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CHAPTER TWO
Literature Review
2.1 Concept of ethics in nursing.
The concept of professional ethics has been used extensively in
literature and scholars have developed various perspectives about it.
Creasia and Parker (2013) define ethics as an expected standard and
behavior of a group as described in a professional group’s code of
conduct. Pera and Van Tonder (2015) corroborate this by describing
ethics as being focused around word such as right, wrong, good, bad,
ought and duty. To the latter, some individuals within a professional or
occupational arena would come together to define what should be and
what should not be, what duties are bad or even good and these would
have to be the standard way of doing things amongst them. These
ethics are often codified into a body of knowledge and referred to as
the professions’ code of ethics.
Within nursing practice, the code of ethics is a set of normative
principle that underlies nurses’ purpose and associated value. These
codes of ethics are meant to explain the professional tasks,
responsibilities and obligations of nurses towards patients. They are
also meant to guide the action of nurses and the decision they take in
line of their duties as well as inform the public of the intent of nursing
(Vanlaere and Gastmans, 2014). Gastman’s (2016) affirms this by
defining nursing as the total skills and attitudes used in providing care
to a fellow person.
Nursing, like many other professions has ethics that are to orient the
professional conduct and behavior of practitioners. Johnston (2014)
explained nursing ethics to be the examination of all bioethical and
ethical issues from the view of theory and practice taking into
consideration culture, environment and other factors, ethics thus
become the foundation of committed service to the people within
nursing practice.
Therefore, ethics in nursing is defined as a set of expected standards
and behavior which governs the nursing profession with regards to
morality and acceptable conduct of professional nurses.
2.1.1 Nursing as a Profession
Nursing is a profession concerned with the provision of services
essential to the maintenance and restoration of health by attending the
need of the sick person (William C, ShielJr 2018).
Professionalization is an important characteristic of in-service careers.
The concept of professionalization is expressed in terminology of many
job groups and has a long history. Especially in social context over the
years, many people spoke about the professionalization in nursing and
it features; therefore, there are multiple definition and characteristics
for professionalization in nursing (Fateneh, Mahvash and Mohammead
2016). Professionalization describes education, training and other
activities that transform a worker into a professional and social
professes by which an occupation becomes a profession (Stuart Berg
Flexner, 2012).
Nursing profession status is an inter profession and intraprofession
challenge among nurses, sociologist and historians for many years,
other scientist considered nursing as a semi-professional career. Until
1970, nursing profession was considered as a female work, women
were considered as barriers to professionalization. In nursing to their
high work load and part-time work. Gradually, development of
education standards and professional certificate led nursing move to
professional status. Nursing is a profession within health care sector
focused on the care of individuals, families and communities so they
may attain, maintain or recover optimal health and quality of life (Will
Erstad, 2019).
Nursing is the protection, promotion and optimization of health and
abilities, prevention of illness and injury, alleviation of suffering through
the diagnosis and treatment of human response and advocacy in the
care of individual, families’ communities and population. (ANA, 2012).
Nursing encompasses autonomous and collaborative care of individuals
of all ages families, group and communities, sick or well in all setting
(International Council of Nurses, 2014).
2.1.2 Nurses Level of Adherence to Ethical Principle
Ethical codes are guidelines that orient nurses and ensure that their
decisions are in accordance with the value of the professional system.
These codes show that there is a connection among value, patients’
right and nurses’ duties.
In recent years, healthcare communities have decided to formulate
their norms and values as code of ethics. Considering cultural
differences, ethical values in nursing and healthcare as a human
oriented system have attracted a lot of attention. Advancement in
technology has increased costs of health care, and organizational
changes in the society and also the healthcare system have created
significant problems and challenges for nurses. As a result, they need
professional competence and a framework provided by code of ethics
to make correct judgments during their work, and that is why the
development of ethical codes is considered so vital (Will Erstad, 2019).
Studies have shown that knowledge and application of ethical code is
not so practical for nurses (Numminen, Arend, Leinoklilpi, 2013). Many
nurses do consider the code of professional ethics when faced with
ethical issue, but do not act upon it. In most cases, they do not possess
the power and support to react according to the code, and sometimes
they simply do not know what to do (Wood M. 2015).
Very few studies have been conducted on the level of adherence to
ethical codes among nursing students and nurses, but the results are
contradictory. According to Johnstone (2013), 70% of patients, 86% of
nurses and 53% of nurse managers described nurses’ adherence to
ethical codes/principles as satisfactory. Yet another study conducted by
Vanlaere (2015) showed that only 41.8% of patients found nurses’
adherence to ethical codes to be satisfactory. (Joolaee et al, 2013)
stated that only 39.7% of patients were highly satisfies with nursing
service. According to Borhani et al, (2013) although most nurses and
nursing students were aware of nursing ethics and its significance in
their profession; they were highly concerned about their own capability
to implement ethical codes in clinical setting. (Mostafa, Fareba &
Banafsheh. 2017).

2.1.3 Components of Ethical Principles.

According to American nurses’ association (2017), the following are
component of nursing ethical principle.
• BENEFICENCE: Doing good and right to the patient. The principle
states that healthcare providers must do all they can to benefit
the patient in each situation. All procedures and treatment
recommended must be with the intention to do the best for the
patient.
• AUTONOMY: Autonomy is a vital concept in various contexts,
including ethics, philosophy, and healthcare. In the context of
nursing, autonomy refers to the ability of nurses to make decisions
and act independently, free from external control or influence.

• JUSTICE: Nurses must be fair when they distribute care. For

example, among group of patients that they are taking they of,
care must be fair, justly and equitable among group of patients.
• ACCOUNTABILITY: Accountability is accepting responsibility for
one’s own action. Nurses are accountable for their nursing care
 and other actions. They must accept all professionals and personal
consequences that can occur as a result of their actions.
• FIDELITY: Fidelity is keeping one’s promises, nurses must be
faithful and true to their professional promises and responsibilities
by providing high quality and safe care in a competent manner
• VERACITY: Veracity refers to the duty to tell truth. Nurses must be
completely truthful with patients; nurses must not withhold the
whole truth with clients even when it will lead to patient distress.
• CHARACTER: Refers to mental and moral qualities distinctive to an
individual. A characteristic of a good nurse is one that shows
empathy to each patient, making a true effort to put themselves
in their patient shoes.
• NONMALEFICENCE: Nonmaleficence is to do no harm. This is the
most well-known of the main principles of nursing ethics. More
specifically, it is selecting interventions and care that will cause the
least amount of harm to achieve a beneficial outcome.
• INTEGRITY: This refers to the quality of being honest and having
strong moral principles. Nurses must act according to the
regulatory belief of the hospital or institution you work for and
upholding their standards and expectations regarding patient care.
2.1.4 Nurses Perception on Ethical Issues
Perception is defined by Motamed-Jahromi (2012) as the ability to see,
hear or understand certain event and apply assumption about the
world’s arrangement to integrate sensory information. Perception of
ethics in nursing practice is influenced by the social context within
which the nurses are found. The role of perception of ethics and it
influence on the conduct of nurses regarding how they handle patient
provide efficient and efficacious method of promoting and enhancing
quality of care (Valimiki, Katajisto and Suhonen, 2014).
Leino-Kilpi et al (2013) compared the perception of nurses and elderly
patients’ perception of the realization of autonomy, privacy and
informed consent and found out that there are varied opinions about
how well ethical provision are maintained in nurses’ profession and
practice. Yeh et al (2013) suggest that there should be a connection
between traditional ethical education and nurses’ perception of clinical
reality through the development of operative curricula to ensure nurses
the development of operative curricula to ensure nurses clear
understanding of ethical issues in their profession.

2.1.5 Level of Knowledge of Nurses on Ethics in Nursing Profession

It is known that nurse need more preparation with knowledge, skills
and the ethical competences to fully assume their place in making
healthcare system safer. (seneada plunge plange-Rhule,2014).
Nurses have been found to be deficient in their ability to demonstrate
the competencies necessary to engage in ethical reflection, ethical
decision making and ethical behaviour. (Cannarts, Gastronomes and
Diatec de Castille 2014). This raises issues with how nurses are able to
perform their professional duties in ways that are consent with the
requirement of the nursing profession. Some nurses believe that they
are not adequately prepared to handle ethical problems in line with
their professional practice because of the issue of insufficiency of ethics
education during nursing training (Vynkier et al, 2014). Such nurses go
on practice without having acquired the capacity to meet the necessary
ethical challenges that the profession presents.
A study by Smith, Witt, Klaasen, Zimmerman and Cheng (2012) revealed
that trainee nurses often prioritized the clinical aspects of their training
over the ethical aspects.
(Gasman, 2013) believes that it is important that nurses are given the
requisite education in ethics in order that they will develop ethical
sensitivity, he believes it will make them develop the capacity to discern
the ethical meanings of a particular situation and know the appropriate
response strategy. The depth of nurse’s knowledge of ethics in
profession is worth knowing given that it forms an important aspect of
accepting standards in line of their conduct as professionals.
Ethical dilemma in nursing practice is the situation that need critical
thinking in making decision, which are cost containment issues and
making quality of life and other decisions in patient best interest, with
this during professional training nurses are trained and equiSpped to
understand how to deals with critical situation during rendering care.

2.1.6 Monitoring Ethics in Nursing Practice

The nursing practice upholds its own code of ethics and this is regulated
by strict disciplinary guidelines, with the governing body having more
influence over its member than legislative entities in medical matters.
The department of health issued a health service circular 219.99, which
mandated some requirements of new nursing education programme. In
the nursing and midwifery order 2001, the nursing and midwifery
council (NMC) must establish minimum standards and requirements for
nursing education in professional and ethical issues. (General Medical
Council 2013).
The NMC is an organization established by parliament to protect the
public and regulates the medical and nursing professional standards
using the Register of Medical Practitioners (RMP). The register acts to
allow the monitor entry to the profession and also by monitoring
“fitness to practice” proceeding to ensure all practitioners maintain
consistently high standard of conduct (Nursing & Midwifery Council
2010).
In Nigeria, the Nursing and Midwifery (Registration C.T.C) Act of Cap,
N143 laws of the Federation of Nigeria 2004 provides that the nursing
and midwifery council of Nigeria is the only legal, administrative and
statutory body charged with the responsibility to regulate the standards
of nursing and midwifery practice and code of conduct in the country.
This statute which relates to the ethical nurse and patient relationship is
mostly universal in nature of it is rare to see a wide gap between the
ethics governing the Nigerian nurse and her foreign counterpart, right
from the Florence nightingale pledge of 1983, Nurses pledge of 1950,
American Nurses Association Code for Nurses, International Code of
Nurse (ICN) and down to the National Association of Nigeria Nurses and
Midwives (NANNM) code of ethics. (UniniChioma, 2016).

2.2 Theoretical Review

There are lots of theories that explain professional ethics (ethical
principles). The theoretical orientations this study adopted were; the
deontological and utilitarianism theories.

DEONTOLOGICAL THEORY
Deontology is an ethical theory concerned with duties and rights. The
founder of deontological ethics was a German philosopher named
Immanuel (1724-1804) Kant believed that an act was moral if its
motives or intention were good, regardless of the outcome. Ethical
action consists of doing one’s duty or honoring one’s obligations to
human beings, to do one’s duty was right not to do one’s duty was
wrong. The outcomes or consequences of an action can be desired or
deplored, but they are not relevant from deontological perspective
(Stanford Encyclopedia of philosophy, 2014)
Deontology is derived from the Greek word “Deon means duty and
“Logos”, science” Kant believed that ethical actions follow universal
moral laws, such as “Don’t lie”, “don’t steal”. “Don’t cheat”.
Deontology theory is relevant in this work due to the fact that it
supports the need for nurses to use adherence to ethical principles as a
moral duty and a right of patients, because it advocates to make
assumptions that nurses should base their work on duties, rights and
respects for individuals. More emphasis is placed on the intention of
the individual instead of the outcomes of the action. The deontology
theory requires that nurses totally conform to laid down ethical
obligations and act towards these obligations with a sense duty (Kurtz &
Burr, 2016).
When nurses understand and perceive their ethical standards as a duty
then they will adhere to them. If this understanding is established,
there would be no complaints from patients as well as clients visiting
health institutions.
UTILITARIANISM THEORY
Utilitarian theory was first described by David Hume (1711- ) this theory
was developed further by English philosophers and economist Jeremy
Benthan and John Stuart Mill.
Those who subscribe to utilitarian theory of ethics believe that “what
makes an action right or wrong is its utility, with useful action bringing
about the greatest good for the greatest number of people” (Gyuido
2016, p.4). In other words, maximizing the greatest good for the
benefit, happiness or pleasure of the greatest number of people moral.
Utilitarian theory considers primarily the consequences of action and
claims that actions are judged as right or wrong in relation to the
balance of their good and bad (Bauchamp&Childress, 2014; Burkhardu
and Nathaniel, 2015). The utilitarian theory has both advantage and
disadvantage. Gibson (1993), asserted that “the advantage of
utilitarianism is that the consequences of action are taken seriously and
the disadvantage is that the concern with aggregate happiness
overlooks the value of the individual who, although in a minority may
deserve help.
The utilitarian theory is relevant to this study because, nurses face
multiple challenges encircling ethical dilemmas. There is always
complained on lack of adherence to ethical principles by the society
members especially regarding the best choice. The nurse is often the
person who acts as an advocate and resource to the patient, one of the
ethical tools which nurses rely upon in these challenging situations is
the ethico-legal process. The four principles of health care ethics
namely (Autonomy, Beneficence, non-maleficence and justice)
presented by (Bauchamp and Childress, 2013) provide the nurse a
direction to estimate the significance of the ethical decision in clinical
setting which provides happiness to the greatest number of their
patients and avoid any action that can provide pain or harm their
patients.
Adherence to ethical principles of nursing always help nurses to provide
high quality of care of their patient which in turn guide them to fulfill
their patient’s health needs, therefore maximizing the benefit to their
health and protect themselves, from unethical practices that might
bring consequences to their work negligence, malpractice and sanctions
to their work. By understanding utilitarian theory of ethics nurses can
have dealt with dilemmas ethically and legally based on the greatest
amount of benefit. (Anarado, 2012).
2.3 Empirical Review
Bijani M, (2017) conducted a research on nurses level of adherence to
ethical principle among working class nurses, qualitative research
approach and descriptive – analytical study design were adopted to
conduct the study to compare and evaluate observance of ethical code
among working class nurses. Sampling was done via non-random
census method. Data was collected using structured questionnaire;
findings revealed that 55.5% had good knowledge on adherence to
ethical principle.
Another study was conducted with an objective to assess the level of
adherence to ethical principles among nurses by (Mmomennasab
2016). In this study, descriptive – comparative study was adopted, data
were collected using three questionnaires based on Iranian nurses
ethical codes with a focus on clinical care. The reliability of the
questionnaire was verified by test – retest method. After all, the data
were analyzed using the SPSS Statistical Software. According to the
results, 86% of the nurses adhere to ethical principles.
Andrews Nartley, et al (2017) this study aim to compare the view point
of patients, nurses regarding the extent to which clinical ethical codes
are observed a descriptive cross-sectional study, which involved 30
ophthalmic practitioners. The practitioners were purposely sampled
from four government hospital in Republic of Ghana. Respondents were
required to complete a simple self-administered questionnaire. The
questionnaire was designed to elicit responses on practitioners’
awareness of the ethical code and the patient’s charter. A total of 30
practitioners participated in the study, 11 (36.7%) of the practitioners
were male while 19 (63%) were female. The result shows 86% reviewed
the code of ethics while 16% were able to fully implement the patient
charter in their practice.