Nursing Section DOI : 10.7860/JCDR/2019/39668.12680
Year : 2019 | Month : Mar | Volume : 13 | Issue : 03 Page : LC01 - LC05

Disrupted Value System among Nursing Care Managers: A Qualitative Study

Alireza Nikbakht Nasrabadi1, Mitra Khoobi2, Soodabeh Joolaee3, Mohammad Ali Cheraghi4, Majid Ahmadi Hedayat5

1 Professor, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
2 PhD Student, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
3 Professor, Department of Ethics, School of Nursing and Midwifery, Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.
4 Professor, Department of Critical Care of Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
5 Lecturer, Department of Critical Care of Nursing, Critical Care, Research Deputy of Applied Sciences University, Ebne-Sina Hospital, Tehran, Iran.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Mitra Khoobi, PhD Student, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tohid Square-Zip Code: 1419733171, Tehran, Iran.
E-mail: mitra.khoobi@yahoo.com
Abstract

Introduction

The degradation of moral and professional values and incompatibility between value and performance affects the individual’s value, and leads healthcare staff to completely abandon the profession.

Aim

To investigate the experience of nursing care managers regarding the disrupted value system.

Materials and Methods

In this qualitative research paper, data were collected using semi-structured interviews with nursing care managers. Content analysis (based on Graneheim and Lundman’s approach) was utilised in data analyses. A total of 14 Iranian nurses with at least five-year experience of working in the hospital as nursing managers participated in this study.

Results

The data analysis revealed one main category “disrupted value system” and two subcategories “impaired moral integrity and breaking the moral framework”. The findings of the study indicated that the experience of nursing care managers in disrupted value system is associated with the sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, scarifying for the organisation, failure to observe the ethical framework and rules, ignoring ethical principles and moral degradation.

Conclusion

Nursing care managers experience a great deal of moral distress on a daily basis and despite their efforts to manage and tolerate these distresses, they suffer from many psychological complications. The results of this research can propose new meanings of disrupted value system, and thus facilitate the plans to control and reduce it based on new meaning.

Introduction

The disrupted value system is a phenomenon that causes a feeling of discomfort and anxiety in individuals [1]. Since ethical issues are inseparable parts of nursing practice, undesirable experience, which is called disrupted value system, has become a serious issue among nursing care managers [2]. The degradation of moral and professional values and incompatibility between value and performance along with the feeling of being restricted in doing appropriate ethical actions affect the individual’s value system, and even in some cases, make healthcare staff to completely abandon the profession [2]. The importance of disrupted value system in nursing practice has been mentioned in some studies [1-3]. Majority of national and international studies related to this topic have been conducted on clinical nurses, especially nurses working in critical care units. This is while, in the United States there are 2.5 million nurses, from whom 10% (250,000 nurses) have managerial positions [2-5]. In Iran, the number of employed nurses is around 140-150 thousand, and about 10% of them (14,000) are nursing managers in governmental and non-governmental hospitals [4,5].

Nursing care managers have a unique position in the health care system so that their actions, behaviours and decisions have the greatest impact on nursing work environment and nursing profession [6]. The workplace of nursing care managers is expected to be an ethical environment away from distress, where they can manage and supervise the provision of holistic care to patients and clients [7].

In such an environment, nursing care managers are expected to play managerial, facilitating, and supervisory roles. They are also expected to pay attention to the allocation of resources in accordance with their organisational rules and policies. In such situation, the duality of the role, the disruption of value system, moral distress and tension are manifested as a result of imbalance between the needs of organisation, nurses, and patients [8-10].

Currently, there is no comprehensive report on the experience of clinical nursing care managers regarding disrupted value system in foreign and domestic literature from 2007 to 2017. Some disparate studies show that, facing ethical challenges and conflicts affects the nursing care managers’ response to organisations, colleagues, and patients [11,12].

It is worth pointing out that, some studies indicated that nursing care managers also need care and training because they experience higher level of moral distress [13]. As a result, deeper understanding of nursing care managers’ experiences of disrupted value system can play an important role in achieving job satisfaction, improving inter-professional relations, promoting professional identity and self-confidence, reducing job burnout, creating appropriate organisational atmosphere, increasing organisational effectiveness, promoting health of nurses and patients, and finally increasing the quality of care which is the main objective of any healthcare system [14-20].

The researcher hopes that the results obtained from this study will be a good basis for improving the performance of nursing care managers in their decision-making and management activities. In fact, illustrating the experiences of nursing care managers in their own context helps their management system to address the barriers to the development of ethical environment, so they can take effective steps towards making appropriate ethical decisions. Since disruption of nursing care managers’ value system is the most important factor that affects the entire quality of nursing care, a deeper insight into this issue can help nursing care managers to play a more effective and holistic managerial role.

Materials and Methods

This qualitative content analysis aimed to explore the experiences of nursing care managers regarding the disrupted value system. Qualitative content analysis approach is mainly used to improve the researcher’s understanding of the phenomenon [21,22]. This qualitative study (content analysis) was conducted in the teaching hospitals affiliated to Tehran University of Medical Sciences from a period of October 2016-December 2017. In the present study, the participants included 14 clinical nursing care managers with at least bachelor’s degree in nursing and five years of work experience as nursing care managers. The participants were selected purposefully among those who had a rich experience in the field of study, were able to establish appropriate communication, and were willing to share their experiences with the researcher. In the present study, semi-structured interviews were conducted individually and face-to-face as the main method of data collection by researcher. All questions were open-ended, including two questions such as “what would come to your mind when you hear the word disrupted value?” or “what does the disrupted value mean to you? “Before performing the interviews, the researcher visited the study setting and communicated with the participants, explaining the aim of the study. Those who were able to establish appropriate communication, and were willing to share their experiences with the researcher were selected. Then researcher obtained informed consent from all participants and set the date for the first interview. Interviews were recorded with recorder. Phone numbers of the participants were also recorded for future correspondence.

Ethical Considerations

This study was approved by Ethical Committee of the Tehran University of Medical Sciences Register number is 9323199001-1. Authors provided necessary information about the goals and method of study to the potential participants and written informed consent was obtained from them. Also, the permission for recording of the interviews was obtained from the participants and they were assured about their right to withdraw from the study at any time for any reason. They were also assured about the principles of confidentiality and anonymity.

Trustworthiness

Trustworthiness was established in accordance with the Graneheim and Lundman’s method [22]. Maximum variation of the samples (like different age, gender, education level, work experiences, different setting) enhanced the confirmability and credibility of the data. The credibility of the findings was maintained by keeping a prolonged engagement with the data (more than nine months). The researchers ensured the depth of the content and its authenticity by thoroughly identifying diverse and novel data. The data were analysed independently by the researchers in order to identify and categorise the initial codes. Then, the codes and categories were compared. The credibility of the data was established through the peer and member-checking. A summary of the interviews was returned to the 14 participants to be confirmed by them. Peer-checking was done by the authors and two PhD nursing students.

Data Analysis

Data were analysed based on the Graneheim and Lundman’s approach [22]. The following steps were taken to analyse the data. Interviews were transcribed verbatim and their texts were studied several times in order to gain a general understanding of the content. Then the texts were divided into condensed semantic units and the condensed semantic units were abstracted and labelled with codes. The codes were classified into subcategories and categories according to their similarities and differences. Finally, the main category was formulated as the expression of latent concepts in the text.

Results

In total, 14 nursing care managers participated in this study, from whom six were men and eight were women. The participants’ demographic characteristics are presented in [Table/Fig-1]. The data analysis revealed one main category and two subcategories. The main category was “disrupted value system”, and the two subcategories included; impaired moral integrity and breaking the moral framework, which is shown in [Table/Fig-2].

A summary of the participants’ demographic characteristics.

NoGenderAge (year)Marital statusEducation levelWork experience (year)HospitalInterview time (minute)
1Female45MarriedBS20Public65
2Male28SingleBS5Public70
3Male31MarriedMS10Private50
4Female51MarriedBS25Public55
5Female30MarriedMS6Private60
6Female32SingleBS5Private45
7Female27MarriedBS5Public55
8Male33MarriedBS10Public40
9Female26MarriedMS7Public45
10Male40MarriedBS18Private45
11Female25MarriedBS9Public50
12Female34SinglePHD10Private45
13Male39MarriedPHD13Private75
14Male35MarriedMS10Public60

Main and subcategories.

Main categorySubcategoriesCodes
Disrupted value systemImpaired moral integrityThe sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, and scarifying for the organisation
Breaking the moral frameworkFailure to observe the ethical framework, Failure to observe the ethical rules, the sense of bypassing the issue, ignoring ethical principles.

Disrupted Value System

Disrupted value system was the main category in this study, which included two subcategories of “impaired moral integrity” and “breaking the moral framework”. This category refers to the fact that, the experience of nursing care managers in disrupted value system is associated with the sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, scarifying for the organisation, failure to observe the ethical framework and rules, ignoring ethical principles and moral degradation.

Impaired Moral Integrity

Impaired moral integrity in nursing has become a challenging issue among nursing care managers that leads them towards disruption of their value system. Nursing care managers illustrated their experiences through phrases such as; sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, and scarifying for the organisation. In this regard, one participant stated:

“When you know about the condition of a patient and the lack of visits by the doctors, you know that you are lying and not telling the truth. You are lying about something that you know it is not true, and then, when the patient does not even complain, you feel very bad. You tell yourself, how would I feel if I was in the position of that patient? It is not a good feeling. You actually are scarifying yourself for the organisation to do what? You do this at the expense of denying your own beliefs and values that were sacred for you before.” (P 1).

The participant number 10 acknowledged that: “As a matron, part of what I consider to be professional is to attract people, who have knowledge, skills and professional ethics, to the system to care for the patient. However, I have a staff that I suspected him to have addiction, so I secretly tested him for addiction and the result was positive, but I could not dismiss him. When I discussed the issue with him, I found out that he takes care of a sick family member on his own, so I could not dismiss him. However, it made me feel that I did not adhere to the principles, values and the red lines that I believed in, and this upsets me all the time”.

Another participant in this regard stated: “I was in the ward 5, where one of the doctors came and, for personal reasons, asked for the replacement of a nurse who was caring for a chronic patient and took the matter to the director’s office, where they asked me to do so. So I had to replace the nurse despite my wishes, even though she was a very good staff with high morality. Later, when the patient asked for the same nurse who was looking after him, I had to lie. I had a sense of emptiness as I could not keep that staff. Even now, thinking about that makes me feel that, my value is been separated from my performance.” (P 12).

Breaking the Moral Framework

The category of breaking the moral framework included concepts, such as failure to observe the ethical framework, the sense of bypassing the issue, ignoring ethical principles, and moral degradation. Below are some of the nursing care managers’ experiences in this regard:

A participant stated that:” IV infusion is a good example. For instance, in the morning you come to work and take over the shift when a patient says that the previous shift has not administered his IV infusion for him. So you do some checking and realise he has not received his infusion. In such situation if you tell the patient that he is right and his IV infusion has been missed, he will lose his trust in nursing staff and leave the ward unsatisfied. His family may say that; I will take my patient some where else where he can receive a proper care, this is the time that you have to lie and say his doctor has ordered to stop his infusion or something else to convince him his infusion has not been missed. Then, you will have to face yourself and start to feel, you have some how by passed the issue and you know this is immoral.”(P 9).

In addition to above statements, another participant, in regard to ignoring the ethical principles, stated: “We had a patient in the ICU who had just been extubated and was ready to be transferred to the ward. A novice nurse instead of vitamin B injected him with Atracurium and the patient had to be intubated again. So when the patient’s family asked for the reason for re-intubation, I had to lie to them and say it was because of his initial infection. The additional cost was unfortunately added to the patient’s bill. It was in that time when I felt how much I have become morally degraded. Later, I resigned from the ICU because I could not forget that experience and the fact that, how much I ignored the ethical principles.”(P 11)

Another participant in this regard acknowledged: “One night, one of the main doctors in the hospital, who was also a stockholder of the hospital, brought a relative to the emergency room and wanted him to be transferred to the ICU to receive more care, but there was no vacant bed in the ICU. He ordered one of the ICU patients to be transferred to the ward so his patient could be admitted to the ICU. One of the alert patients was selected and, despite his need for ICU, and his reluctance, crying and stress, he was transferred to the ward. At that time I experienced a very bad sense of moral degradation. Despite the need of that patient for ICU, we did an unprofessional and unethical practice and transferred him to a ward at 2 o’clock in the morning when he was resting, just to admit the doctor’s relative. The sense of moral degradation could not leave me and the thought that, how much we have become degraded ethically to do such thing just because of the pressure of a shareholder doctor.” (P 14).

Discussion

The findings of this study are related to the experiences of nursing care managers in disrupted value system. This main category included two subcategories, including impaired moral integrity and breaking the moral framework.

The results showed that such experiences, which are caused by the violation of ethical and professional values and the mismatch between value and performance, while having the sense of restriction to do ethical intervention, distort the value system of the individuals and, in some cases, make them to completely abandon the profession. Jiwani B, as an ethicist in his research: “TRANSLATING VALUES INTO ACTION” acknowledged that, moral integrity includes ethical judgment, personal-professional values compatible with performance, professional honesty, and ethical management [23]. Similar to present result, he also wrote; “people who experience moral integrity in their working environments not only recognise the right from wrong, but also adhere to it in practice. Maintaining moral integrity in the workplace is essential, as it not only creates a distress-free environment but also takes credible measures to establish successful inter-professional relationships [23-25]. Another study by McLendon H and Buckner H, indicated that ignoring ethical principles leads to a sense of worthlessness in people after a while, and this, by disrupting moral integrity leads to the disruption of people’s value system and reduction of professional interactions [17]. In this study, nursing care managers stated that when their performance and their decisions had been contrary to their ethical values, they have had a sense of separation from the principles of ethical values and have experienced a great deal of distress. Such experiences have also caused the emergence of a concept such as impaired moral integrity.

In religious texts, religion and ethical values of any society have significant impact on the health, education and political, social and organisational policies, and consequently, the health care. The cultural and religious roots of Iranian people are spreading into health system and pay special attention to ethical issues. The ethical values obtained in the study of Shahriari M et al., show the moral values of nurses. They acknowledged in their research that, since the use of these values and applying them in all levels of nursing practice leads to the value of nursing and the coherence of nursing practice, failure to act on these values leads to the sense of worthlessness, emptiness and moral degradation and, consequently, can prevent the promotion of nursing practice [26]. These results are consistent with the findings of present study. In this study, nursing care managers referred to concepts such as ignoring ethical principles, incompatibility between values and performance, disrupted ethical coherence, and ignoring own beliefs, and stated that experiencing these concepts has led them towards disrupted value system.

One of the categories of disrupted value system in this study was the impaired moral integrity, which included the sense of ignoring own beliefs, distortion of learned values, distortion of transparency, emptiness, victimisation, and scarifying for the organisation. Participants in the present study repeatedly referred to the ignoring of their own beliefs, shifting from their values and lack of coordination between their action and values. They also stated that every time they experience such emotions in their work, they feel they are even more shifting away from their ethical values. Similar studies have also shown that, nursing care managers who repeatedly face the degradation of values in their workplace, gradually develop a sense of worthlessness, victimisation, and incompatibility between values and performance, and this in turn, makes them abandon the profession all together [27,28]. Ganji M and Dalvi M, in a research stated that reduction of distress in clinical environments helps ethical management and leadership and, consequently, can reduce the intention to leave the profession [29]. Thus, the managers, by expanding the culture of ethical values and reducing the occupational stressors, can increase the trust, loyalty and organisational commitment of nurses and, consequently, decrease their work abandonment. They emphasised that, “if we fail to create a moral atmosphere in the workplace, the organisation will move towards the degradation of moral values. They also stated: “shifting away from moral values have a negative and long term impact on the self-esteem of nurses, and this adversely affects the performance of nurses at all levels, family function, and quality of care [29]. In the review studies that have classified and defined the nurses’ moral values, having authority to make decision independently based on ethical principles has been considered as the most important ethical value of nurses. The experts in these studies have considered ethical values and adherence to them as the protectors of human dignity [9,28,30]. According to these results, it can be concluded that if a man for any reason is shifted away from the chain of ethical values and is not able to act in accordance with ethical values, he will suffer an irreparable loss, which creates a favourable ground for the decline of his value system.

Regarding the disputed value system, the second category was breaking the moral framework. Basically, a profession should inevitably fulfil its obligations through a moral framework. The nursing profession is also not excluded from this principle. Professionalism is linked with the commitment to ethical principles, and any disregard for these ethical principles leads to an impaired moral framework [31]. In the current world scenario the role of health centres is increasingly highlighted, nursing care managers in each organisation, have greater responsibilities as the leaders. The professionalism and its moral framework require managers at all levels and institutions to understand these principles and act accordingly [32]. If managers, including nursing care managers, are forced to ignore ethical framework due to organisational reasons or non-written policies, particularly in situations where they experience ethical distress on a daily basis, they would not only violate the ethical frameworks but also experience the sense of disputed value system. Since nursing care managers in every setting are seen as behavioural role models, they must adhere to these ethical values, codes, and behavioural frameworks. Paying attention to ethical models by managers and their management team is a prerequisite for having an ethical environment [33]. The results of present study are also in line with these findings. Nursing care managers referred to concepts such as; failure to observe ethical framework, the sense of by passing the issue, ignoring ethical principles, and moral degradation. In a study by Ravani pour M et al., participants believed that, any disregard for the commitment to ethical principles could undermine the best practices of nurses and their professional qualities [34]. Hence, these results are also consistent with the findings of present study. In a study entitled; “Developing ethical codes in nursing”, Jolaee S et al., pointed out that performance based on ethical principles is one of the main components of providing ethical and quality care. Therefore, it is imperative that nurses, in any position and level, should practice in accordance with the principles of moral values. Adherence to ethical framework reflects nurses’ commitment to society and their profession and improves their sense of satisfaction [35]. According to the results of Jolaee S et al., study, one can conclude that, what conveys a sense of value in nursing profession is the loyalty towards ethical principles. This applies not only to the nursing care managers, but also to all occupational levels. Nursing care managers in this study also acknowledged that disrupted value system for them is like moral and professional degradation, and this creates a sense of worthlessness in them [35].

Studies show that, management and leadership within the ethical framework in nursing has always been a controversial moral issue. The management and leadership of nursing care managers in situation where they are forced to ignore ethical integrity and break the ethical framework create a tense atmosphere. This atmosphere disrupts the performance of personnel under their management and increases their errors, thus the managers would develop a sense of inefficiency in their performance and repeating these experiences would disrupt their ethical values [29,36]. In line with the above mentioned arguments, another study by Ludwick R and Silva MC, refers to ethical framework as a guide in nursing professions. This ethical framework is considered a standard for nurses’ performance. If these ethical codes lead to the ethical performance of nurses, they will create a sense of value in them [37].

Limitation

The authors selected a purposeful sampling for this study; accordingly, the study findings might have very limited generalizability.

Conclusion

The findings of this study suggested that nursing care managers experience a great deal of moral distress on a daily basis and, despite their efforts to manage and tolerate these distresses, they suffer from many psychological complications. The results of this research can propose new meanings of disrupted value system and thus facilitate the plans to control and reduce it based on new meaning. Given the complexity, abstraction and multidimensional nature of the studied phenomenon, these findings can have many implications in the field of nursing management and leadership.

References

[1]Jiménez-López FR, Roales-Nieto JG, Seco GV, Preciado J, Values in nursing students and professionals: An exploratory comparative study Nursing Ethics 2016 23(1):79-91.10.1177/096973301455713525488764  [Google Scholar]  [CrossRef]  [PubMed]

[2]Camicia M, Chamberlain B, Finnie RR, Nalle M, Lindeke LL, Lorenz L, The value of nursing care coordination: A white paper of the American Nurses Association Nursing Outlook 2013 61(6):490-501.10.1016/j.outlook.2013.10.00624409519  [Google Scholar]  [CrossRef]  [PubMed]

[3]Bartram D, Curwen A, Hardy B, Building a thriving workforce In Practice 2012 34(6):355-61.10.1136/inp.e3809  [Google Scholar]  [CrossRef]

[4]Eskandari F, Comparison of nurses between Iran and other world basij news 2015 [cited 2015 17 october] Available from: http://tnews.ir/news/852f41018330.html  [Google Scholar]

[5]Mirzabeigim. Iranian nurse managers meeting. Iran: Ministry of Health and Medical Education; 2016 [cited 2016 20 october]; Available from: http://behdasht.gov.ir/?siteid=1&pageid=1508&newsview=148722  [Google Scholar]

[6]Christovam BP, Porto IS, Oliveira DCd, Nursing care management in hospital settings: the building of a construct Revista da Escola de Enfermagem da USP 2012 46(3):734-41.10.1590/S0080-62342012000300028  [Google Scholar]  [CrossRef]

[7]Senna MH, Drago LC, Kirchner AR, Dos Santos JLG, Erdmann AL, De Andrade SR, Meanings of care management built throughout nurses’ professional education Northeast Network Nursing Journal 2014 15(2):196-205.10.15253/2175-6783.2014000200003  [Google Scholar]  [CrossRef]

[8]Skytt B, Ljungren B, Carlsson M, The roles of the first-line nurse manager: perceptions from four perspectives J Nurse Management 2008 16(1):1012-20.10.1111/j.1365-2934.2006.00684.x  [Google Scholar]  [CrossRef]

[9]Toren O, Wagner N, Applying an ethical decision-making tool to a nurse management dilemma Nurse Ethics 2010 17(3):393-402.10.1177/096973300935510620444780  [Google Scholar]  [CrossRef]  [PubMed]

[10]Wlody G, Nursing management and organizational ethics in the intensive care unit Crit Care Med 2007 35(1):S29-S35.10.1097/01.CCM.0000252910.70311.6617242604  [Google Scholar]  [CrossRef]  [PubMed]

[11]American Nurses Association. Code of ethics for nurses with interpretive statements. 1, editor. America: American Nurses Publishing; 2015  [Google Scholar]

[12]Shakeriniya E, Ethical Distress, Hiddend Stress in Nursing Ethics and Medical History 2012 4(4)  [Google Scholar]

[13]Giordani JN, Bisogno SBC, Silva LAAd, Perception of nurses regarding management activities for user assistance Acta Paulista de Enfermagem 2012 25(4):511-16.10.1590/S0103-21002012000400005  [Google Scholar]  [CrossRef]

[14]Jaafarpour M, Khani A, Evaluation of the nurses’ job satisfaction, and its association with their moral sensitivities and well-being J Clin Diagn Res 2012 6(10):1761-64.10.7860/JCDR/2012/4068.263823373046  [Google Scholar]  [CrossRef]  [PubMed]

[15]Nasrabadi AN, Khoobi M, Cheraghi MA, Joolaei S, Hedayat MA, The lived experiences of clinical nurse managers regarding moral distress Journal of Medical Ethics and History of Medicine 2018 11(1)  [Google Scholar]

[16]Varcoe C, Pauly B, Storch J, Newton L, Makaroff K, Nurses’ perceptions of and responses to morally distressing situations Nursing Ethics 2012 19(4):488-500.10.1177/096973301143602522619236  [Google Scholar]  [CrossRef]  [PubMed]

[17]McLendon H, Buckner H, Distressing situations in the intensive care unit Dimensions of Critical Care Nursing 2007 26(5):199-206.10.1097/01.DCC.0000286824.11861.7417704676  [Google Scholar]  [CrossRef]  [PubMed]

[18]Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson J, The relationship between moral distress and perception of futile care in the critical care unit Intensive and Critical Care Nursing 2007 23(4):256-63.10.1016/j.iccn.2007.03.01117681468  [Google Scholar]  [CrossRef]  [PubMed]

[19]Rice EM, Rady MY, Hamrick A, Verheijde JS, Pendergast DK, Determinants of moral distress in medical and surgical nurses at an acute tertiary care hospital Journal of Nursing Management 2008 16(1):360-73.10.1111/j.1365-2834.2007.00798.x18324996  [Google Scholar]  [CrossRef]  [PubMed]

[20]Lewis S, Qualitative inquiry and research design: Choosing among five approaches Health Promotion Practice 2015 16(4):473-75.10.1177/1524839915580941  [Google Scholar]  [CrossRef]

[21]Creswell J, PlanoClark V, Designing and conducting mixed methods research 2012 2ndThousand OaksCA sage  [Google Scholar]

[22]Graneheim U, Lundman B, Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness Nurse Educ Today 2004 24(2):105-12.10.1016/j.nedt.2003.10.00114769454  [Google Scholar]  [CrossRef]  [PubMed]

[23]Jiwani B, Ethically justified decisions Healthcare management forum 2015 Los Angeles, CASAGE Publications Sage CA10.1177/084047041456266325838581  [Google Scholar]  [CrossRef]  [PubMed]

[24]Mack S, How to Incorporate Ethics at Work 2018 :1Available from: http://smallbusiness.chron.com/incorporate-ethics-work-26131.html  [Google Scholar]

[25]Scott S, Examples of Integrity in the Workplace2018: Available from: Small Business - Chron.com http://smallbusiness.chron.com/examples-integrity-workplace-10906.html  [Google Scholar]

[26]Shahriari M, Mohammadi E, Abbaszadeh A, Bahrami M, Nursing ethical values and definitions: A literature review Iran J Nurs Midwifery Res 2013 18(1):1-8.  [Google Scholar]

[27]Mitton C, Peacock S, Storch J, Smith N, Cornelissen E, Moral distress among health system managers: exploratory research in two British Columbia health authorities Health Care Anal 2011 19(2):107-21.10.1007/s10728-010-0145-920217482  [Google Scholar]  [CrossRef]  [PubMed]

[28]Shahriyari M, Abbas zadeh A, Mohammadi I, Bahrami M, Definition on nursing ethics value from Quran and Islamic literatures Bioethics Journal 2016 4(14):27  [Google Scholar]

[29]Ganji M, Dalvi M, The Impact of ethical leadership on job stress and occupation turnover intention in nurses of hospitals affiliated to Shahrekord University of Medical Sciences Journal of Shahrekord University of Medical Sciences. [Research] 2014 16(1):121-28.  [Google Scholar]

[30]Duthie K, Bond K, Juzwishin D, Improving leadership through values-based decisions. Healthcare management forum 2014 Los Angeles, CASAGE Publications Sage CA10.1016/j.hcmf.2014.08.00925671880  [Google Scholar]  [CrossRef]  [PubMed]

[31]Epstein B, Turner M, The nursing code of ethics: its value, its history The Online Journal of Issues in Nursing 2015 20(2)  [Google Scholar]

[32]Sanjari M, Zahedi F, Aalaa M, Peimani M, Parsapoor A, Aramesh K, Code of ethics for Iranian nurses Journal of Medical Ethics and History of Medicine. [Research] 2011 5(1):17-28.  [Google Scholar]

[33]Bostani S, Strategies to promote professional ethics in nursing education system Development Strategies in Medical Education. [Research] 2015 2(2):13-22.  [Google Scholar]

[34]Ravani pour M, Vanaki Z, Afsar L, Azemian A, The standards of professionalism in nursing: the nursing instructors’ experiences Evidence Based Care 2014 4(1):27-40.10.7748/ns2013.06.27.40.26.s35  [Google Scholar]  [CrossRef]

[35]Jolaee S, Bakhshandeh B, Mohammadebrahim M, Asgarzadeh M, Vasheghanifarahani A, Shariat E, Nursing code of ethics in Iran: the report of an action research Journal of Medical Ethics and History of Medicine. [Research] 2010 3(2):45-53.  [Google Scholar]

[36]Zahra Masumi SZ, Golalizadeh Bibalan F, Roshanaei G, Observance of midwifery Code of Ethics among midwifery students and its related factors. 2016. [Code of Ethics; Midwifery; Professional Ethics] 2016 10(35):2010.21859/mej-103511  [Google Scholar]  [CrossRef]

[37]Ludwick R, Silva MC, Ethics: nursing around the world: cultural values and ethical conflicts Online Journal of Issues in Nursing 2000 5(3)  [Google Scholar]