Journal of Medical Ethics and History of Medicine

Original Article

Obstacles and problems of ethical leadership from the perspective of nursing

leaders: a qualitative content analysis

Maasoumeh Barkhordari-Sharifabad1, Tahereh Ashktorab2*, Foroozan Atashzadeh-Shoorideh3

1PhD Student in Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran;
Department of Nursing, School of Medical Sciences, Yazd Branch Islamic Azad University, Yazd, Iran.
2Professor, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical

Sciences, Tehran, Iran.

3Assistant Professor, Department of Nursing Management, School of Nursing and Midwifery, Shahid Behshti University of

Medical Sciences, Tehran, Iran.

Corresponding Author: Tahereh Ashktorab

Address: Vali-Asr Avenue, Cross of Vali-Asr and Neiaiesh Highway, Opposite to Rajaee Heart Hospital, Tehran, Iran.
Postal Code: 1996835119.
Email: [Link]@[Link]
Tel/Fax: +98 2188655366

Received: 25 Jul 2016

Accepted: 5 Feb 2017
Published: 21 Feb 2017

J Med Ethics Hist Med, 2017, 10:1

© 2017 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences. All rights reserved.

Abstract
In the nursing profession, leadership plays a significant role in creating motivation and thus enabling nurses to provide high quality
care. Ethics is an essential component of leadership qualifications and the ethical leader can help create an ethical atmosphere,
offer ethical guidance, and ensure the occupational satisfaction of personnel through prioritizing moralities. However, some
issues prevent the implementation of this type of leadership by nursing leaders. The aim of this study was to identify and describe
some problems and obstacles in ethical leadership faced by nursing leaders, and to help them achieve more accurate information and
broader perspective in this field.
The present study was conducted using a qualitative approach and content analysis. A total of 14 nursing managers and
educators were selected purposefully, and deep and semi-structured interviews were conducted with them. Content analysis was
performed using an inductive approach.
Three main categories were obtained after data analysis: ethical, cultural and managerial problems. “Ethical problems” pertain to doubt
in ethical actions, ethical conflicts and ethical distress; “cultural problems” include organizational and social culture; and “managerial
problems” are connected to organizational and staff-related issues.
Nursing leaders put forth various aspects of the problems associated with ethical leadership in the clinical setting. This style of
leadership could be promoted by developing suitable programs and providing clear-cut strategies for removing the current
obstacles and correcting the organizational structure. This can lead to ethical improvement in nursing leaders and subsequently
the nurses.

Keywords: Ethical leadership, Nursing, Content analysis, Qualitative research

J Med Ethics Hist Med 10: 1, February, 2017 [Link] Maasoumeh Barkhordari-Sharifabad et al.

Introduction values and a population of more than seventy million

Today, health care organizations are subject to rapid people. Islam is the formal religion in this country
and fundamental changes aimed at enhancing the (18), and a combination of Iranian and Islamic
quality of service, patient satisfaction and cultures form its identity. The religious discipline
productivity (1). Parallel with these changes, nurses and cultural beliefs of the Iranian people have
face cases such as heavy workload, increased patient entered the health care system and ethical issues are
awareness, various problems related to staff skills, prominent in the patient care protocols (19, 20). The
lack of resources, low occupational and life quality, nursing manpower in Iran is estimated to exceed
and workplace violence (2). However, there is the 150,000, forming a considerable portion of the health
expectation that nurses should treat patients in an care staff. The Iranian health system, like any other
ethical manner and put ethics first in their developing country, suffers from limited manpower
professional performance. Across the world, nurses and financial resources inconsistent with health care
are guided to use professional codes that emphasize requirements (20).
their obligation to respect, protect and defend the Similar to their peers in many other countries,
fundamental rights of the people involved in nursing Iranian nurses are dissatisfied with their jobs due to
and health care (3). work pressure and shortage of time and resources
One of the most powerful methods to promote ethics that prevent them from proper fulfillment of their
in health care and the nursing practice is to role duties (21). Furthermore, they have been shown to
model ethical performance on the managerial level suffer from inappropriate work environment, lack of
(4). Nurses in formal leadership positions should support, discrimination, conflict, limited
promote ethics (5), which means they should opportunities for development, dissatisfaction with
implement ethical leadership (6), an approach that work conditions due to heavy workload and unusual
has attracted much attention in recent years. This work hours, lack of power, and undesirable social
style of leadership involves the development of status (22). Government policies have resolved
appropriate normal behavior through personal nurses’ concerns to some extent, including workload
actions and interpersonal interactions, and also and nurse-patient professional issues; however, there
promotion of such behaviors in subordinates through is still the need for a solution to increase the quality
bilateral exchanges and strengthening of decision- of care and improve patient safety (20, 23).
making (7). Ethical leaders must strive to model and It seems that these problems are imposed by lack of
support ethical performance (4) and at the same time leadership skills in nursing managers. Studies have
be sensitive to moral issues and enhance nurse's revealed that task-oriented behaviors are the
performance by fostering respect for human dignity; dominant style of health care leaders and educational
thus, they can play an important role in promoting systems in Iran (24). Leadership plays a role in
patient safety (8), increase the capacity to discuss creating a culture of care (25), and leadership ethics
and act upon ethics in daily activities (9), and and confidence in nursing leaders are important
support the ethical competence of nurses (10). components of a healthy work environment culture
Some studies in this field have indicated that ethical (6, 17, 26, 27); therefore, this study aimed to identify
leadership leads to reduced work leave and increased the barriers that impede the application of ethical
job satisfaction in nurses through decreasing moral leadership in health care settings in Iran. Thus, the
distress and creating an ethical milieu (11). authors decided to conduct a qualitative research in
Furthermore, this style of leadership boosts this field from the perspective of formal nursing
confidence in the leader, organizational commitment, leaders in order to get more detailed information on
and psychological empowerment among the the nature of the problems and obstacles in ethical
personnel (12). Moreover, it exerts considerable nursing leadership.
effects on the staff’s creativity and their energetic
feeling (13). Disappointment and lack of confidence, Method
commitment and motivation are among the side The present study used conventional qualitative
effects of leaders’ unethical behavior that influence content analysis and purposive sampling to
both patients and organizational efficacy negatively investigate the problems and obstacles of ethical
(14). Some studies have demonstrated that the leadership in nursing. Conventional content analysis
leaders’ supportive behavior and confidence in is usually the preferred method in studies that focus
management are essential for stabilizing nursing on elucidating a phenomenon. This design is suitable
values. These behaviors include empowering nurses to when there are limited numbers of existing theories
express their concerns and worries, and providing or sporadic literature on the phenomenon under
recommendations for improving their work study. In this case, the researchers avoided the
environment and nursing care (15 - 17). application of presupposed categories and managed
The Islamic Republic of Iran is located in the Middle to distill the categories from the data. Hence, the
East and enjoys one of the oldest civilizations of the categories are manifested through deduction (28).
world. It is a developing country with specific ethical

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Seeing that in the qualitative approach, the continued till data saturation was achieved so that no
phenomena must be investigated in their natural new code of data could be retrieved.
context, the hospitals and nursing schools of Tehran, In this study, the common points were identified,
Iran, were selected as the research setting. Among coded and categorized by using latent content
the formal nursing leaders, those with at least 2 years analysis. In this method, the researcher searches for
of managerial work experience who wished to specific concepts and the meaning of all the data
participate in the study were chosen. Selection within the context, and will then design the structural
criteria for the educators included experience in model that can relate the meaningful classes with
teaching ethics, leadership status, and publication of similar themes (29).
books and articles in the field of leadership and All interviews were recorded on tape and the
ethics. These individuals possessed deep information transcripts were typed, reviewed and coded at the
and experience related to the subject under study end of each interview. To observe the principle of
(they were key informants) and could provide the confidentiality, participants’ names were not
researcher with much information. As decision- revealed. Instead, each of them was given a specific
makers in the health care system, clinical leaders and number and their important particulars such as age,
university authorities cannot be separated from each type of degree, and managerial experience were
other, and the emergence of ideas on ethics requires recorded.
the participation of both; therefore, nursing educators Data were analyzed simultaneously and continuously
were also involved in this research. Moreover, the by collecting information. Semantic units were
participating educators had some experience in extracted in the form of initial codes or open codes
clinical settings and leadership, and a number of from the interviews. The codes were reread several
them were occupied in the capacity of formal leaders times and placed in subcategories on the basis of
at the time. This study tried to cover a sample with similarity and proportion of the participant
great variety in age, gender, management level, expressing the same topic. Next, the subcategories
department, and work experience. To find the more were compared with each other and those with
experienced participants with a richer reservoir of similar characteristics were combined to create wider
data, the initial sample was used, which included categories, which were presented once more.
nursing educators with a 22-year management Some of the measures taken to enhance data
experience at various levels of nursing as well as accuracy included prolonged involvement with the
teaching ethics. topic, confirmation of findings by the participants,
A total of 14 individual interviews were conducted. and observer reviews. To ensure dependability of the
Data saturation was achieved after 11 interviews, but data, in addition to the members of the research
an additional three were carried out to reach team, two experts out of the research team were
certainty. As confirmed by research participants, the asked to evaluate the interviews, codings and
interviews were held in a quiet room in their categories. As regards the conformability of the data,
workplace at hospitals and colleges. all research steps, including data collection and
All interviews were conducted by the first author, a analysis, observer reviews and the research process
female PhD candidate in nursing, and a nursing were documented on a regular basis. To enhance
instructor. She has received the customary training transferability, the entire process of the research and
for PhD students to prepare for doctoral all the work done in the course of the study were
dissertations, and has also completed a content prepared in clear and accurate written form to enable
analysis workshop. others to track and study population characteristics.
After obtaining the approval and written informed This study was approved by the Human Research
consent from the participants, deep and semi- Ethics Committee of Shahid Beheshti University of
structured interviews were conducted to collect the Medical Sciences in Tehran, Iran. In the course of
data. The interviewer began with general questions the study, permission was obtained from the
and proceeded to ask, “Where is the position of authorities of hospitals, departments and colleges.
ethics in your leadership?” Then, based on the goals The interviewer began by introducing herself and
of the study, the more detailed questions followed, explaining the purpose of the research to the
for instance: “Have you ever been in a situation participants, who were then asked to complete the
where you did not do what was ethical despite being demographic questionnaire and informed consent.
aware of it? Please explain.” and “What happened Moreover, permission to record the interviews and
that led you to behave like that?” take notes was obtained from the participants, and
In order to obtain more data and clarify certain confidentiality and subjects’ freedom to participate
issues, some probing questions were also asked, such in or withdraw from the research was observed. The
as: “Can you give us an example? What did you participants were also assured that their names will
mean by that? Can you explain further?” not be revealed under any circumstances. Interview
Individual interviews lasted for 35 to 90 minutes and tapes are kept anonymously in a safe place and can
the participants were then asked to discuss any be accessed only through codes assigned by the
remaining issues that came to mind. The interviews researcher.

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Results
There were 14 participants with a mean age of 46
years and an average management experience of 12 Table 1: Characteristics of the study participants
years. In terms of managerial level, 3 were Characteristics Number
supervisors (all matrons), 6 were head nurses, and 5 Male 6
were nursing educators (Table 1). Gender Female 8
Analysis of the handwritten notes on participants’ Bachelor’s degree 6
Education
experiences of the problems associated with ethical Master’s degree 3
Level
leadership in nursing resulted in the formation of 73 Doctoral degree 5
original codes, which were reduced to 21 after Head nurse 6
merging similar codes. Eventually, three main Position Supervisor 3
categories and 7 subcategories emerged that are Nursing educator 5
presented in Table 2. Major groups included ethical
problems, cultural problems and managerial
problems.

Table 2: Generated categories, subcategories and examples of codes

Categories Subcategories An Example of the Code
- Negative outcome of introducing a role model to
Doubt in ethical act staff
- Uncertainty about how to deal with staff
- Conflict between the needs and expectations of
nurses
Ethical conflict - Conflict in meeting the similar needs of employees
Ethical Problems - Conflict between leaders’ values and the values of
the organization
- Discomfort following the implementation of
procedures in accordance with organizational policies
Ethical distress and rules
- Dissatisfaction caused by being forced to perform
certain tasks due to shortage of staff
- Absence of a culture of democracy in the
organization
Organizational culture
- Lack of the proper culture in introducing the role
model
- Negative public perception of the nursing
Cultural Problems
community
- Negative feelings of patients’ families with regard to
Social culture
the night shift
- Attitude of the majority of the population to nurses as
physician assistants
- Lack of power and authority in recruitment
- Physician-oriented system
Issues related to organization - Low regard for the nursing profession
- Lack of facilities
Managerial Problems - Characteristics of the clinical environment
- Staff's abuse and bullying
- Undesirable behavior such as speaking ill of each
Issues related to staff
other
- Understanding of justice among personnel

From the perspective of the nursing leaders in this types of problems are sophisticated and pervasive
study, there are three major types of problems and due to their far-reaching implications and varied
obstacles in ethical leadership: ethical, cultural and solutions on the one hand, and uncertain events and
managerial problems. personal impressions on the other. The reason is that
acts performed by nurse leaders affect staff, patients
Ethical problems and other people. If these acts affect others
Ethical problems were among the categories inconsistently, or harm them in an uncontrolled
abstracted from the data. In nursing leadership, these manner, ethical problems arise. This category

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consists of three subcategories of doubt in the ethical to act in accordance with organizational values and
act, ethical conflict, and ethical distress. justify them for the personnel, even though they
A) Doubt in the ethical act: Quite often the might have different opinions. Participant number 9, a
consequences associated with ethical choices are not 44-year-old nursing PhD with 5 years of
clear, and this will make leaders doubt their ethical management experiences states:
performance. Participant number 2 who has a PhD in [It is interesting that sometimes high-level executives or
nursing and 8.5 years of management and leadership security managers tell us to be tactful, and by that they
experiences at various levels puts it this way: mean we should tell a lie, pretend to be more skillful
[I introduced an ethical example to others in a than we actually are, and ignore many things. I'm
meeting, but my ethical act was associated with an not like that.] (Participant No. 9)
adverse result, which made a group of people upset. I Participants believed that ethical leadership is harder
thought I was introducing a model, but others and more complex in the clinical setting than other
thought that I was accusing them of not acting work environments such as nursing education due to a
ethically. Now, I do not know if it was ethical or not, if high rate of ethical conflict:
it is ethical, so why didn’t what we read about in [In my opinion, there is a great deal of ethical
books work?] (Participant No.2) conflict about leadership and management issues in
Some participants stated that doubt in the ethical act is hospitals…. You don’t know who’s right, the patient
a challenge in nursing leadership. For example, or the ward nurse, because nurses work really hard
participant number 11, a 45-year-old nurse with 9 on various shifts and are under a tremendous
years of experiences in different wards says: amount of pressure. On the other hand, you see that
[I try to behave in the correct way and pay attention patients are also right and want to receive the best
to these issues, for example, I try to be friendly with service possible.] (Participant No. 2)
the personnel and respect them, but I see they have C) Ethical distress: Participants stated that when
different perceptions. They take advantage of my they are faced with obstacles that force them to act
kindness…. Sometimes I think maybe I am not doing against their ethical beliefs, they feel discomfort,
it right and I should be like the others and treat them dissatisfaction and frustration. They acknowledged
in a way so they won't dare to disobey me.] that they are often involved in situations where they
(Participant No. 11) know the right way to do things, but organizational
B) Ethical conflict: Differences in ethical values in policies and rules and lack of support from superiors
practice will lead to ethical conflicts. Participants make it impossible for them to perform their duties
admitted that sometimes they are involved in appropriately and this causes them distress and
situations where the needs and expectations of nurses discomfort.
are in conflict with each other. Participant number 6, a [Sometimes I'm asked to do something that is not
38-year-old nurse with a 6-year experience in head within the rules, but is right by logic, reason and
nursing and supervisory says in this regard: humanity. I know that if I do that, the consequences
[I have a novice among my personnel. Well, ethically will come back to me and I’ll be held accountable
I should team her up with a more experienced later. These things make me sad and angry.]
employee, but in such cases, the more experienced (Participant No. 2)
ones will complain because this will increase their Another condition that causes ethical distress in
workload. They may request to work with another nursing leadership is lack of adequate and skilled
person in the same shift. See, you are involved in a manpower in wards. In this regard, participant
situation where you don’t really know what to do, so number 5, a nursing expert with a 20-year experience of
what does ethics say here?] (Participant No. 6) head nursing in different wards says:
Another aspect of the conflict is that both employees [The ward nurse calls me and says her child is sick
have similar desires, and therefore the nurse leader and asks me to give her a day off or change her shift.
experiences negative feelings as to whose needs to I don’t want to say no to her, but I am short on staff,
meet under the circumstances. Participant number so I oblige her to come. The situation makes me very
14, a master of nursing with 20 years of management sad, but I do not have any other choice.] (Participant
experiences at various levels (head nurse, supervisor No. 5)
and matron) says: Similarly, participant number 9, who is a 44-year-old
[When planning shifts, you can't always be fair; for PhD with 5 years of management experience, states:
example, on many occasions, two employees needed a [I am forced to put someone that I don’t trust in
day off on the same date, and it was very important for charge. I just do this so that somebody fills the post,
both of them to take that particular day off. On the because I do not have any efficient workforce. It is
other hand, it was impossible for me to let both of clear that I am very dissatisfied with this situation,
them have a day off because I was short on staff, so I but there is nothing I can do.] (Participant No. 9)
had to choose one.] (Participant No. 14)
Participants stated that sometimes there is a conflict Cultural problems
between their values and beliefs and those of the In data analysis, cultural problems were abstracted as
organization. As nursing directors, they are expected the second category. Like any other institution,

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hospitals and health care centers have their own axes such as inappropriate procedures, guidelines
beliefs and norms that determine the way of and evaluations as well as the poor performance of
thinking, behavior and performance of employees the nursing staff. This category consists of two
within the organization. The beliefs and opinions of subcategories: issues related to the organization and
organization members reflect those of the society in issues related to staff.
which they grew up. The nursing leaders in this A) Issues related to the organization: Lack of
study noted cases that can be classified as cultural authority in recruitment, low regard for nursing,
problems, including two subcategories of social shortage of manpower and resources, and certain
culture and organizational culture. clinical characteristics were mentioned by the
A) Social culture: Culture is a model of values, participants in this respect. Of the above-mentioned
beliefs and attitudes of people in every society, and factors, they considered the first as one of the most
the culture of any organization, including health care challenging. For example, participant number 13, 44
centers, is therefore no exception. Lack of respect for years old, with 15 years of management experience
the nursing profession and the negative public image states:
associated with it were among the cases that the [The problem with our job is that the employment
participants pointed out. This negative attitude has criteria are the same for all the staff; the payment is
an impact on the self-confidence and motivation of also the same… yet, the work done by different
nurses, including nursing leaders. Leaders with low individuals varies from individual to individual. The
levels of self-confidence and motivation cannot play head nurse does not have the authority for proper
their leading and supportive role as may be expected. employment and payments; this is an obstacle to the
In this regard, participant number 9 states: administration of justice.] (Participant 13).
[When I passed the nursing entrance exam, I did not Participants had also experienced a lack of respect
get much positive feedback. My family got upset that for nurses. They said that sometimes decisions are
I was going to nursing school, and, well, that's all it made for the nursing department without considering
takes to diminish one’s self-confidence. It is much their opinions. Nurses are simply asked to implement
better now, but the impact still remains.] (Participant those decisions, and do not even receive
No. 9) explanations and clarifications on the process. For
The Iranian society is a family-centered one, and this example, participant number 8 says:
creates a negative attitude towards women working [Apart from the fact that sometimes they make
late hours and night shifts. Some participants decisions about us without asking for our opinions,
mentioned this as an obstacle to their ethical they do it without even telling us how to implement
practice. For example, participant number 13 says in those decisions, let alone expect us to act ethically.]
this regard: (Participant No. 8)
[The night shift is a problem for some female One source of power for leaders is their authority,
personnel, as their families simply don't understand which is based on reward and punishment. In order
that nursing means working nights and circulating to use these power sources fairly, it is essential to
shifts. Very often you see families call and say, evaluate staff performance, the most important
“Don’t assign X for the night shift.] (Participant No. purpose of which should be the improved quality of
13) patient care and safety. But nursing leaders believe
B) Organizational culture: Organizational culture is that the common evaluation method of staff
a control agent that shapes the attitudes and behavior performance is not fair:
of employees, and the participants pointed out the [We deal with humans in our workplace, so a fair
problems in this area as one of the cases. For evaluation of personnel is hard. For example, they
example, participant number 3, a 52-year-old nursing provide a patient with education, their care quality is
PhD with 7 years of experience in management different from each other, and it is difficult to
states: evaluate how much harm is brought about due to the
[One problem is that there is no culture of errors they make.] (Participant No. 13)
democracy in our organizations, that is, when you Characteristics of health care organizations and in
believe that you should lead a group in a democratic particular clinical environments, which are a
way, you will get hurt.] (Participant No. 3) component of the nursing profession, have created
Another participant says: challenges for ethical leadership:
[People are encouraged to introduce a model in [Given the circumstances of the clinical
ethical leadership. Well, I did, and it caused environment, it is so hard to establish democracy
annoyance, which means that doing so will bother and justice. There are guidelines, instructions and
people and is not conceived as a norm for policies in the clinical environment that might be in
employees.] (Participant No. 2) conflict with the spirit of democracy.] (Participant
No. 3)
Managerial problems B) Issues related to staff: Ethical or unethical
Another issue in the field is connected to managerial behavior and performance of the nursing staff can
problems. These problems revolve mainly around trigger positive or negative consequences at the

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organizational level; thus, non-observance of some The results of this study demonstrated that the
ethical standards is a source of concern for efficient unexpected outcomes of ethical behavior could cause
leaders. One of the things referred to by the nursing leaders to hesitate about performing ethical
participants in this study was abuse and bullying on acts. One issue that is raised in emergence of ethical
the part of nurses. Participant number 10, a specialist complaints is that not all criteria used to justify
nurse with 18 years of management experience ethical beliefs are fair, as they are affected by the
states: ethical beliefs of a culture or a person (34). In one
[There are some people who complain no matter study, Scott states that identification of a right
how you plan their shifts. You give them good shifts performance is a challenge to organizational
that they like, but when they see that others got good resources. She believes that consideration of others’
shifts too, it’s like they feel jealous…. Sometimes views, detection of unintended consequences and
they disrupt your ward’s atmosphere, for example by engaging in continuing education is useful for
irritating someone, and then it is no use trying to be tackling this challenge (30).
just.] (Participant No. 10) Today, ethical conflicts and controversies are
Adherence to ethical values on the personal level is inevitable in health care organizations round the
the individual dimension of ethics, and a lack thereof globe, and this may lead to ethical distress (35). The
will cause greed, selfishness, speaking ill of others, study participants had experienced this conflict
and so on. Such behaviors will lead to an escalation between the nurses’ expectations and needs, their
of conflict in the organization. Participant number 9, own values and beliefs and those of the organization,
a 44-year-old PhD with 5 years of management and the needs of patients and the personnel. Other
experience says: studies have shown that in the changing health care
[When I was manager, I noticed that people can environment, ethical leaders encounter three
perform a lot of unethical acts and sometimes they different values, i.e., individual (power, value and
do whatever they can to cause harm to one another.] respect), professional (patient-centered care) and
(Participant No. 9) organizational values (competition, risk-taking and
Participants believed that members of the staff are position) (31). Lack of balance between care and
different from each other, even if placed in similar management duties may lead to ethical conflict in
circumstances. One challenge faced by nurse leaders leaders (32). Nursing managers experience conflicts
was lack of acceptance of individual differences between individual and organizational ethics,
among the staff, and a sense of injustice. In this especially when they cannot provide quality care due
regard, participant number 7, 47 years old, with 9 to organizational constraints (33).
years of management experience at various levels The results of this study showed that obstacles such
states: as organizational policies and rules, lack of support
[There are too many individual differences among from superiors, and lack of sufficient and qualified
personnel. Well, one considers these in planning manpower will weaken leaders’ capability to
shifts and such, but to make them understand these perform ethical acts and create ethical distress. These
differences is another story. For example, none findings are similar to those of the study by Gaudine
accepts that one person’s quality of work differs and Beaton.
from that of others. They may think that I pay more Their findings revealed that disagreement with
attention to X and have someone’s back more than organizational policies over employee discipline,
others.] (Participant No. 7) centralized decisions, and lack of ethical resources
available to nurses are among the sources of ethical
Discussion distress in ethical leaders (36). Shirey and Fisher
The findings of the present study were similar to believe that ethical distress arises from role
those of other studies on this topic. Three main complexity and increased stress, and is a source of
categories were identified, indicating the psychological stress associated with conflicts
participants’ perceptions and experiences of ethical experienced by nursing managers (37). However,
leadership barriers and problems in the sociocultural due to the descriptive and general nature of
context of the Iranian health care setting. It should be problems, sources of ethical distress were not
mentioned that all formal nursing leaders in this specifically investigated in this study.
study showed a kind of positive feeling and interest Leadership and management are affected by cultural,
with respect to this leadership style. This was to be social, and economical factors. Cultural problems
expected as members of the nursing workforce are were one of the categories extracted from the
committed to ethical practice in their profession (6). participants’ statements. The role of culture in
Ethical problems were among the abstracted human behavior is one of the most important
categories in this research. Nursing leaders concepts discussed in behavioral sciences. In the
experienced doubt in the ethical act, ethical conflicts
present study, participants considered cultural and
and distress in the clinical setting. Other studies with
professional identity as one of the factors
similar findings have also mentioned these issues (30
contributing to the promotion of the profession and
- 33).
professional attitude. Positive or negative cultural

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factors can be seen in any society. For example, studies (53 - 57). In a study by Gilbert et al., 86.2 %
negative attitudes towards nurses expressed by the of nursing managers witnessed bullying by the
participants can be effective on their self-confidence, nurses and 52% of them were victims of bullying
authority, professional socialization process and (56). Aitamaa et al. also investigated issues common
professional identity. These findings are approved by among the staff, for instance lack of cooperation,
other studies as well (21, 38 - 45). The sociocultural help and trust, groundless criticism, and non-
context can greatly affect the leadership course and commitment to group decisions (39). Latent
efficacy factors, as well as the approval of leadership behaviors such as insulting or humiliating others and
features in a specific social culture (46 - 48). The backbiting are among destructive overt behaviors
assessment and interpretation of leaders’ behavior (58, 59). The participants mentioned the difference
and characteristics are related to various in attitudes towards the same subject as one cause of
sociocultural backgrounds. these behaviors. This is consistent with the findings
The participants experienced improper by Aitamaa et al. For example, in planning personnel
organizational culture such as an absence of model shifts and holidays, some see justice as assignment
acceptance, which affected their ethical leadership. of various shifts in equal numbers, while others
The cultural values of an organization are usually a believe in planning shifts by taking into account the
reflection of the society and the environment in wants and life conditions of personnel (39).
which it belongs. Some other studies have suggested
that the organizational culture is correlated with Conclusion
individual and leadership efficacies. This study showed that despite the emphasis on
The constructive aspects of organizational culture ethical leadership in existing research, there are
encourage individuals to find a way for self- some barriers and problems in the implementation of
correction and acquiring job satisfaction (49). this style of leadership. These obstacles have various
Similar to this study, Aitamaa et al. referred to aspects in ethical, cultural, and managerial domains.
organizational and cultural factors such as lack of Identification of these factors can promote the ethical
respect for, and the general negative attitude towards dimension of leadership. Health care policy makers
the nursing profession in health care organizations, may utilize the findings of this study to formulate
stating that this culture has a negative impact on programs and clear-cut strategies to remove these
nurses’ work motivation (39). Moreover, research on barriers and improve organizational structure and
leadership points out that an understanding of the thus promote this style of leadership. Moreover,
organizational culture cultivates the efficacy of development of organizational ethical codes for
leadership (50), and that ethical leadership plays the guiding the performance of nursing leaders in
mediating role in the relationship between the confrontation with these problems may be helpful.
organizational culture and personnel consequences Ethical leadership is feasible through correction of
such as satisfaction, extra effort, effectiveness (51). social and organizational cultures, and securing the
Data analysis confirmed that managerial problems public confidence in nursing from organizational and
are obstacles for ethical leadership. Issues related to extra-organizational aspects. In conclusion, nursing
the organization such as lack of power and authority leaders are required to consider the individual and
in recruitment, low regard for the nursing staff, occupational features and characteristics of
shortage of manpower and resources, and specific personnel when approaching these problems.
clinical features were among the cases referred to by Discussions about the nursing profession and nursing
the participants. This is not consistent with the leaders’ conditions can improve the standards in this
findings by Fradd, who emphasizes the important regard. The leaders themselves play a key role in
role of nursing mangers in organizational decision- such discussions and should make their actions
making in the scope of nursing (52). Of course, other clearer and more specific. The findings of this study
studies have highlighted the limited power and may help with the development of an instrument for
influence of nursing managers and nurses and lack of investigating the barriers and problems of ethical
their participation in organizational decision-making leadership in nursing.
and inequality of professions in organizations (21, Further studies are required on ethics in management
39, 42). and research, specifically in the case of each of the
In this study, participants referred to behaviors on obstacles, causes of ethical problems, and their
the part of the personnel that disrupted the frequency and severity as well as their differences in
environment and had an impact on the quality of various levels of management. yleneserP , ereleis
care, thus challenging ethical leadership. For very limited information about the values, resources
instance, mistreatment, bullying and behavioral and mechanisms to resolve ethical problems, and
disorders such as defamation were among the cases that could be the basis for future research.
referred to by the participants.
Behaviors such as bullying are quite common in the
nursing profession, as has been reported in many

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J Med Ethics Hist Med 10: 1, February, 2017 [Link] Maasoumeh Barkhordari-Sharifabad et al.

Acknowledgement This study was approved by the Human Research

Authors would like to express their deepest gratitude Committee of Shahid Beheshti University of
to the Deputy of Shahid Beheshti University of Medical Sciences under the ethics code
Medical Sciences who provided financial support for [Link].1393.697 on 15.2.2015.
this project, as well as the participants, and all our
colleagues who helped us in conducting this
research.

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