitudes and behaviours sensitive to human rights and dignity in all personal, managerial, and professional relationships, as well as support the development of strategies and directives designed to protect human rights, patient rights, and vulnerable groups. The International Council of Nurses⁴ has also identified ethical behaviours related to the protection of human rights such as protecting the privacy of electronic or paper-based health records, participating in human rights actions (such as preventing and detecting trafficking), helping vulnerable groups, providing universal education, and reducing poverty. The European Nurse Directors Association¹³ stated that executive nurses should contribute to the development and implementation of policies that ensure respect for patient rights, dignity, and safe care. Another ethical behaviour under this principle was that nurse managers should support an organizational culture based on respect and value for human beings. Many studies also emphasize that managers should be respectful.^32,36,37

Another behaviour under the principle of humanism was that nurse managers should acknowledge and respect the family-social life of employees. The latest ethical report published by the International Council of Nurses⁴ also includes statements on the importance of work–life balance, a healthy life, and development. The last behaviour under the principle of humanism indicated that nurse managers should not remain silent in crimes against human rights and make efforts to correct injustice. In relation to this behaviour, the International Council of Nurses⁴ stated that guidelines should be developed to address workplace problems such as violence and harassment, and the American Health Care Executives³² stated that executive nurses should create a work environment free of violence.

Conclusion and recommendations

The nursing managerial ethical principles and behaviours identified in this study may form the basis for guiding the roles, duties, responsibilities, behaviours, and relationships of nurse managers. By complying with these ethical principles, nurse managers can ensure that the organization achieves its goals and creates an appropriate environment for the provision of high quality and cost-effective patient care. In this manner, nurse managers can contribute to positive outcomes for patients, staff, leaders, the profession, and society.

According to the literature, professional associations and organizations determine the managerial ethical principles with which nurse managers should comply, and these principles are regularly updated in order to adapt to worldwide needs and developments. For this reason, managerial ethical principles and behaviours should be determined in line with national and international changes in health and the professional field.

It is recommended that the managerial ethical principles and behaviours identified in this study be used by other public and institutional organizations (especially the Association of Executive Nurses), that training programs be established to ensure that executive nurses working at all levels in private and public institutions comply with these principles, that they be included in the ethics course programs of higher education institutions providing nursing education, and that their compliance with these ethical principles and behaviours be evaluated in appointments to managerial positions.

Footnotes

Author’s Note

This study is submitted a doctoral thesis in Istanbul University-Cerrahpasa Institute of Postgraduate Education, Department of Management in Nursing.

Acknowledgments

Thanks to all the experts who participated in the Delphi rounds.

Author Contributions

Güzin Ayan: Conceptualization, Acquisition of data, Analysis and interpretation of data, Data curation, Writing – original draft, Writing – review & editing. Ülkü Baykal: Conceptualization, Acquisition of data, Analysis and interpretation of data, Data curation, Visualization, Project administration, Writing – original draft, Writing – review & editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Güzin Ayan

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