Article

Nursing Ethics
2014, Vol. 21(6) 642–658
Searching for ethical ª The Author(s) 2014
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leadership in nursing 10.1177/0969733013513213
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Kara Schick Makaroff

University of Alberta, Canada
Janet Storch and Bernie Pauly
University of Victoria, Canada
Lorelei Newton
British Columbia Cancer Agency, Canada

Abstract
Background: Attention to ethical leadership in nursing has diminished over the past several decades.
Objectives: The aim of our study was to investigate how frontline nurses and formal nurse leaders
envision ethical nursing leadership.
Research design: Meta-ethnography was used to guide our analysis and synthesis of four studies that
explored the notion of ethical nursing leadership.
Participants and research context: These four original studies were conducted from 1999-2008 in
Canada with 601 participants.
Ethical considerations: Ethical approval from the original studies covered future analysis.
Findings: Using the analytic strategy of lines-of-argument, we found that 1) ethical nursing leadership must
be responsive to practitioners and to the contextual system in which they and formal nurse leaders work,
and 2) ethical nursing leadership requires receiving and providing support to increase the capacity to
practice and discuss ethics in the day-to-day.
Discussion and conclusion: Formal nurse leaders play a critical, yet often neglected role, in providing
ethical leadership and supporting ethical nursing practice at the point of patient care.

Keywords
Administrators, codes of ethics, ethical leadership, formal nurse leaders, frontline nurses, nurse executives

Introduction
Nightingale and other early formal nurse leaders (FNLs) gave specific attention to ethics, with chapters, arti-
cles, and books being written about the ethical responsibilities of FNLs. However, attention to ethics and nur-
sing leadership has waned over many decades. Few researchers have tackled this subject. Those who have done
so have found it difficult, given the complexities of the role and the changing context of the healthcare envi-
ronment. In a previous article,1 we documented our search for ways to understand what has seemed a lack of

Corresponding author: Kara Schick Makaroff, Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy,
11405-87 Avenue, AB T6G 1C9 Edmonton, Canada.
Email: [email protected]
Schick Makaroff et al. 643

attention to ethical leadership. We offered some recommendations for filling a perceived gap between what
registered nurses (RNs) need and what is missing from FNLs. In this article, we seek to further our initial rec-
ommendations by taking an expanded look at the literature and using our own research findings to answer the
following research question: ‘‘How do frontline nurses and FNLs envision ethical nursing leadership?’’
To understand the perceptions of frontline nurses about their views of ethical nursing leadership, we
draw from four studies involving interactions with FNLs. In each of these studies, FNLs were known by
a range of titles including administrator, manager, supervisor, or charge nurse. As part of one of these stud-
ies, we sought to determine FNLs’ own perceptions of their ethical leadership from nurses in executive posi-
tions, such as chief nursing officer or a nurse at a similar administrative level.

Literature review—decades of neglect?

At the inception of the discipline of professional nursing, ethical instructions for FNLs were clearly
described by Nightingale. Nightingale’s Notes on Nursing, published in 1860, contains the following
directives:

The person in charge of everyone must see to be just and candid, looking at both sides, not moved by entreaties, or
by likes and dislikes, but only by justice; and always reasonable, remembering and not forgetting the wants of
those of whom she is in charge. She must have a keen though generous insight into the characters of those she
has to control. They must know that she cares for them even when she is checking them; or rather that she checks
them because she cares for them. (pp. 47–48)2
Let whoever is in charge keep this simple question in her head (not, how can I always do the right thing myself,
but) how can I provide for the right thing always to be done? (p. 43)2

Other early nurse writers of ethics texts for nurses also included attention to the ethical leadership of
nurse management. Aikens3 includes a chapter on ‘‘Ethical standards for head nurses’’ (p. 224) focusing
on issues such as fairness, favoritism, finding fault, loyalty, and other aspects of being in charge. Other man-
agerial texts for nurses were discussed in our previous article.1 In general, attention to ethical responsibil-
ities of nurse leaders varies considerably over time.
In our review of the literature, we purposefully selected recent textbooks on nursing leadership (also
titled as nursing administration or management). We found that only about half of these books include
an in-depth chapter on ethical responsibilities of FNLs;4–6 others feature a chapter combining ethics and
law (mainly focusing on law),7,8 and yet others include no hint of attention to ethics at all, even in the
index.9–11
With regard to journal articles on ethical leadership of FNLs, we again purposefully selected four journals
that had published in the area of ethical leadership. We electronically reviewed and hand-searched all volumes
and issues of these four journals in their entirety for a comprehensive review. We found only a dozen such arti-
cles over a 20-year publication period of the journal Nursing Ethics.1 Continuing to search other journals for up
to a 20-year period, we found that Nursing Philosophy had one article,12 Nursing Research had one article,13
and Nursing Inquiry had four articles.14–17 The Journal of Nursing Administration contained a few articles that
made specific reference to ethics in titles or abstracts over a 10-year period of monthly issues. The authors of
these articles addressed ethical issues and challenges faced by nurse leaders,18,19 and the ethical dilemma of
12-h shifts.20 A few others included ethical dimensions, for example, positive aspects of nurse resistance,21
organizational respect and justice for nurses,22 and servant leadership.23 Some articles contained ‘‘values’’
in the title, but these rarely translated into ethical values. Three articles that focused on frameworks for nursing
practice or clinical ladders included specific reference to ethics in their modeling.24–26 Civility in nursing
was a more recent topic with one article27 emphasizing that ‘‘as healthcare providers, we all have an ethical

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responsibility to care for those who care for others’’ (p. 329). Nursing Leadership was the final journal reviewed
(from 1999–2012) for indications of attention to ethical leadership in nursing. This journal included substantive
articles on ethical behaviors almost every year with both clinical and leadership emphases, for example, articles
on building a moral community,28–31 on conscientious objection,32 and on the silencing of nurses’ voices.33
Three29,30,32 of this journal’s articles originated from our research group. We targeted Nursing Leadership
directly as we wanted to reach FNLs.
In our selective review of these journals and books, there were occasional chapters or articles focusing on
the changed and changing environment of healthcare beginning with the move to industrial and business
approaches to management34,35 and later focusing on the current context of care and the complexity of lead-
ership in these environments.10 This focus implicitly suggests a changing set of values and shifts in the
moral climate of healthcare in which efficiency and effectiveness are valued over care and quality of care.
Tschudin36 stated the nature of these changes and subsequent challenges well when she noted that the
‘‘[c]oncept and reality of the market has dominated our lives for the past decades’’ (p. 123). As such, this
changing moral climate underscores the reality that ethical leadership, like ethical nursing practice, is not
simply an individual challenge and problem; rather, it is an issue requiring support from senior leaders, as
well as the employees they are responsible to, in order to address serious ethical issues at an organizational
level. The context in which questions about ethical leadership emerge is highly significant in order to under-
stand the perceptions of frontline nurses and nurse executives since individual FNLs are embedded in struc-
tures and policies that facilitate and constrain their leadership.
Along with an appreciation of contextual constraints, nurses and their leaders need clearer understand-
ings about the focus and meaning of ethical leadership in nursing. It is not merely about resource allocation
decisions, with the remaining ethical practices relegated to frontline nurses, but it is about daily ‘‘moral rec-
titude’’ as articulated in 1977 by Levine:37

Ethical behavior is not the display of one’s moral rectitude in times of crises. It is the day-to-day expression of
one’s commitment to other persons and the ways in which human beings relate to one another in their daily inter-
actions. (p. 846)

Levine’s comments can be applied to nurses at all levels of an agency or organization and are astute in
removing the common perception that ethics in practice or leadership is about handling dramatic situations
where ethical decisions have to be made. Thus, ethics in practice and in leadership take on added dimensions
of ethical obligations that span every moment of every day.
We turn now to a synthesis of data from across our four Canadian studies in nursing ethics in order to
determine what frontline nurses in practice expect of their FNLs regarding ethical leadership, and impor-
tantly, how FNLs perceive ethical leadership. Evidence of potential renewed interest in the area of ethical
leadership is apparent in diverse settings in Canada. For example, the Canadian College of Health Leaders
is currently engaged in a review of its code of ethics,38 and leaders in regional health authorities are
actively seeking better ethical frameworks for ethical decision making for leaders.39 The 2012 Catholic
Health Alliance of Canada Health Ethics Guide–Third Edition40 includes enhanced sections on govern-
ance and administration including a new section focused on ‘‘fostering an ethical climate’’ (pp. 100–102).
These are encouraging signs of renewed sensitivity to ethical leadership broadly in healthcare delivery.

Study design
This study is a meta-synthesis, and we chose meta-ethnography41 to guide our design. Meta-ethnography
was chosen because it facilitates synthesis of multiple qualitative studies to create a meta-synthesis of
‘‘comparative understanding’’ (p. 22)41 so that the results are greater than the sum of the parts.

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Table 1. Summary of studies.

Title Methodology Data collection Number of participants

Ethics in practice Interpretive/ Focus groups 87 (in 19 focus groups)

constructive
paradigm
Ethics in action Participatory action Interviews Approximately 40
research Group meetings
Cross-site
meetings
Leadership for ethical Participatory action Group meetings 12 formal nurse leaders, 82 frontline nurses,
policy and practice research Conferences and 6 graduate students ¼ 100
Interviews
Moral distress and ethical Survey Survey— 374
climate survey qualitative
questions
Total participants ¼ 601

We followed Noblit and Hare’s41 seven steps for conducting a meta-ethnography.42,43

1. Getting started

The guiding research question in our study was ‘‘How do frontline nurses and FNLs envision ethical nur-
sing leadership?’’

2. Deciding what is relevant to the initial interest

We purposefully selected qualitative research findings from four of our studies that explored the notion
of ethical nursing leadership. The studies included,

(a) Ethics in Practice,30,44,45

(b) Ethics in Action,17,46
(c) Leadership for Ethical Policy and Practice (LEPP),31,47
(d) Measurement of Nurses’ Moral Distress and Ethical Climates in British Columbia.48

These studies were conducted from 1999–2008 in Canada with over 600 participants. Table 1 outlines
the original studies, methodologies, data collection, and number of participants.
Data included published30,44–48 and unpublished49 articles from the first and second studies identified
above because the original data were no longer available to us. For the third study, original data from lead
team meeting notes and interviews with nurse executives were used in our analysis. These data had not been
previously used in publications pertaining to ethical leadership. From the fourth study, we drew upon pub-
lished articles as well as original data. Where it was possible, we went back to original anonymized data.
Ethics approvals from the original studies covered future analysis.
Meta-ethnography highlights the context in which original research was conducted,41–43 and because we
collectively participated in the original studies, we have intimate knowledge of the contextual elements
from these four studies. It was for this reason that we chose to limit our meta-synthesis to these studies. This
is an inherent limitation and we recommend that future research incorporate additional studies to evolve our
understanding of ethical nursing leadership.

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Table 2. Synthesis of findings.

Frontline nurses Formal nurse leaders Synthesis of findings

‘‘How do frontline nurses Supportive Responsive to systemic needs Responsive to practitioners and
and formal nurse Visible  Justifying work by linking the contextual system
leaders envision ethical Responsive to government/health Receiving and providing support to
nursing leadership?’’ authority priorities practice and discuss ethics day
 Learning to work in a to day
new political context
Receiving and providing support
 Strengthening ethical
practice

3. Reading the studies

Published articles and original data were read multiple times while noting the data that attended to our
research question.
4. Determining how the studies are related
We began to analyze data from the two participant groups, frontline nurses and FNLs, separately.
Themes from the two populations were identified so they could be juxtaposed with each other.
5. Translating the studies into one another
Themes from the two populations were compared for similarities and differences. During the fourth and
fifth steps, we began working towards articulation of synthesis.
6. Synthesizing translations
Noblit and Hare41 specifically outline three possible strategies for analysis: reciprocal translations as
syntheses, refutational synthesis, and lines-of-argument synthesis. In meta-ethnography, one or all three
of these strategies may be completed. Reciprocal translations are used when multiple studies can be com-
pared directly because they are ‘‘reciprocal,’’ meaning they are about very similar topics. Refutational
synthesis is employed when studies are in opposition to each other. In this article, we chose to use lines-
of-argument because it infers ‘‘what we can say of the whole (organization, culture, etc.) based on selective
studies of the parts’’ (p. 62).41 Lines-of-argument are historical, comparative, emic, and holistic. For the
purposes of our study, we were curious about how two different (yet inter-related) populations of nurses,
frontline nurses and FNLs, envisioned ethical nursing leadership and what we could infer from such
examination.
7. Expressing the synthesis
The following findings section, and Table 2, express our synthesis.

Findings
To express our findings, first, we synthesize the findings for each group, frontline nurses and FNLs. Second,
based on examining similarities and differences between the groups, we examine the relationship between
the two groups and synthesize findings into a new interpretive context.

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Frontline nurses and ethical leadership

Frontline nurses described three characteristics that they valued in their FNLs: those who were supportive,
visible, and responsive. At times, these qualities were highlighted because of a lack of support, visibility, or
response in their experiences with their leaders.

Supportive. What is striking across our research projects is the consistency of RNs’ hopes for ethical lead-
ership from their FNLs. In our first study, titled Ethics in Practice,30,44,45 RNs indicated their desire for
more stable, competent, confident, and supportive nurse leaders. Concerns were raised about formal lead-
ers’ reluctance ‘‘to raise ethical concerns or to advocate for clients or staff’’ (p. 10).30 Many nurses described
their leader as not visible and expressed their frustration about having ‘‘no administrative support,’’ but oth-
ers empathized with administrative nurses, stating ‘‘I find that there is not a lot of support. I don’t think that
they [administration] don’t want to give it, I don’t think they have the availability to give it to us’’ (p. 87).44
Some nurses talked about having gone home alone, feeling terrible about work not done in keeping with
standards of care, and speaking to no one about it, thus bottling up their stress. Many nurses found that just
talking about their own ethical challenges in our focus groups was meaningful and helpful:

When someone else’s perspective comes to it . . . all of a sudden it isn’t the huge problem anymore—gee, it’s not
just me that felt this way, it’s a more common feeling than I realized. I guess it gives me permission to have felt
that way, knowing that other people have the same issues. It cuts it down inside. (pp. 87–88)44

In sharing their stories about ethical difficulties, they found a sense of connectedness they valued. Few
nurses felt they could debrief these ethically challenging situations with their nurse leader since many felt
leaderless:

I wish we had more of an opportunity to share with our colleagues . . . we have a very large staff, and I’d like to be
able to draw on their experiences and their attitudes. It might reassure me in some ways in people that I do not
know very well, that they’re, ethically speaking, coming from a good place too. (p. 9)30

Visible. In our second study, Ethics in Action,17,46 nurses also spoke about not feeling they had a leader:

We are like a ship without a captain and we’re out there. When they took the head nurse position away, I remem-
ber what happened. We all felt that in the acute care, everywhere, where’s our leader? Our manager? And then
they took the uniform off our manager to boot. And gave her such a large portfolio that she can’t possibly be on
top of what is going on and she’s trying to say that ‘‘You are really autonomous, you make decisions for your-
self.’’ But really, you just need the support of a leader too, and that’s what is missing and I think even somebody
quite brutal, it wouldn’t matter, anybody. (p. 3)49

Frontline nurses said they wanted ‘‘a visible formal nurse leader who: can read between the lines,
would listen and recognize an issue, would take action/provide response, and would welcome nurses’
voices’’ (p. 17).49 They were deeply concerned about working over-census, overtime, callbacks to work,
and use of co-ed beds:

The question of whether co-ed beds were ethical arose as part of our discussion in the context of our research. In
particular some nurses were concerned that having a man admitted to a room with three elderly women violated the
dignity of those involved particularly the elderly women . . . Subsequently, although the hospital policy did not
change, as a collective the nurses created their own working policy to address the issue of co-ed rooms. (p. 7)17

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Doane et al.17 note that these nurses gradually realized that they were not able to do this work alone, that
they needed ‘‘organizational structures and policies that supported’’ good care at the bedside (p. 8).
Nevertheless, they readily took up the chance to learn and practice ethics discussions, to better under-
stand impediments to ethical practice, and to develop confidence in their ability to consult, confer, and
to make change. One nurse participant wrote about that experience:

For the first six months we shared stories with each other about the ethical distress we experienced in our work.
We were all finding ourselves in situations in which we did not feel we could fulfill our ethical obligations and
commitments to our patients . . . [but] we became more comfortable and capable in articulating our experi-
ence . . . . our meetings came to be known as ‘‘ethics debriefings’’ and they provided a forum in which we
acquired a common language for talking about ethics in our practice. (pp. 9–10)50

These nurses then worked with their FNL to integrate ‘‘ethics debriefing’’ into each staff meeting.
In this case, it was the nurses who pressed the leader to incorporate ethics and ethics discussions in
practice. They also realized that without the leader’s support, their meaningful ethics debriefings
would not be sustainable.

Responsive. Recognizing the importance of nurse leadership for sustainability, we planned a participatory
action study alongside nurse executives to work toward that end. In this third study, LEPP,31,47 nurses had
opportunities to learn more about ethics in practice and to engage with their FNLs. This engagement
included diverse interactions from province-wide conferences where large and small groups engaged, to
on-site meetings between leaders and frontline nursing staff to enhance knowledge and understanding.
In the first year of this study, there was high enthusiasm from FNLs and good engagement. However, a rap-
idly changing context of healthcare changed nurse leaders’ priorities, forcing them to attend to new
priorities.
During this time, a fourth study began entitled Measurement of Nurses’ Moral Distress and Ethical Cli-
mates in British Columbia.51 Added to the quantitative measurement scales were three qualitative questions
about moral distress that became a significant part of our findings.48 The qualitative findings of this study,
which were nested within the larger LEPP study, were remarkably consistent with findings reported by
Storch et al.30 relative to nurse leaders. A perceived lack of leadership was identified as a pervasive prob-
lem. Many referred to having an ‘‘absent manager’’ often coupled with reference to the non-nurse manag-
er’s ‘‘lack of knowledge about and/or support for the role of the nurse, given that managers often were not
nurses’’ (p. 492).48 As Varcoe et al.48 explain, when nurses approached their manager, the result was one of
many possibilities: the nurse might find inaction or being ‘‘blown off,’’ might find her leader to be demean-
ing or to resist and deflect concerns, or to be responsive to actions. In the case of those who had negative
experiences, many judged their manager to be ineffective. Varcoe et al.48 note that ‘‘two formal organiza-
tional responses to morally distressing situations were identified by some participants: ethics consultations
and debriefing of the situation. In some situations, debriefing was described as talk and ‘nothing came of it.’
In other situations, such responses were evaluated as helpful, particularly when both support and change
ensued’’ (p. 496).
In summary, frontline RNs expected their FNLs to be stable and supportive, competent, and willing to
‘‘take charge.’’ They wanted a visible nurse leader who could read between the lines, listen and recognize an
issue, take action and provide response, and welcome frontline nurses’ voices. While the desire for visible,
supportive FNLs is by no means an innovative finding, what these frontline nurses expressed in a new way
was their willingness to contribute48 within a community of practice,52 working alongside of FNLs, to pro-
vide leadership, change, and patient care that was ethical.

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FNLs and ethical leadership

Two main themes thread through FNLs’ perspectives of ethical leadership. (These FNLs were in executive
positions, such as chief nursing officer or at a similar administrative level.) First, the ability to provide ethi-
cal leadership is situated with the need to be responsive to systemic (or system-wide) needs of their health
authority, as well as provincial or federal governments. Health authority and government priorities drove
how they set their priorities and the ability to enact ethical leadership. Second, to enact ethical leadership
they needed to both receive and provide support.

Responsive to systemic needs. FNLs discussed the requirement for them to be responsive to systemic needs in
their health authority or from provincial/federal governments. Two sub-themes identify how they responded
to these systemic needs. The first sub-theme is justifying their work in a way that ties into government/
health authority priorities. The second sub-theme is learning to work in a new political context.
Justifying work by linking to government/health authority priorities. FNLs clearly articulated that their health
authority or their government had many competing agendas, priorities, and initiatives. In response, they
learned to strategically ‘‘link’’ or ‘‘justify’’ their work in relationship to the initiatives that were being given
priority in the system. A common phrase used by FNLs was that a particular initiative was ‘‘one of many
priorities’’ which was in competition with other initiatives.
In numerous ways, FNLs were deeply attuned to where and how their organization was focusing time,
energy, human resources, and finances. As one leader explained, these initiatives are ‘‘the ones that are
absolutely going to take precedence.’’ These ‘‘popular’’ initiatives were the ones that FNLs used strategi-
cally as leverage to move along their own nursing priorities. Popular initiatives included patient safety, spe-
cific research projects, healthy workplaces, staff turnover, mental health in the workplace, ‘‘Balanced Score
Cards,’’ patient metrics, and fiscal restraints. While these priorities were not unrelated to ethics, they con-
tained set foci, for example, hand washing, and so on, that only laterally focused on ethics. FNLs justified
their own work in nursing by ‘‘moving these other agendas along.’’ In this manner, their leadership was
evident as they looked at the ‘‘big picture’’ and found ways to ‘‘bring nursing to the table’’ and advance
their own nursing priorities.
FNLs had varying views of what it meant to enact ethical nursing leadership in this context. For example,
one leader said,

With all of the competing demands, how can [ethics] be embedded in the way we work i.e. strategic initia-
tives? . . . Embed ethics among how we approach our work, including people across all levels of the orga-
nization. So, this can be applied across all initiatives.

As this FNL explains, she purposefully looked for ways to embed ethics within priorities in her health
initiative. Her view of ethics was that it should be integrated into all aspects of her work and her leadership.
Another nurse leader agreed that ethics must be woven into the fabric of their practice, but this leader saw
ethics in a specific way:

Fundamentally it is all about ethics and ethics, of course, being about the distribution of scarce resources . . . the
reality of a very tight fiscal environment that has no give in it . . . if we look at the ethics of scarce resources,
every dollar that I want for professional development, for healthy workplace initiatives potentially takes away
from our ability to serve the patients coming through our doors.

Given that this nurse leader equated ethics largely with the allocation of scarce resources (i.e. a narrow
and restricted view of ethics), she believed that when she prioritized ethical distribution of resources she was
taking resources away from the care that patients would receive. This caused her angst.

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Other FNLs had a different view of priority initiatives. They believed that having an interdisciplinary
focus was a priority, and so advocating solely for nursing would not be tolerated. One FNL said,

Are ethics in nursing an issue? Of course they are. But they’re an issue to all disciplines and most folks in my role
in the health authorities have responsibilities for multiple disciplines, not just nursing . . . But restricting this
discussion to nursing is challenging and if I, in my position, start trying to take that approach not only will I get
lambasted, I will be unsuccessful in moving any kind of an agenda forward so that’s gotta be one of the challenges
that people hear loud and clear. It’s pretty tough to focus specifically on nursing by someone in our roles. Polit-
ically suicide, okay?

There was no mention of working with interdisciplinary teams to advance an agenda for ethical leader-
ship, or of seeking ways to embed ethics in their organizational priorities. All FNLs agreed that ethics was
integral and should be woven into their work. However, their interpretation of what constituted ethics in
their practice was diverse as was their vision of how this could be enacted in their own leadership.

Learning to work in a new political context. The second way that FNLs responded to systemic needs was
through adapting and learning to work in a new political context. One leader said, ‘‘can we shift the para-
digm from ‘more is less’ to ‘there is less?’ This is a politically strategic move.’’ The new context included
less nursing staff, fewer formal leaders, ‘‘financial incentives to cut,’’ union negotiations, and provincial
elections. Workloads for nurses were constantly changing, as were the FNLs’ portfolios. One leader spoke
of the necessity to have the ‘‘capacity to move in-between jobs.’’ Over the course of the LEPP project, four
FNLs held two different roles in 3 years, and another had three different roles in 3 years. One executive
summed up working in this new political context by stating that FNLs ‘‘have shorter timelines, need imme-
diate results and actions.’’
Learning to work in a political context, nurse executives frequently did not use ethical language for stra-
tegic reasons.53 For example, one FNL said,

I found that sometimes the language [of ethics] can alienate practicing practitioners because it can seem so con-
ceptual and it can seem so remote from what you are doing on a daily basis. But I find when you get into being
able to talk it through then people get more comfortable. But it’s probably true of any particular field the special
language that you run into in that field can be a barrier for those people that aren’t like ‘‘scientists’’ in it.

While FNLs agreed that ethics was a part of everyday practice, the language was seen as reserved for a
special scientific field. One leader said, ‘‘let’s embed [ethics] into practice and who the hell care what it’s
called.’’ Another leader explained that she did not use the word ethics because ‘‘people’s eyes glaze over.’’
And so for strategic reasons, many FNLs chose not to use ethical language in the context of their work
because they felt it created distance between themselves and others.
FNLs also held some reservation of ethical language for political reasons. One leader explained,

The people that take up this language are people that are union activists . . . they are using the language to lever-
age some of the initiatives that they would like to get going . . . Like it or not, the union is seen as an adversary
quite often in a managerial system . . . So, what you sometimes see is the language being taken up, but they need
to—‘‘beat up’’ isn’t the right word—but it’s used as a negotiating strategy and so in some ways I would suggest
that the language has been co-opted.

While FNLs strategically linked their own work in relationship to organizational priorities, the above
leader had also noticed that unions had ‘‘co-opted’’ the language of ethics to leverage their own initiatives.
In response, FNLs spoke of ‘‘using whatever language [others] understand most effectively’’ in order to
influence agendas and decision makers. These leaders’ responses to the language of ethics was in contrast

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to frontline nurses who found that ethical language helped them share with each other about the day-to-day
ethics that they encountered in their practice.
FNLs were often hesitant to use ethical language explicitly, instead often using ‘‘values’’ as their refer-
ence to ethics. As noted in the literature reviewed, these values ranged from economic to personal values
with limited alignment with ethics. This is a common conceptual mistake in much of management literature.
Leaders used the language of values, such as ‘‘a values frame,’’ to express how they enacted ethical lead-
ership and influenced ethical climate in their organizations without making explicit reference to ethics. In
doing so, they tend to distance the body of knowledge of ethics. Yet FNLs expressed their sense of having
sought to balance (ethical) values within the contextual values and priorities of the systems in which they
worked.

Receiving and providing support. FNLs described their own expectations of what it meant for them to enact
ethical leadership. The main expectation related to receiving and providing support, including a sub-
theme of strengthening ethical practice.
FNLs explained that in order for them to respond to systemic needs, they needed support from their
superiors and from the system. Support was needed from their senior executive board, their CEO (Chief
Executive Officer), COO (Chief Operating Officer), and from other FNLs. As one leader explained, it is
a mutual relationship: ‘‘How can I support them and how can they support me?’’
Leaders widely recognized that they, and their superiors, worked within a broader system, full of fiscal
and personnel constraints. As mentioned earlier, they ‘‘reframed’’ their work to ‘‘fit with agendas that the
health authorities and the Ministry have . . . it becomes a bit of a management challenge for the [FNLs]
when they’re managing so many other things.’’ In this manner, they strategically sought ways to align with
organizational priorities that would provide them with support; however, it was not always possible. A num-
ber of leaders spoke of feeling curtailed by the system, in turn experiencing ‘‘stress,’’ ‘‘distress,’’ and even
‘‘moral distress.’’ One FNL explained it this way:

The crush of needing to provide the patient care despite the label of practice leader is truly, I would say, an exam-
ple of moral distress. And in turn, that gives me moral distress because my ability to improve that, ameliorate that,
through structural changes is very limited given two things:
#1. Just the health authority structure itself, but
#2. The lack of dedicated funding to put more positions in place, or to say to that person suddenly, ‘‘okay, you’ve
got 20% protected time now for your practice leader roles.’’

FNLs did not discuss in detail how they attended to their own moral distress outside of describing their
strategies to align with organizational strategies to support their own work, and expressing their own need
for support from colleagues and superiors.
Leaders were keenly aware that in their executive roles, they needed to provide support to frontline
nurses, as well as staff in other disciplines due to the large portfolios that they held. Their interpretation
of support echoed the support that frontline nurses called for. FNLs spoke of ‘‘engaging the staff in discus-
sion about their work’’ with the belief that staff had ‘‘creative solutions’’ to their concerns. They included
frontline nurses, interdisciplinary staff, managers, and administrators in such discussions. However, a few
FNLs held counterviews that staff could not provide solutions. One said, ‘‘I still don’t see how nurses really
have the skills to present ethical concerns and work through the resolution.’’ They seemed to underestimate
the knowledge, wisdom, and skill of their frontline nurses. This leader experienced great tension between
what she felt frontline staff expected of her and what she (and her senior management) could deliver.

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Again, echoing frontline nurses, many FNLs were aware that they needed to be visible and accessible.
One FNL said, ‘‘you have to be accessible on shifts and on Saturdays and in the evenings . . . it also is a
measure of respect . . . being there when the staff are there is important. It has an enormous amount of cur-
rency for them.’’
Providing support was discussed in the context of a broad recognition that there was a ‘‘lack of support
available within the system,’’ which was beyond their control. In turn, they could not always provide the
support they knew was needed. One FNL described this in detail:

It’s troublesome . . . [nurses] want to practice direct care nursing and there’s so much ‘‘noise’’ I’ll call it, external
pressures, internal pressures, and there’s the government and there’s the unions and there’s a lot of factors now
impacting the ability of a nurse just to do a really good job with a patient that she’s assigned to, or he’s assigned
to, on the shift and I think the cushion around that is getting smaller and smaller so I think that it’s showing up in
terms of moral abandonment.

FNLs used different language to describe the effects they saw on staff when they did not receive support
including moral abandonment, distress, stress, moral distress, and anxiety.
Strengthening ethical practice. Recognizing the distress that frontline nurses experienced, FNLs believed
that in order to provide support, they needed to strengthen ethical practice. While a few leaders were respon-
sible for ethics as part of their portfolio, they were in the minority. Nonetheless, many expressed the belief
that ethics was central to their leadership. For example, one leader summarized that ethics ‘‘is just the core
really of my job,’’ and another explained, ‘‘fundamentally, it is all about ethics.’’ Ethical practice was not
only core to their leadership role, but they believed it was core to nursing practice ‘‘across all levels of work,
regardless of the topic.’’ Even so, it was difficult to name these ethical encounters. Leaders believed ethical
practice occurred ‘‘on a daily basis,’’ like ‘‘small little daily twinges.’’ Another expanded, ‘‘I would say that
there isn’t a minute that goes by that there isn’t something happening in the health authority that doesn’t
have a bit of ethical tension.’’ FNLs viewed their own jobs as inherently ethical, and they expressed the
belief that they, as well as frontline nurses, daily faced ethical challenges.
In response, they saw that their role in providing ethical nursing leadership was to strengthen ethical
practice through a number of strategies. Some used traditional ethics avenues such as consultations with
institutional ethics committees, yet others hired clinical ethicists and organized discussions of ethical dilem-
mas that occurred in practice. Some other FNLs hosted forums where ‘‘staff can come and ask questions and
if they have issues/questions that need to be brought forward, [I] will go with them to present to the Board.’’
Other leaders recognized that day-to-day practice needed ethical support. For example, one FNL saw
that the health authority was ‘‘putting in place policies and procedures or mechanisms that are a barrier
to staff . . . particularly around the areas of workload–overtime, overcapacity; there’s a huge ethical overlay
to that.’’ This leader felt that they needed to offer ethical support for frontline providers to work in this
context. FNLs acknowledged that frontline nurses and other interdisciplinary staff ‘‘are the face of ethical
care’’ and that in order to provide ethical nursing leadership, they needed to provide frontline staff with
support that would strengthen their capacity to practice ethically.

Synthesis of ethical nursing leadership

Looking at the similarities and differences between frontline nurses and FNLs, these findings can be synthe-
sized to further answer our research question of how these two populations envision ethical nursing lead-
ership. Two main threads are woven through these four studies. First, ethical nursing leadership must be
responsive to practitioners and to the contextual system in which they and FNLs work. Second, ethical

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nursing leadership requires receiving and providing support to increase the capacity to practice and discuss
ethics in the day-to-day context.

Discussion
It is notable that this meta-synthesis was conducted by members of the same team that conducted the orig-
inal studies included in this review. Thus, we were able to bring to the analysis a clear understanding of the
context of the four studies as well as intimate knowledge of the findings from previous research. This anal-
ysis was further strengthened by our ability to supplement the published literature with actual texts from
team meetings and interviews. Meta-ethnography typically draws upon published findings rather than orig-
inal data in secondary analysis.42 However, because we had access to both types of data, we had more com-
parative and historical data to use in our lines-of-argument analysis from which we inferred to the larger
culture. Meta-synthesis, and in this case the use of meta-ethnography, highlights the important role of FNLs
in providing ethical leadership and supporting ethical nursing practice at the point of patient care. While it
was clear throughout our program of research that ethical leadership was a central and important feature of
ethical nursing practice, undertaking this meta-synthesis enabled us to gain further insight into and under-
standing of ethical nursing leadership in relation to not only what may be needed but also what facilitates
and/or hinders the practice of ethical leadership. This work draws attention to the important, and somewhat
neglected, need for FNLs to have organizational support in order to enact ethical leadership. In this discus-
sion, we highlight five key findings. Furthermore, we offer recommendations for strengthening ethical lead-
ership among FNLs. In doing so, we emphasize ethical nursing leadership ‘‘as simultaneously a deeply
personal and communal process that requires thoughtful reflection and intervention at all levels’’ (p. 239).45

Everyday ethical leadership

First, it is evident from these findings that FNLs view their practice as inherently ethical and, regardless of
the language used or chosen, believe that they have an important role in providing ethical guidance and sup-
port to frontline nurses. It is interesting to note that statements by frontline nurses regarding qualities
required of nurse leaders and what FNLs believe they do as part of their daily practice is relatively consis-
tent. In contrast, and based on findings from our own and other research,1 frontline nurses do not necessarily
perceive FNL as visible, responsible, and supportive. This highlights a gap between perceptions and actions
that requires more attention. Specifically, what are the behaviors and actions of FNL that are perceived by
frontline nurses as providing ethical nursing leadership? In the review and revision of nursing codes of
ethics, as well as standards of professional practice, it would be highly relevant to ensure inclusion of state-
ments that call for thoughtful ethical leadership as a means of supporting and fostering ethical nursing lead-
ership. Such a standard or guideline might help FNLs consider how much they connect their daily activities
with ethical thinking and action.54

Enacting ethical leadership

Second, FNLs clearly face challenges in their ability to enact ethical nursing leadership. Chief among these
challenges is navigating the current healthcare environment in which values related to quality of care may
be of second priority to business and market-orientated values of efficiency and cost effectiveness.55 Such
values have driven large-scale changes in healthcare delivery with formal nursing leadership positions
being dramatically affected. In Canada, FNL positions have been eliminated, eroded, and devalued, contri-
buting to a loss of visibility of formal nursing leadership at both managerial and executive levels. Thus, it is
not always clear if the frontline nurses in our studies were speaking of particular nursing leaders or if they

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even had a nursing leader as a manager or director. It may be that these nurses were responding to difficul-
ties due to the lack of nurses in formal leadership positions. In part, such changes in formal nursing lead-
ership roles may explain the gap between perceptions and actions. In addition, many formal nursing leaders
have had their span of responsibilities expanded considerably, making it difficult to provide the kind of visi-
ble daily leadership for ethical practice that frontline nurses stated they require. ‘‘Pressures on production
and getting the bottom line right’’54 limit attention to wholeness and relationships critical to supporting
frontline nurses (p. 121).

Ethical leadership obscured

Third, FNLs described the notion that ethics is embedded in their practice, but they also clearly expressed
that it is often difficult to name ethics or to advocate for or against changes that might impact ethical prac-
tice. In some of our work, we heard the clear tension that nurse leaders must navigate between demands of
the organization and the needs of frontline nurses to provide quality care. This tension is not new and is
historically located in the move of professional nursing into healthcare organizations where obligations
to the organization are in tension with obligations to patients and quality care.56–58 FNLs in this study often
chose not to use the word (or language) of ethics, even though they maintained that ethics was a consider-
ation to them in their daily practice. In this sense, ethics was practiced covertly and/or obscured. This is
unfortunate and needs to be offset by visionary leadership based upon ‘‘an ethical stance that ‘people mat-
ter’ and that what they mind about matters’’ (p. 107).58 The people who matter include patients, clients,
nurses, and leaders.
Organizational vision, mission, and values often highlight the importance of value-based ethical com-
mitments to patients and, in some cases, to staff. Organizational codes of ethics are visible signs of this com-
mitment as well as the presence of ethics resources (e.g. clinical ethicists, ethics consultation services,
debriefing, and education). These tangible organizational resources can be utilized by FNLs to enact the
responsibilities and competencies associated with ethical nursing leadership. Furthermore, there is a need
for formal acknowledgement of the importance of ethics as part of FNL leadership competencies. Other-
wise, as described above, FNLs may rely on clandestine strategies to support ethical practice, thus further
obscuring the ethics work they do and, by extension, their ethical leadership. It is possible that some nurse
leaders may even abandon the notion that ethics is an important aspect of their role in a context where ethics
has to be practiced covertly.

Building capacity for ethical leadership

Fourth, there is a need to focus on and develop the ethical competencies of FNLs as part of organizational
leadership. In nursing education, an increased emphasis on ethics as part of nursing leadership, manage-
ment, and administrative education would be an important and welcome addition to the nursing curriculum.
Furthermore, this increased emphasis may be an important suggestion as the Canadian Nurses Association
and other international nurses associations revise their current codes of ethics.

Ethical leadership key to ethical climate

Fifth, a key rationale for strengthening ethical nursing leadership is to support ethical nursing practice as
part of excellence in patient care. We have faced a decade of concerns about nursing recruitment and reten-
tion, as well as continuing concerns about nurses leaving their profession.59 Within the field of nursing
ethics, there is a recognition that nurses often quit because they experience moral distress and do not feel
supported to practice ethically.60 Pauly et al.’s51 study demonstrates a strong correlation between moral

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distress experienced by RNs and the ethical climate within which they practice. Ethical climate can be
understood as evolving from the professional relationships between nurses and their patients, co-
workers, supervisors, and other healthcare professionals and is greatly influenced by management or lead-
ership practices.61,62 Thus, the ethical climate constitutes the context in which ethical decisions are made
with implications for quality patient care and outcomes. We know that disengaged management or leader-
ship affects both retention and the quality of practice environments.63 It has also been well established that
improved nurse retention and satisfaction result in both improved quality of patient care and significant
financial savings to the organization.64 Indeed, when asked about retention, many nurses placed greater
importance on improving quality of workplaces than increasing wages.54 Therefore, supporting and
strengthening ethical leadership will play a significant role in contributing to a positive ethical climate
in which the nurse, patient, and organizational outcomes will be considerably enhanced. This raises two
possible areas for action.

Calls for actions

An important and urgent first step would be to better understand how to frame organizational ethics
resources in the current organizational milieu. This may give us insight into how these resources can be best
used to strengthen the organizational ethical climate. There are helpful examples in how the need for clinical
ethics, as part of organizational resources, have been rationalized by organizations such as Veterans Health
Administration.65 Thus, it may be prudent for nurse leaders to argue for resources to better develop their
own capacity in ethics in order to be strong ethical leaders, as well as to equip the organization with ethics
resources to enhance the ethical climate. Furthermore, it may be extremely valuable for FNLs to articulate
the need for organizational codes of ethics and view these as policy documents to guide practice, as well as
promote and support the development of ethical nursing leadership competencies and education for all lev-
els of FNLs. For example, senior nurse executives could endorse professional development that supports
nurses to gain competencies in ethical nursing leadership as part of leadership development. This profes-
sional development must include strategies and guidance to connect the FNL with frontline nurses in ways
that support not only those practicing at the point of care but also the FNLs. ‘‘Ethical leadership requires not
just one leader but a team of people who can lead and learn together, thus enabling all to take a leading role
in deliberations’’ (p. 122).58 We ardently believe that FNLs have the tremendous potential to positively
influence the ethical climate of their organizations. The potential to improve outcomes for the organization,
staff, and patients through the processes of making formal ethical leadership visible and sustainable is
profound.
A second step would be to undertake research to identify the links between ethical leadership and ethical
nursing practice, as well as patient outcomes. One fruitful area could be the exploration of FNLs’ experi-
ences of moral distress. Also a better understanding of the reasons that nurses leave nursing and the role that
moral distress plays would be beneficial to illuminate the meaning of a positive ethical climate.

Conclusion and recommendations to take forward

We can conclude from this meta-synthesis of four studies, that there is an urgent need to strengthen, and
make visible, ethical leadership among FNLs. Ethical leadership is an important aspect of creating an ethi-
cal climate in which both nurse and patient outcomes are enhanced. Yet FNLs are often caught in the tension
between enacting ethical obligations of the profession and working within the priorities and needs of their
healthcare organizations and governments. To not even be able to speak of ethics, has us questioning a con-
text in which moral commitments are not seen as part of professional work and ethics has to be practiced
covertly. However, in the current context that emphasizes business and market values, it is not surprising

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that the ability of nurse leaders to enact ethical leadership based on values related to compassionate and
competent care can easily be dismissed or devalued. Thus, FNLs require support and resources to enact their
ethical commitments. Such support and guidance should be found in Codes of Ethics, Professional Stan-
dards of Practice, organizational codes of ethics, and resources for ethical practice that focus on the devel-
opment of ethical leadership.

Acknowledgments
We wish to acknowledge other members of the original research team on the project Leadership for Ethical
Policy and Practice including Patricia (Paddy) Rodney, Colleen Varcoe, Rosalie Starzomski, Lynn Steven-
son, Lynette Best, Heather Mass, Tom Fulton, Barbara Mildon, Fiona Bees, Anne Chisholm, Sandra
MacDonald-Rencz, Amy McCutcheon, Judith Shamian, and Charlotte Thompson.

Conflict of interest
None declared.

Funding
This work was supported by the Canadian Health Services Research Foundation/Canadian Institutes of
Health Research (Grant #PHS-73043); Health Canada, Office of Nursing Policy (2006-07-17).

Research Ethics Board approvals

Written consent was obtained in the original studies. Review committees included the University of Vic-
toria Human Research Ethics Board; University of British Columbia Human Research Ethics Board; Van-
couver Island Health Authority Research Ethics Board; Fraser Health Authority Research Ethics Board; BC
Cancer Agency Research Ethics Board; Vancouver Coastal Research Ethics Board; Interior Health Author-
ity Research Ethics Board.

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