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Nursing Ethics
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Ethical competency of nurse ª The Author(s) 2016
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leaders: A qualitative study 10.1177/0969733016652125
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Maasoumeh Barkhordari-Sharifabad
Shahid Beheshti University of Medical Sciences, Tehran, Iran; Yazd Branch, Islamic Azad University,
Yazd, Iran

Tahereh Ashktorab and Foroozan Atashzadeh-Shoorideh

Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract
Background: Ethics play an important role in activating the manpower and achieving the organizational
goals. The nurse leaders’ ethical behavior can promote the care quality by affecting the nurses’ performance
and bringing up several positive consequences for the organization.
Objectives: The aim of this study was to identify and describe the ethical competency of nurse leaders in
cultural domains and the working conditions of the Iranian healthcare setting to arrive at a more
comprehensive and specific perspective.
Methods: This was a qualitative conventional content analysis study conducted with the participation of 14
nurse leaders at various levels. The participants were selected using the purposive sampling method, and the
required data were collected using deep interview and also semi-structured interview. A deductive method
of content analysis was applied in data analysis.
Ethical considerations: This study was conducted in accord with the principles of research ethics and
national rules and regulations relating to informed consent and confidentiality.
Findings: Data analysis resulted in 17 subcategories that were subsequently grouped into three major
categories including empathetic interactions, ethical behavior, and exalted manners.
Discussion: Our findings are consistent with previous ones, yet presenting a more complete knowledge
about aspects of ethical competency of nurse leaders. The nurse leaders can provide a proper behavioral
model for the work environment through the use of new information.
Conclusion: The nurse leaders introduced various aspects of ethical competency, so the leaders’ ethical
competency could be promoted via planning and managing some ethical development programs. More
future research is needed regarding the experiences of the subordinates and other related parties.

Keywords
Competency, content analysis, ethic, leadership, morality, nurse, qualitative study

Corresponding author: Tahereh Ashktorab, Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University
of Medical Sciences, Vali-Asr Avenue, Cross of Vali-Asr and Neiaiesh Highway, Opposite to Rajaee Heart Hospital, Tehran
1996835119, Iran.
Email: [email protected]

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2 Nursing Ethics

Introduction
Nurse leaders in formal positions, also called supervisors, managers, administrators, or charge nurses,1 are
part of the healthcare system who manage the greatest group of the health system staff, that is, nurses.2 They
play a considerable role in determining the organization mission, perspectives, and employees’ values.2,3
Leadership is an indispensible component of management playing a significant role in the manager’s
operations.4 The nursing managers should influence the nursing staff5 and affect their behavior directly
through their own leadership6 and functioning as a mediator between the organizational and professional
values.5 The nursing leaders have an essential role in forming the ethical climate of the organization7 and
providing the ethical framework for members of the organization.8 Ethical behavior on the part of the leader
is the necessary prerequisite for creating an ethical organization and is key to obliging the followers to
observe the ethical behavior and gaining better results.9 Ethics are strategically important as they are able to
activate or deactivate the manpower and can be also used to achieve the desired goals more quickly.10
Hence, the leader’s competency has a significant effect on efficacy of organizational and group perfor-
mance helping them in resolving the organizational challenges and improving social relations,11 so it is very
important for the success of the organization.10 The variety and complexity in the nursing leaders’ ethical
behavior in various cultural contexts render innovation and exploration of the visible and invisible angles of
ethics as necessary. One appropriate method for this purpose is conducting a qualitative research leading to
the discovery of the latent dimensions of concepts and phenomena. Since the present researchers found no
qualitative study on the ethical competency of nurse leaders in the sociocultural contexts of the Iranian
healthcare settings, this study aimed at abstraction of various ethical themes and concepts in the domain of
nursing leadership based on their own experiences.

Background
Nurses are a vital component of the healthcare system so that they constitute the largest group of healthcare
system employees.12 Similar to many other countries, nurses in Iran face challenges such as staff shortage,
high workload, unidentified duties, equipment shortage, low salary,13 weak social status, and the gap
between theory and practice14 that leading to their dissatisfaction with work and feeling of disappointment
and frustration.13 Ultimately, these parameters collectively exert a negative impact on the quality of nursing
care.14 Moreover, significant changes have been made in the healthcare setting over the past two decades.
These include, for instance, changes in the disease pattern, increased average longevity, application of
technological advancements, and creation of innovative procedures like organ graft.15 As the acuity and
intensity of patient care have increased, the creation of a safer setting and provision of better quality of care
have faced more challenges. Additionally, the number of patients who need more skills and the knowledge
of intervention and assessment is constantly increasing demanding expertise in working with complicated
technologies. Other factors making the work environment more complex include financial pressures,
reliance on complementary manpower, and the ever-changing models of ethnicity, generation, and gender
that affect the work setting.16
These factors have caused nurses to encounter a new scenario of challenges daily in their care.2 The
spectrum of incidence of various unethical events at the micro and macro levels confirms the need for as far
as possible a better management of behavior and ethical performance in the work environments.17,18
Therefore, there is the need for dynamic nursing leaders to guide the clinical performance to ensure
obtaining proper outcomes in the patients.19,20
The nursing managers can promote the nurses’ clinical competency and subsequently the care quality
through applying the leadership skills.21 Observance of ethical values is among the characteristics of
leaders with high efficacy.22 These leaders urge their staff through behaving to them fairly and morally to

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Barkhordari-Sharifabad et al. 3

improve their performance.23 The nursing leaders ought to be aware of the degree to which their actions
are ethical. They should also be alert to the method of improving their actions with regard to managerial
ethics to promote the healthcare quality.24 The ethical leaders are expected to apply the ethical behaviors
and create a work environment in which the values are identified and shared so that these values direct the
ethical action. In such an environment, individuals feel safe and are sure that they will be heard.25 An
ethical approach in leadership, by valuing the exalted human values and beliefs and supporting and
encouraging, induces the feeling of usefulness and efficacy on nurses and health services staff and
provides context for the effective conduct of their duties, and finally, leads to satisfaction of their
psychological needs.26
Quantitative studies in this field have shown that leaders who rely on ethical values leave significant
effects on feeling of being energetic, capable, and creative in staff.27 Moreover, the leaders’ ethical behavior
results in staff’s organizational commitment, their confidence in the leader, and their psychological empow-
erment.28 The nursing leaders, in fact, promote the organizational capacity for maintaining nurses and
reducing turnover and increasing their occupational satisfaction through creating an ethical climate and
decreasing ethical distress.29 On the contrary, leaders’ unethical behavior may lead to disappointment,
frustration, lack of confidence, and lack of interest and commitment in the followers and consequently,
imposing negative effects on the patients and organizational efficacy.30
A meta-ethnography study by Makaroff et al.1 showed that the ethical leader in nursing should be
responsible with regard to the staff and the nursing system and needs to receive support for promotion of
ethical performance and debating ethical issues. The four themes of ‘‘integrity, justice, decisiveness while
considering the consequences, and power of information’’ are reported in qualitative research by Gray for
ethical leadership in nursing education.31 Some other qualitative studies have been carried out on leaders’
ethical behaviors in nonmedical sources.32–35
However, the important point here is that one part of ethical priorities of each profession is derived, in
addition to the defined values of that profession, from the values and priorities of the community and also
the values of individual members of that professional group.36 Additionally, development of ethical beha-
vior in various educational systems possesses special features. That is why the nature of ethical issues is
formed in such a way that it has many sociocultural aspects. Hence, a survey of ethical and occupational
competency in cultures and working conditions may predispose to new discoveries.37,38
Iran is a developing country with its own specific ethical values. This country is located in southwest of
Asia with a population of about 70 million. The clergymen governing the state do not separate politics from
religion. Indeed, the religious discipline and the cultural beliefs of people have entered the national health
system with the ethical and spiritual issues being prominent in its patient care protocol. The nursing staff in
Iran is estimated to include 150,000 nurses at different levels, while the healthcare system in Iran like any
other developing country is challenging limitations in financial and manpower sources to remove its
healthcare requirements. It is further mandatory for nurse leaders to find a suitable solution as part of the
organizational leadership for increasing the care quality and patient safety in spite of the limited sources.39
The cultural variables and managerial presuppositions affect the management performance of the human
sources. A leader’s assumptions of the interests and the method of socialization of personnel depend on his/
her understanding of community value domains determined by the society and are affected by the socio-
cultural characteristics. The assessment and meaning of behavior and also leaders’ traits may be widely
different in various sociocultural aspects. In fact, there are various ideas and expectations of the nature of
leadership in different cultures.40 Consequently, it appears that the identification of nurse leaders’ ethical
competency with the two domains of leadership and ethics, both related to the social culture and ethical
values of the community, is mandatory.

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4 Nursing Ethics

Aim
The main purpose of this study was determining the ethical competency of nurse leaders in the Iranian
cultural context and working conditions of the Iranian healthcare system.

Methodology
This study was a conventional qualitative content analysis of nurse leaders’ ethical competency. Qualitative
content analysis is an appropriate procedure for obtaining reliable and valid results from textual data to
create knowledge and innovative ideas and for provision of facts and practical guide of performance. The
goal of this method is the compression and extensive description of a phenomenon, and its outcome is the
descriptive strata or concepts of the phenomenon.41 The participants of the study were selected using the
purposive sampling method which is suitable for qualitative research designs. In this method, the researcher
looks for the subjects who are rich in the issue under study who are capable of expressing the facts with an
inclination for participation.42 Informed written consent was obtained from the participants after their oral
consent. The sample volume was determined on the basis of the time of data saturation. After 11 interviews,
no new information was obtained indicating data saturation; however, to make sure, three more interviews
were conducted. The participants of the study were 14 nursing managers and faculty members. The reason
for selecting this sample volume was their assumed mastery of the subject under study.
The inclusion criteria were as follows: being a volunteer for participation and a nursing management
experience of at least 2 years. The inclusion criterion for faculty members demanded them to be expert in
management and ethics. Faculty members were selected as university leaders and as a role model for
students because the leaders of clinical nurses are not separate from university nurses both functioning
as healthcare decision-makers. On the other hand, the future leaders of the clinical nurses are the present-
day students being trained by faculty members. So, the leadership of university leaders is effective in this
regard like the clinical leaders. Hence, the emergence of some ideas regarding ethics requires the cooper-
ation between these two groups. By the way, the faculty members participating in this study had a working
experience as both clinical and university leaders, while some of them are presently performing their formal
leadership.
The required data were collected through deep and semi-structured interviews which were conducted in a
quiet place at an appropriate work hour convenient for the participants. The interview included open-ended
questions and based on the interview guide. It began with demographic information, work experience, and
various other questions for diversity of nursing unit and went on with a general question on the position of
ethics in the participants’ guidance and leadership. Then, the interview was continued with a more specified
question on the basis of research objectives. Some questions were ‘‘To do so, what characteristics should
you have?’’ and ‘‘What happened when you did so?’’ Furthermore, some probing questions were asked to
gain more information and elucidate the topics, that is, ‘‘Can you explain more?,’’ ‘‘What did you mean?,’’
and ‘‘Can you give an example?’’ The interviews were recorded by an MP3 player. After the completion of
each interview, it was carefully heard and then it was transcribed using the Microsoft Word processor. The
minimum and maximum times of the interviews were 35 and 90 min, respectively.

Data analysis
Content analysis with a deductive approach was used to analyze the data. In this study, the common points
were identified, coded, and classified using the latent content analysis method. Latent content analysis
involves the process of identification, coding, and categorization of the primary data models. In this method,
the researcher seeks the specific contextual meaning of concepts in the data and then designs the model and

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Barkhordari-Sharifabad et al. 5

structure that can categorize all meaningful categories and themes.43 The unit of analysis in this study was
all the interviews which were reviewed many times after typing. In this way, the semantic units were
extracted as sentences or paragraphs distilled from the texts and expressions in the interviews, the primary
or open codes were extracted, and then, the codes were categorized in one class by grouping the codes with
common semantic load and given a name. After each new interview, the previous categories or classes were
revised or merged or even a new category was created. In this way, the main themes of the study were
abstracted through categorization, and the relationships between the categories were determined.
The accuracy of data with regard to credibility was promoted with the application of different strategies
such as variety in participants regarding age, gender, work experience, variety of nursing units and various
managerial hierarchies, prolonged engagement with the participants, immersion in data, and revision of
participants and colleagues. Regarding transferability, an attempt was made to elaborate on all the details of
the study so that no ambiguity was left. Also, regarding dependability in this study, two outsider observers
were asked to survey and approve the data collection and analysis processes. The gleaned data were
documented in all stages of the study as a detailed report to help confirmability of the research.

Ethical aspects
To observe the ethical principles in human research, the required permission was obtained from the intended
universities and hospitals. Also, informed written consent was obtained from each participant. The parti-
cipants allowed the recording of interviews and the anonymous use of the culled data. At first, the research
purposes and procedures were explained to the participants. The participants entered the study by providing
first oral and then written consent. The researchers observed the ethical principles of anonymity, confi-
dentiality of information, the right for voluntary withdrawal from the study at any stage, and permission
from Shahid Beheshti University of Medical Sciences in Tehran, Iran. Moreover, it should be mentioned
that this study was approved by the Committee of Ethics in Research at the university with ethical code of
sbmu.rec.1393.697 at 15.02.2015.

Results
Of 14 participants of the study, 8 were female and 6 were male. Their age range was 38–56 years, with a
mean managerial experience of 12 years. Also, of 14 participants, 6 held a BS in nursing, 3 held an MSc in
nursing, and 5 held a PhD in nursing. Regarding the managerial hierarchy, 3 were clinical supervisors and 5
were head nurses. Furthermore, 5 were nursing faculty members. On the whole, most of them had worked in
different wards. In data analysis process, 17 subcategories were obtained which, in turn, fell into three main
categories (Table 1).

Empathetic interactions
One of the abstracted themes was empathetic interactions which is one of the fundamental concepts of
nursing. This main category includes six subcategories of resolution of problems and wishes, making
confidence and assurance, mutual liking and respect, establishing human and ethical interactions, empathy,
and cooperation.
(a) Solution of problems and wishes: Client’s problems, work difficulties, employees’ problems, and
other issues occur frequently and need to be resolved. An efficient leader helps individuals identify
the problems and work throughout the process of problem solving to find a logical solution to the
problem. One participant says:

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6 Nursing Ethics

Table 1. Main categories and subcategories of ethical competency of nurse leaders.

Main categories Subcategories

Empathetic interactions Solution of problems and wishes

Establishing confidence and assurance
Mutual liking and respect
Establishing the human and ethical interaction
Empathy
Cooperation
Ethical behavior Supportive behavior
Contributory behavior
Fair behavior
Ethical behavior toward wrongdoers
Ethical behavior toward patients
Exalted manners Honesty
Humility
Sincerity
Decisiveness and determination
Good-temperedness
Patience and tolerance

Assume one’s child is sick, they say you should come to work, the law says you can’t take sick leave for
your child’s sickness; Now, if my own child gets sick, do I oblige my wife to go to the office? No, I do
not. The law also doesn’t permit me give them a sick leave, anyhow, you should solve the problem in
any possible way. (Participant 14)

Some participants referred to the consequences of not paying attention to this case. For instance,
participant 7 puts it this way:

I believe that if the nurse does not come to work in high spirits, or if they have mental worries, they don’t
practically perform their task properly; I always emphasized that a mother with a sick child should never come to
work . . . , such a mother can not concentrate on serving the patient . . .

(b) Establishing confidence and assurance: Another subcategory of ‘‘Empathetic Interactions’’ was
‘‘Establishing Confidence and Assurance.’’ Employees’ confidence in the management is neces-
sary for interpersonal relations and organizational efficacy. As participant 7 says:
Indeed, a feeling of confidence was between the nursing office and all the personnel, that is, the
mentality was created that if the nursing office is not doing something, it is because it can’t do it, if
it can, it will do it!

Management effectiveness could be due to the ability of building confidence in staff. Participant 2 refers
to the difficulty of building confidence in the staff and says:

It’s hard to building trust in others, is no easy task.

(c) Mutual liking and respect: ‘‘Mutual Liking and Respect’’ was another subcategory noticed by the
participants. Considering this criterion, the manager is required to respect their subordinates, pay
attention to problems, and behave to the staff respectfully without any insolence or contempt. They
should notice the staff’s human values. In this regard, one of the participants says:

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Barkhordari-Sharifabad et al. 7

In the clinical setting, if we really wanna say ethical leadership, we gonna value our personnel, we
should respect ‘em. (Participant 8)

A participant who was instructor of ethics with 22 years of managerial experience at various levels
asserts in this regard:

I believe that the most important things in ethical leadership are respect, love, and interest, that is, the thing called
today as positive energy; this energy is nothing but the energy of love, the energy of belonging, and love towards
others.

Of course, not only the leader should like their staff, the employee should also like the leader. In this
regard, participant 2 says:

If we gonna be a good manager, we gonna be a good leader. A good leader is liked by others. This makes the job more
difficult, as others do not like you so simply. That’s why I thought I should try hard so others like me in some way.

The participants emphasized that liking and respecting is mutual. For example, participant 5 says:

My belief is if you like someone, that someone will like you, too. They say respect brings you respect.

(d) Establishing the human and ethical interactions: A manager should notice their ethical role on
interaction with others as establishing an ethical human interaction is one of the components of
empathetic interactions. In this regard, participant 13 renders the interaction method as the most
important factor mentioning it as a challenge in nursing. As this participant says:
In my opinion, the interaction method that a nursing manager should use with their personnel is the most
important issue to be considered: you should always work in two fronts, one is the personnel’s front, and
the other is the patient’s front; you should establish a balance between the two.

Moreover, participant 11 asserts in this respect:

They’ve already understood that I’m not the type of person to be influenced by flattery or the like; they know it is
useless and ineffective.

(e) Empathy: For empathy, the leader should place themselves in others’ shoes, see through their eyes,
and feel by their hearts. Almost all participants expressed this subcategory. Active listening is the
prerequisite for empathy. For instance, participant 3 states it this way:
It’s important that we listen to the stories of people, we should listen to them . . . , try to understand them
and figure out what they say.

A participant who was PhD in Nursing with 8.5 years of managerial experience at various levels asserts
in this regard:

The supporting part (leadership) mostly refers to ethics, that is, how far I support them, how far I understand them
when they say they have problems; I should behave them the way I like to be behaved.

(f) Cooperation: The successful leaders are pathfinder and have a spirit of cooperation. This is
reflected in participant statements who was instructor of nursing with 6 years of managerial
experience at various levels:
Basically, I went there to work. I accepted the responsibility of taking care of the patients in the wards
I went to.

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8 Nursing Ethics

Or for instance, participant 11 who was head nurse with 9 years of managerial experience at various
nursing units says:

I never told now that I am a manager or headnurse, I should not do the care. It is not at my level. It is not my duty. I
didn’t say such things, rather, I did the task.

Ethical behavior
Another main category that was included in the ethical competency of nurse leaders was ethical behavior.
This category consisted of five subcategories including supportive behavior, contributory behavior, fair
behavior, ethical behavior toward wrongdoers, and ethical behavior toward the patient.
(a) Supportive behavior: Many participants stated in their experiences that supporting the staff is an
effective factor in ethical leadership. One participant says
In my opinion, if someone wants to be an ethical leader, based on my own experiences, they should
reinforce their supportive role. (Participant 2)
Moreover, the participants mentioned representativeness of the group as one of the leader’s missions. For
instance, participant 3 says:

An important part of our mission is the representativeness of the group that we lead.

Of course, they emphasized that this support should be right and corrective. As participant 14 puts it:

We have a ward chairperson here, we want to change him/her. One reason is that s/he defends whatever the
personnel do! Mere defense is useless. The defense should be right and corrective.

(b) Contributory behavior: According to this category, the leader should be in contact with the staff,
involve them in related decision-makings, seek their views on different problems, and pay attention
to these views. One participant says:
I use my personnel’s opinions, I don’t impose only my own opinions. (Participant 4)
Participant 13 says in this regard:

Previously, I used to emphasize my own authority. I wanted order in affairs, there was a kind of dictatorship and
imperative behavior. Now, I try to have a consultative approach and want the personnel to do things on their own
will; I do not oblige them to do anything.

(c) Fair behavior: The participants stated that the ethical leader should be a law-oriented person who
implements legal procedures. Participant 2 says:
What was important to me was the implementation of rules and regulations in the legal framework and
at the same time try to acquire popularity in some way.
Based on these assertions, the ethical leader should implement the legal procedures in the same way for
all individuals, treat all persons equally, differentiate between good and bad staff, practice neutrality in all
issues, and avoid selling favor or favoritism. As an example, participant 1 expresses it in this way:

Ethical relation demands the feeling that you are valuable as a creature and that this is an opportunity for me to have
relations with you . . . , in that case, a manger won’t discriminate among the employees, then, the manger won’t like
the employees for their flattery, rather, they will like the staff for human values.

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The participants further declared that one cause of staff’s dissatisfaction is that the manager does not
differentiate between the good and the bad staff and that justice is not practiced. For example, participant 11
claims that

At work, I could observe that the conscientious workers were somehow dissatisfied with some authorities. I
searched the cause and found that the managers were indifferent to good and bad personnel.

(d) Ethical behavior toward wrongdoers: A further characteristic of the ethical and professional
managers is their treatment toward the wrongdoers. Among the unethical behaviors of the wrong-
doers mentioned by the participants were training the staff and friendly reminding instead of
catching them red-handed on their wrong-doing, blaming oneself in creating the error, and the
importance of the method of noting the errors. Participant 10 gives an example:
When they commit an error, I remind them in a friendly and pedagogic manner, I do not try to catch
them red-handed.

Or participant 14 explains it further:

In the first place, I incriminate myself; since the system has been at my hands, I blame myself. I should see where
the fault is, it is not deliberate by 99%; it may be done deliberately only by 1%. Well, who has set this system?
Sure, the manager; maybe someone has committed a fault, this does not exonerate the manager . . . ’’

(e) Ethical behavior toward the patient: Another domain was the nurse leader’s behavior toward the
patient which should be based on ethical origins. Undoubtedly, the nursing manager needs an
ethical behavior toward the patient. In fact, the manager’s type of treatment can function as a very
influential factor in the affairs of the organization and can help its development greatly. One of the
head nurses refers to prioritizing the patient in this regard and asserts:
The first thing in my mind about the patient was that the patient has ultimately their own position. They
have some expectations from us. (Participant 11)
Additionally, participant highlights the significance of patients’ satisfaction when s/he says:

The patients’ satisfaction is a very important condition for me.

Exalted manners
Another theme abstracted from nurse leaders’ experience was ‘‘exalted manners.’’ Having characteristics
such as honesty, humility, sincerity, decisiveness and determination, good-temperedness, and patience
requires a kind of subtle understanding, attention, and continuous care from the nurse leaders.
(a) Honesty: This feature was expressed by most nurse leaders. Leaders not showing this characteristic
should not expect an ethical behavior on the part of their subordinates. For example, participant 14
says:
During my several years of managerial experience, I learned that truthfulness is very important.
Honesty is the first thing. Your personnel should understand that you have honesty and truthfulness.
A small lie has a great effect. If you tell a small lie, they won’t believe what you say anymore.

(b) Humility: Another feature stated by the participants was humility. As one participant says:
This point of serving the people, i.e., humility, really exalts humans. (Participant 1)

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10 Nursing Ethics

Participant 6 states it in this way:

Some people think that when they become authorities, they become more prestigious if they keep away from their
personnel, but s/he was not such a person, s/he was very humble.

(c) Sincerity: This feature was also noticed in the nurse leaders’ experiences as an ethical dimension.
Sincerity means straightforward and direct talk. Without sincerity, many problems remain unex-
pressed. Then, the need for change will never emerge and the conditions will remain de facto as
they are presently. Participant 10 says:
I’m very sincere with them. Everybody knows this. I won’t tell much in their absence. I won’t backbite
them.

(d) Decisiveness and determination: Another human skill that must be possessed by every leader is
decisiveness. Its empirical evidence was obvious in the speech of nurse leaders including items
such as having determination and attraction along with intimacy and devotion at the same time and
also the manager’s self-construction:
I tried to feel that the personnel were my brother, sister, . . . In this way, there was a friendly situation,
but when I said that Mr. such and such should come to work, they knew that they must come. They did
not await for me to became serious to come. (Participant 14)
Furthermore, another participant with 15-year experience as a head nurse at different wards says:

The experience I acquired was that you should be very self-constructed yourself. Someone who wants to be the
manager of the nursing section must have worked on themselves very much. They should be self-constructed.

(e) Good-tempered: The most important feature of ethical leaders in nursing is that they are human-
centered. The nurse leaders are in contact daily with many people. Hence, they need to be good-
humored and kind and possess this ethical characteristic. In this way, they can influence other
individuals. As one participant asserts:
Among their features, the most important one was good-temperedness, good-humouredness and kind-
ness. It was as if you forgot your sorrows when you met them. You felt that their main and only concern
was your problem. (Participant 1)
(f) Patience and tolerance: Leadership is a difficult and sometimes exhausting process; hence, the
leaders ought to possess patience and tolerance so they can tolerate and overcome the problems they
encounter. Participant 13 says:
Patience is very important and indispensible. Patience with the personnel whose personal differences
are great, whose problems are extensive. Though they may hold the same academic degree, they are
cognitively different.

Discussion
This study contained some similarities with other studies on this topic. In this study, conducted on the
ethical competency of nurse leaders in the sociocultural context of the Iranian healthcare setting, three main
categories each with a number of subcategories were abstracted. Nonetheless, it should be pointed out that
the abstracted concepts and themes are intermingled and have no clear-cut borders as they sometimes
overlapped.

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One abstracted category was empathetic interactions. The nurse leaders should consider the problems
and wishes of the nurses and try to resolve them. They should create confidence and assurance, like them,
respect them, empathize with them, cooperate with them, and establish an ethical and human interaction
with them. These concepts were the subcategories that formed the main categories. The leadership should
always contain the relations between the leader and the subordinates since the quality of the relations
between the leader and the staff is the key factor to improving the staff’s performance and organization
productivity. The statements made by the nurse leaders indicated the characteristic called empathetic inter-
actions. In line with this study, the findings of other studies pointed to variables mentioned above.6,44–49
The nurse leaders’ effective relations with staff along with empathy predispose to confidence and
assurance. The ethical leaders should be cautious with what they say and do as they should acquire the
subordinates’ confidence. On the whole, ‘‘they should walk the talk and talk the walk.’’6,44,50–52 Confidence
is the basis of constructive conflict, commitment to goals, personal responsibility, and achieving to group
purposes. Staff’s confidence in the leader leads to their greater satisfaction.6
Confidence in leaders is created by behaviors such as open communications, honesty, accessibility, and
dependability.33,53 Keselman30 asserts that the ethical leaders should go beyond their personal benefits and
focus on what is beneficial for all the group or organization. The ethical leaders should behave on the basis
of their ethical principles and respect the rights of the employees, stakeholders, customers, or patients. They
should value the staff, respect their rights, and behave to them on the basis of dignity and respect.30 The
participants of this study referred to mutual respect. One dimension is the managers’ respect for staff and the
other dimension is employees’ respect for the manager. Self-respect and respect for others are among the
most controversial and fundamental ethical values to be debated. The quality of respect reflects the ethical
concerns. Respect is the principal ethical attitude which develops other ethical principles.54
Regarding the resolution of staff’s problems and wishes referred to by the participants, Heres and
Lasthuizen6 demonstrated that the ethical leaders notice the others’ welfare and satisfaction of the basic
needs of their followers. They are able to understand the feelings, thoughts, and actions of other individuals.
They are people-oriented and are concerned with their empowerment. They know how the employees feel
and know what they want to do. The ethical leadership is people-oriented, caring, open, and communicative.
They consider the various needs of the stakeholders and the short-term and long-term consequences of
ethical decisions for them. This characteristic makes the leader to think of problems variously in inter-
personal situations and be aware of many behavioral options. The ethical leader facilitates and reinforces a
high-quality relationship between the leader and the followers.6 A leader who values the status, respectful-
ness, and the presence of the employee in their interactions and communications, and who displays the
logical, reasonable, and just acceptance in their assessment and communications, is looked at as a moral-
based leader by the employees.55
Moral-based behavior and its subcategories hold a special position in a nursing manager’s leadership.
The participants expressed that an important part of their mission is that they are the representative of their
group and that in order to be an ethical leader, they need to reinforce their supportive role. Organizational
support is one important index of the nurses’ work setting. The supporting work environments are the most
important factors in creating nurses’ occupational satisfaction. Enjoying social support by nurses affects
positively the treatment of patients, staff’s occupational satisfaction, and absorption and maintenance of
manpower. The results of Feather et al.,48 also in line with the findings of this study, showed that staff
nurses’ management supportive behavior included good communication, showing respect and caring for the
nurses that have an impact on their job satisfaction. An environment with high social support reduces
occupational tensions and challenges and maintains the nurses in the organization.56 To influence the
followers, the leaders ought to induce confidence, loyalty, and support in them.6 If the leaders treat their
followers justly and are loyal to and supportive of them, the followers will most probably compensate for it
with appropriate behavior and the leaders will probably encounter to a lesser degree employees’ behaviors

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12 Nursing Ethics

that disturb the leaders’ or group’s affairs.57–60 An ethical leader favors the staff even at difficult times and
supports the followers. They are loyal to the staff.6 Managers’ support of the staff plays a significant role in
their professional outcome and promotion of their performance.61
Contributory behavior was one of the subcategories that was noticed by the participants. These behaviors
were identified in several studies.32,62 Ethical leaders empower their followers through provision of con-
tribution in decision-making processes, through permission for the expression of their views and attitudes
on the issues, through helping them to determine their objective and motivating goals, and through provi-
sion of personal support and opportunities for personal growth.57,63 Improving the quality of the relations
between the managers and their employees leads to increased submission of authority and power to sub-
ordinates and their contribution to the decision-making process due to the confidence climate. Also, the
level of subordinates’ responsibility increases and the individuals deserve more rewards. Moreover, the
corrosive changing of the staff in various posts decreases, and a positive attitude toward performance
assessment is created.64
One of the nurse leaders’ moral-based behaviors was fairness and law-centered. On the basis of this criterion,
the ethical leader in nursing is required to be law-oriented and implement the lawful procedures equally for all
individuals. They should display the same behavior toward all staffs, be neutral in concerned issues, and prevent
various forms of selling favor and favoritism. This finding is similar to that of Gray.31 His research results
showed that fairness requires compliance with the rules and it is assumed that the universal standards will apply,
but they must also be flexible to suit individual situations.31 In Brown et al.’s65 view, one characteristic of the
ethical leaders is being people-oriented and displaying a fair behavior toward the subordinates. A fair inter-
personal behavior toward followers reinforces the relational dependence of the followers to the leaders,
promotes the status of the ethical authority of the leaders, and increases the followers’ motivation for imitating
the leaders.59,66 Power division and fairness is related to confidence in management.57
Regarding incidence of errors, the participants emphasized the type of reaction to staff’s errors, method
of approaching the errors, and the proportion between error and leaders’ reaction. Since the main respon-
sibility of nurses is provision of high-quality care to patients, nurse leaders should supervise them to
perform their duty acceptably and correct their errors in performance. Our findings are in line with Cathcart
and Greenspan67 who found that in the case of incidence of any nursing error, instead of depriving the nurse
from continuing their duties, an attempt should be made to promote the nurse’s perception of nursing
performance and of the meaning of the error. This behavior indicates the belief that promotion of perfor-
mance is a dialog in which the concern with the ethical and clinical leadership is best surveyed and trained
using a non-judgmental and respectful manner.67 Because many factors contribute to the incidence of
nursing care errors, hence the first step for decreasing the nurses’ performance errors is the early detection
of causes that predispose to their occurrence.68 Consequently, the nursing leaders ought to have a systemic
approach to nursing care errors.69 The authorities’ reaction to performance errors, the why of error treat-
ment, type of reaction to errors, and proportion of reactions to errors are effective in preventing the
occurrence of errors and in reporting the errors when they occur.70
Patient-centeredness and ethical behavior toward the patients were among the cases noticed by the
participants. It seems that ethical leadership is the cornerstone of patient-centered care and its essential
aspect is organizational commitment to the value of the healthcare clients, patients, and their families. It is a
defender of promotion and implementation of high-quality safe care in all activities.30 Makaroff et al.1
assert that patients’ safety has priority for nurse leaders.
Another category is the exalted manners of nurse leaders. Honesty, humility and criticism, sincerity,
decisiveness and determination, good-temperedness, and patience and tolerance are ethical concepts that
are accepted as human values. Most theoretical and experimental studies emphasize that ethical leadership
is primarily based on the leaders’ personal ethical values71–73 and their ethical bravery in maintaining these
values and principles even in the face of powerful extrinsic pressures, difficulties, and great dangers.34,71,74

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Barkhordari-Sharifabad et al. 13

Ethical leadership is linked to a collection of ethical properties such as honesty, sincerity, confidence,
humility, assurance, respect, responsibility, and justice and righteousness.34,50,57,62,75,76
Truthfulness and honesty are basic values applied in ethical relations with others. Ethical leaders act
honestly and fairly. They select principal and just options, are reliable and honest, do not sell favors nor
commit favoritism, and accept the responsibility of their actions.33
Criticism and humility are also among the ethical leaders’ characteristics referred to by the participants.
They claimed that they accept their errors humbly and apologize their staff for their mistakes. They believe
that not only the staff or organization but also the leaders may commit errors. Ethical leadership means that
the leaders should be able to accept their errors, make the errors debatable, and be responsive. Additionally,
they use their errors and mistakes as valuable learning experiences for both themselves and their
organization.6
The ethical leaders are good-tempered and possess patience and tolerance. Today, the leaders and
organizations face a wide world of information, organizational complexities, and unsecure situations. The
toleration of such disastrous conditions is part of the leadership of organizations for survival.77 The
participants of the study further referred to decisiveness, determination, and sincerity. Decisiveness means
that the individuals express their positive and negative feelings without violating the others’ rights, respect
both themselves and others, and do not allow others to abuse them. On the other hand, they respect the wants
and wishes of other people and interact with them using wise methods.78 Decisiveness is an invaluable
component of successful professional performance by the help of which challenges of the nursing profes-
sion could be overcome.79

Conclusion
This study revealed that despite the different religious beliefs and socioeconomic and cultural conditions of
the Iranian society, the behaviors and ethical competencies of the Iranian nurse leaders are highly similar to
those of other countries. Generally speaking, the universal community has many common ethical values.
Ethical competency forms an important portion of the general competency of the nurse leaders and their
capabilities for exerting effect and motivating the nurses with ethics-centered behavior, sympathetic inter-
actions, and exalted manners for better care provision and desired consequences for both patients and
nurses. It has an extraordinary potential for influencing the ethical atmosphere of the organization.
Additionally, this study depicted the various aspects of ethical competencies of the nurse leaders in the
Iranian society. The nurse leaders may promote their potentials as ethical leaders by being aware of these
aspects and by a good perception of them. They can use these aspects as a model to guide their performance.
Also, they may further advance the ethical atmosphere through equipping the nursing work environment
with ethical sources. The findings of this study may further be applied to organize the organizational ethical
codes for guiding the nurse leaders’ performance.
Moreover, the ethical competency of the nurse leaders may be promoted by teaching these aspects to all
levels of nurse leaders. In this way, the healthcare decision-makers can plan some ethics promotion
programs for nurse leaders can enhance their ethical competency. These programs stabilize the exalted
goals and introduce specific strategies and activities which ultimately result in a comprehensive list of
reinforcing factors of ethical competency. An emphasis on ethics as part of leadership training in nursing
management is important in nursing education. It is better to add it to the nursing curriculum.
Ultimately, it should be pointed out that this study was carried out only in the hospitals and universities
related to the Ministry of Health and Medical Education. It is recommended that future research be directed
at private hospitals and other healthcare professions in Iran. Also, it is advisable that the subordinates’
experiences and other beneficiaries be noticed in this regard.

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14 Nursing Ethics

Acknowledgements
This study is part of nursing doctoral thesis and a research proposal. The authors thank the Deputy-in-
Research at Shahid Beheshti University of Medical Sciences who supported them financially. The authors
also thank all the participants and member check and peer check that helped them in the completion of this
study.

Declaration of conflicting interests

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

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: The budget of this project was allocated by Shahid Beheshti University of
Medical Sciences, Tehran, Iran.

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