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Nursing Ethics
1–13
Ethical leadership outcomes ª The Author(s) 2017
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in nursing: A qualitative study 10.1177/0969733016687157
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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: Leadership style adopted by nursing managers is a key element in progress and development
of nursing and quality of healthcare services received by the patients. In this regard, the role of ethical
leadership is of utmost importance.
Objectives: The objective of the study was to elaborate on the ethical leadership and its role in
professional progress and growth of nurses in the light of work condition in health providing institutes.
Methods: The study was carried out as a qualitative study following conventional content analysis method.
In total, 14 nursing faculty members and nursing managers at different levels were selected through
purposive sampling method. Semi-structured interviews were used for data gathering. The data were
analyzed using latent content analysis and constant comparison analysis.
Ethical considerations: This study was conducted in accordance with ethical issues in research with
human participants and national rules and regulations related to informed consent and confidentiality. The
study was approved by the Committee of Ethics in Research at the Shahid Beheshti University of Medical
Sciences in Tehran, Iran, under the code: sbmu.rec.1393.695 on 15 February 2015.
Findings: Five subcategories were obtained based on the analysis, which constituted two main categories
including ‘‘all-inclusive satisfaction’’ and ‘‘productivity.’’ Nursing leaders highlighted the point that their
ethical behavior creates ‘‘inner satisfaction of the leader,’’ ‘‘employees’ job satisfaction,’’ and ‘‘patients’
satisfaction.’’ Improvement of productivity was another outcome of ethical behavior of the leaders. This
kind of behavior resulted in ‘‘providing better services’’ and ‘‘inspiring ethical behavior in the employees.’’ It
has great influence on progress and growth of the nursing profession.
Conclusion: By creating an ethical climate, ethical leadership leads to positive and effective
outcomes—for the patients as well as for the nurses and the leaders—and professional progress
and development of the nursing profession. Therefore, an ethical work environment that supports
nurses’ progress and development can be developed by paying more attention to moralities in
recruitment, teaching ethical values to the leaders, and using a systematic and objective approach
to assess morality in the environment.

Keywords
Content analysis, ethic, ethical leadership, leadership, morality, nursing, outcome, 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, Iran.
Email: t.ashktorab@sbmu.ac.ir
2 Nursing Ethics

Introduction
Ethical leadership approach entered the leadership and management literature in the last decade of the 20th
century.1 Ethical leadership in nursing consists of creating and supporting an appropriate environment for
the provision of high-quality and cost-effective healthcare and also ensuring the individuals’ ethical beha-
vior. Ethical leadership attracts the individuals’ attention to ethical issues and moralities through determin-
ing and analyzing the common values and accommodating between fundamental values of nursing and
nursing behavior. It also includes ethical commitment for respecting the nurses and behaving them on the
basis of justice and empathy.2
Character, conduct, and institutional practices form the major aspects of ethical leadership in nursing. By
‘‘character,’’ we mean possession of skills and manifestation of ethical acts, noticing the ethical issues, and
demonstration of features such as role modeling, motivation, and authenticity. ‘‘Conduct’’ represents
conveying the relationship between high ethical standard expectations and high-quality care, supporting
ethical acts in daily living, and holding the individuals responsible in the case of violation of ethics and
standards in providing high-quality care. Finally, ‘‘institutional practices’’ are expressive of creation of
ethical work environment, noticing dignity, safety, and rights of the patients, and creation of the individual-
based official and professional routines according to ethical and professional principles and values in
healthcare provision.3
Ethical leaders can provide ethical leadership via creating an ethical community, that is, they must
produce a climate in which the values are determined and shared, and these values guide the ethical act
so that individuals are ensured that they are heard and listened to.4
Nowadays, only the ethical leaders can create trust and commitment in the organization and prepare the
ground for carrying out the affairs in the right way.5 However, it is the employees’ right to work in an
organization in which they are considered, well understood, and respected. There should be also mutual
trust, honesty, and integrity and they should feel that they are part of the organization. The leader that creates
such an organizational environment is a leader that reflects ethics and trustworthiness in all his or her
behaviors and is faithful to moral values. Such a leader follows the ethical codes that reflect righteousness,
trying to reach the best with honesty at all times.6 Therefore, a leadership style that pays attention to ethical
dimensions is needed to improve nurses’, patients’, and the healthcare organizations’ outcomes.7
Ethical leaders are described as honest, altruistic, and disciplined who make just and harmonious
decisions. They give a special place to ethics in their programs and implement it by notifying the ethical
principles to the employees, showing ethical behavior clearly and consciously and introducing a reward/
punishment system for employee’s adherence to ethical behavior.8 In other words, leaders have the posi-
tional power (such as authority, rewards, and punishments) and personal power (such as skills, abilities, and
traits of a leader) to create an ethical work climate.9 Ethical leaders use the position of leadership to promote
ethical behavior at work and reward ethical behavior and discipline unethical behavior.10
Nightingale is one of the first nursing leaders who paid much attention to ethical aspects. She named, in
her writings in 1860, the ethical guidelines for nursing leaders; the guidelines were honesty, fairness,
neutrality, respecting the employee’s needs, and having a wide vision about the characteristics of
employees.11 In contemporary periods, hospitals and other health organizations need to adopt specific
strategies to create an environment based on ethical leadership, ethical performance, and ethical bravery.12
Despite the outstanding importance of ethical leadership, this concept and its consequences in nursing
have been investigated sporadically. Studies on the outcomes of ethical leadership in nursing are mostly
quantitative studies that have emphasized the relationship between ethical leadership and the variables that
may have impact on them. The quantitative studies conducted on nursing have indicated that ethical
leadership, through creating an ethical climate and decreasing the rate and intensity of ethical distress,13
has exerted considerable effects on reduced turnover,14–16 increased competency and job satisfaction with
Barkhordari-Sharifabad et al. 3

respect to care quality,16,17 organizational commitment,17 organizational civil behavior,18 psychological

empowerment,19 and psychological safety and risk management in nurses.20 These consequences affect the
patient positively and enjoy organizational efficacy.21 Similar studies also exist in relation to the association
between ethical leadership and the results of the personnel’s work in non-nursing fields.22–29 Another
feature found in most of these studies is that they have adopted the employees’ viewpoints, while ethical
leadership can be effective on other stakeholders including the health service receivers. Qualitative studies
on the outcomes of ethical leadership have been limited to non-medical fields.30 Studies of the same nature
in health organizations are needed to have a clearer perspective and a basis to discuss and reflect the special
patterns in such organizations.31
The Islamic Republic of Iran, a developing country, is located in the Middle East with one of the most
ancient civilizations in the world. Islam is the official religion of the country,32 and the Iranian identity is a
mixture of Iranian and Islamic cultures. From Islamic viewpoint, leadership and management is a task, trust,
and a big divine responsibility that must be bestowed to competent individuals who must be responsive to
the responsibility.33 The ethical and spiritual issues have been highlighted in the patient-care protocol by the
entrance of religious discipline and Iranian cultural beliefs into the healthcare system. Of course, despite the
different religious beliefs and the sociocultural conditions of the Iranian society, the behaviors and ethical
competencies of the Iranian nurse leaders are very similar to those of other countries. The ethical leaders in
Iran affect the organizational climate through moral behaviors (like supportive, collaborative, and just
behaviors), sympathetic interactions (like mutual respect, meeting needs, and sympathy), and exalted
manners (righteousness and honesty, truthfulness, modesty, and patience).34 From the perspectives of nurse
leaders in Iran, personality features, serving as a model, and spiritual guidance are the major aspects of
leadership and having a nursing perspective, clear obvious objectives, and commitment to nursing are of
utmost importance in the spiritual empowerment of nurses.35
Given the above introduction, this study is a content analysis study following qualitative approach and an
attempt to survey the experience of nurse leaders with regard to ethical leadership outcomes in nursing. The
objective of a content analysis study is to extract knowledge out of experiences about a specific phenom-
enon, leading to deeper perception of the phenomena.36,37

Aim
The objective of this study was to elaborate on the role of ethical leadership on progress and development of
nursing profession given the healthcare service environment.

Methodology
Study design
This study was qualitative component of the larger mixed-method study. The outcome of this qualitative
component was used for designing the instrument.
The study was carried out through conventional content analysis. In total, 14 individual semi-structured
face-to-face interviews with nursing leaders and faculty members were carried out. Given the objectives of
the study, purposive sampling method was adopted. The participants were selected based on the objective of
the study. Purposive sampling is based on the logic that the individual with thorough knowledge will
improve richness of the study.38 We followed sampling method with maximum variability. This method
ensures diversity in the gleaned data. The gleaned data with more diversity and breadth enabled the authors
to have better image of the aspects and the nature of the phenomenon under study.39 To this end, a sample
4 Nursing Ethics

group consisting of nursing leaders and faculty members with different work experiences in different wards
and positions and of both genders was formed.
Inclusion criteria in the case of nursing leaders were a minimum 2 years of experience in management
and the desire to take part in the study and in the case of nursing faculty members were experience in
management and teaching management and ethics. The reason for interviewing with the faculty members
was that nursing leaders in clinical and academic environment are decision-makers in the field of
healthcare services.
The data were gleaned through ‘‘semi-structure private interview’’ so that an appointment was
arranged with participants via telephone after introducing the objectives of the study and determining
a convenient location for interview. Interviews were conducted at the offices of the participants lasting
35–90 min. The interview was private; that is, the other person, apart from researcher and participant, was
not present during the interview. The content of the interviews was based on the experience of the
participants with regard to the position of ethics in leading nurses and employees. General questions
regarding the participant’s approach to leadership and value of ethics in their leadership style were asked
at first. The participant’s answer would determine the trend of the interview. To obtain more information
and have clearer answers, the participants were asked to provide objective examples. No repeated inter-
views were carried out. All interviews were recorded by a digital voice recorder and then transcribed word
by word. To have better understanding of the interview, the author listened to the recorded interviews and
read the transcribed text for several times. Data gathering continued until data saturation was ensured—
that is, no new information would be expected from further interviews and enough support for the
collected data was obtained. After 11 interviews, the author was sure that no new information would
be obtained; however, three more interviews were performed to be on the safe side. No participant refused
or dropped out of the study.

Analysis and findings

Data analysis started along with the data gathering process. To carry out content analysis, the induction
and coding process was performed. Using latent content analysis method, common points were identified,
coded, and classified. To do so, the data were prepared by transcribing the interview. To extract the codes,
the data were reviewed word by word. The words, sentences, and paragraphs with key points pertinent
to the subject of the study were taken as ‘‘meaning units.’’ Primary coding was done using the statements
by the participants and the author’s perception of the statements. The codes were reviewed for several
times and the obtained codes were compared with the primary codes. Afterward, the similar codes were
placed in one subcategory and similar subcategories formed the categories. MAXQDA 10 software was
used to manage the data.

Validity and reliability

To increase reliability and validity—that is, trustworthiness—in a qualitative study, four measures of
creditability, confirmability, dependability, and transferability are used. Data creditability was ensured
through member check, diversity of the participants, and prolonged engagement with the data. With
regard to dependability, the interviews, primary coding, and concept categories were examined by
peer checking. Confirmability of the data was ensured by following specific routine for data gather-
ing, recording research process with details, and following the principles of neutrality. Finally,
purposive sampling with maximum diversity along with recording all the details and deep analysis
ensured transferability.
Barkhordari-Sharifabad et al. 5

Table 1. Categories, subcategories, and some codes of ethical leadership outcomes in nursing.

Main categories Subcategories An example of codes

All-inclusive Inner satisfaction of the leader
satisfaction
Employees’ job satisfaction
Patient’s satisfaction
Productivity Providing better services
Inspiring ethical behaviors in the
employees
Inner satisfaction are looking for honesty.
Inner peace based on patients’ satisfaction.
Dissatisfaction with one’s performance over the years.
Hardworking employees’ satisfaction with ethical behavior
of the leader.
Personnel’s satisfaction based on patients’ satisfaction.
Personnel retaliation behavior in response to non-ethical
behavior of the leader.
Inability of the manager to satisfy all staff.
Positive effect of right doing and following the leader’s order.
More satisfaction with ethical performance of the leader.
Providing healthcare eagerly by the personnel.
Patients encounter fewer problems.
Better follow-up services by the personnel.
Creating a sense of commitment in personnel.
Promotion of honesty among the personnel.
Mutual empathy between the nurses and leader.
Positive and mutual reaction of the personnel in response
to fair and positive behavior of the manager.

Ethical aspects
In observance of ethical consideration, after receiving permission from the intended universities and
hospitals, all the participants were asked to fill out an informed written consent. By signing the form, the
participants allowed the authors to record the interview and use the data anonymously. At the end of the
interview, the participants were ensured that the data will be used anonymously and the participants
permitted such a use. The study was approved by the Committee of Ethics in Research at the university
under the code: sbmu.rec.1393.695 on 15 February 2015.

Results
Of 14 participants, 6 had bachelor’s degree, 3 had master’s degree, and 5 had PhD. Regarding managerial
position, three were supervisors, six were head nurses (two supervisors had worked as matron as well), and
five were nursing faculty members. Participants had 12 years of management experience on average. In
total, eight participants were female and six were male with a mean age of 46 years.
Interview analysis revealed 228 primary codes, and by combining similar items, this figure recued to 32,
and eventually, the five subclasses were placed in two main classes (Table 1).

All-inclusive satisfaction
One of the extracted categories was all-inclusive satisfaction. Professional ethics tries to achieve satisfac-
tion of all stakeholders including managers, personnel, health service seekers, and other users. The nursing
leader, by following ethical values, reaches inner satisfaction and satisfaction of nurses and patients as well.

Inner satisfaction of the leader. The peace that a nursing leader feels by following ethical behaviors was noted
by the participants. They acknowledged that being honest with their colleagues at work, respecting each
6 Nursing Ethics

other, mutual trust, and showing mutual understanding lead to inner satisfaction and happiness. Participant
No. 2 (PhD of nursing with 8.5 years of management and leadership experience in different positions) said,

When I show them empathy, I mean understanding others, this gives me good feelings. Experiencing a good
climate at work, whether between the personnel and I or among them, makes me happy so that it lets me enjoy
my work.

The participants stated that they would feel inner happiness when the patient is discharged in a happy and
contended frame of mind due to the personnel’s ethical behavior and the ethical climate. This inner
happiness is valued beyond measure. Participant No. 11 (45 years old, 9 years of nursing experience in
different wards) said,

I am at more peace when I see that as a result of my behavior with the personnel, they have done a good job and
the patient is grateful for the good services that are provided by the personnel. I cannot feel calm and satisfied
when the patient is not satisfied. Because I think it must be my personnel’s fault.

The participants also said that looking back to their management and leadership record makes them
feel bad because of their lack of flexibility, strictness, and mere reliance on managerial powers. Parti-
cipant No. 2 said,

I started my work with a masters’ degree and at that time all my colleagues were holders of bachelors’ degree. I
believed that I was better than the others; . . . I was blind by the power; it was good that order returned back to the
hospital but for what price. I have hurt feelings of many of my colleagues and I do not feel good for this even
though I had all the rights to do so.

Employees’ job satisfaction. Job satisfaction is a key and effective factor in achieving competence, motivation,
creating more commitment, improving nurses’ efficiency, and achieving higher satisfaction in the patient.
One of the participants with 20 years of management experience in different wards mentioned,

They would be more willing to work when they see that all personnel are equal before the law including
physicians, personnel, and even I.

Of course, the participants highlighted that it was not possible for a nursing leader to satisfy all the
stakeholders:

As we always say, a manager who satisfies everyone, is not much reliable. (Participant No. 2)

Participant No. 6 (38 years old, BSc in nursing, and 6 years of experience as head nurse and supervisor)
mentioned the outcome of dissatisfaction in the personnel due to unethical behavior of the leaders:

It is not that if we would like to make it hard for the others only because of our superior position . . . they might
show obedience for now, but sooner or later they will return the favor.

Patient’s satisfaction. Ethical behavior leads to the patient’s satisfaction. The patient’s satisfaction is one
of the measures of quality of nursing services that leads to positive response in the society toward
nursing profession.
Participant No. 14 (master of nursing with 20 years of management experience as head nurse, supervisor,
and matron in different wards) said,
Barkhordari-Sharifabad et al. 7

Surely, a leadership, by which I refer to having an influence and power on the personnel, based on good behavior,
honesty, and good communication leads to better services to the patients and their satisfaction when they
are discharged.

The participants noted the point that the patient’s satisfaction is the main measure of quality in
nursing profession. Participant No. 11 (9 years of management experience in different wards)
noted,

I really value the patient’s satisfaction, as it should be the measure of our work. Everything we do is to reach
satisfaction in the patient.

The participants acknowledged that the patients expected timely and professional services with regard to
all medical and healthcare services. They noted that they have met this expectation by adopting an ethical
behavior toward the nurses so that their behavior has made a large contribution to satisfaction of the
patients. Participant No. 8 (54 years old, PhD of nursing, faculty member, and 6 years of experience in
different managerial levels) expressed,

When I am good with my employees, treat them with respect, and show them the right way of doing things . . . ,
you can predict what will happen. That is right, it would result in the patient’s satisfaction in my ward; because
those taking care of the patients are competent and know their job.

Productivity
Another category extracted from the data was productivity with two subcategories of ‘‘providing better
services’’ and ‘‘inspiring ethical behavior in employees.’’

Providing better services. Nursing leaders with strong ethical commitment are the source of great effect on
satisfaction and performance of the personnel. They motivate their colleagues to provide better services to
the patients. Participant No. 6 noted,

The more satisfied the personnel are, the better they are in taking care of the patients; I mean they will do their
best in taking care of the patients.

By adopting ethical behaviors, nursing leaders and managers try to motivate the nurses to provide better
services and achieve the best results. One of the participants with 7 years of experience in management and
an expert and lecturer of nursing ethics said,

In fact, to provide better services to the patients, I need to establish proper and honest relationship with the
personnel who directly deal with the patients. I need to respect their values and treat them with justice . . . such
behavior will result in better services to the patients. This is what our managers need to know.

The participants acknowledged that their unethical behavior may result in nurses refusing to carry
out their tasks in a perfect way, which culminates in patients suffering the consequences. For
instance, participant No. 5, BSc in nursing with 20 years of experience as head nurse in different
wards, stated that

Justice is highly valued by the personnel. For instance, I have heard many times that one of the personnel
would say: it is not a big deal for me to work every holidays provided that others do the same . . . ,
discrimination really bothers the personnel and they surely return the favor whether by not doing their
work properly.
8 Nursing Ethics

Inspiring ethical behavior in the employees. Ethical leaders can influence their personnel by demonstrating
honest and ethical behavior. Through this, they would lead the nurses toward ethics. Participant No. 2 stated,

You can expect honesty, when you are honest.

Ethical leaders can expand the breadth of their behavior by adopting processes designed to create ethical
climate. Participant No. 14 mentioned,

If you helped out someone, they would help you out in time. You can ask the leader’s help and they can
extend their help without hesitation. I mean, it is the manager’s behavior that creates a climate of empathy
and cooperation.

The leaders are the proper behavioral patterns and the employees learn their ways by observing them.
One of the participants with 7 years of managerial experience in different wards and various levels stated,

I have never asked my personnel to do things that I myself am not capable of or not willing to perform. I am the
role model for my staff, therefore, I must act as a responsible person before asking my personnel to
be responsible.

Discussion
In this study, ethical leadership outcomes in nursing in cultural and social fields of healthcare environment
of Iran were examined. Two main categories with several subcategories were extracted. It is notable that the
categories overlapped. The participants acknowledged that ethical leadership brings positive results and
these results motivate them to adopt such leadership style. One of the extracted categories was ‘‘all-
inclusive satisfaction.’’ The participants noted that one of their motivations to be an ethical leader was to
achieve inner satisfaction, job satisfaction in the personnel, and, most importantly, satisfaction in the
patients. In line with this study, the findings of other studies pointed to mentioned subjects.27,30,40–42
In addition to positive effects on the employees, ethical leadership creates the feeling in the leaders and
the management team that they have been more effective.22,43,44 According to the participants’ opinions,
the leader will achieve satisfaction and internal peace and tranquility following their ethical approach
leading, in turn, to job satisfaction in the leader. Nowadays, the role and the importance of personality of
managers in progress and growth of the organization is a well-known issue.45 Ethical leadership not only
leads to improvement of welfare and occupational success of the employees but also improves the welfare
and satisfaction of the leader. This is because leaders can enjoy good professional relationship at work.30
The sense of personal satisfaction and job satisfaction afterward is a key factor in professional success and
improvement of performance.46 The results of Hackett and Wang also in line with the findings of this
study showed that the leaders that follow the six key merits of ‘‘bravery, moderation, justice, contrivance,
altruism, and honesty’’ are the ethical leaders that achieve satisfaction in life and effectiveness in
leadership.40 Behaving according to the moral virtues not only enables individuals in achieving personal
goals that are inherently valuable to them but also helps in achieving the external goals (e.g. profit, honor,
fame, credit, and wealth). All these are effective in improving personal emotional happiness and satisfac-
tion with life.40,47
Job satisfaction is one of the most important concepts that has attracted great attention of theoretical and
fundamental works, on one hand, and is also highly valued by the managers of different levels and human
resource departments, on the other hand. The theme is effective on progress of the organization and is a key
element for organizational growth and excellence.48 In this study, the participants emphasized the role of
ethical leadership in creating job satisfaction in the personnel. This finding is similar to that of Cortese. His
Barkhordari-Sharifabad et al. 9

research results showed that nursing management techniques need to be adjusted to ensure an increase in job
satisfaction in nurses. He continued that factors that ensure job satisfaction in nurses are ‘‘respect, trust,
recognition, reward, improvement of communication quality with nurses, respecting their needs, providing
profession support, and offering functional feedback.’’49 All of these concepts are under consideration in
ethical leadership.
Dynamic organizations, including hospitals, need leaders that respect the employees’ needs along with
organizational development based on environmental factors. These leaders are expected to keep the
employees satisfied and prevent stressors and dissatisfaction caused by the changes of the environment.
Therefore, using an effective and harmonious leadership style relative to special condition of hospitals and
especially the nursing population as a large group of employees is essential.50 Several studies have shown
that ethical behavior of the leader leads to positive outcomes including increased quality of function,
decreased turnover and occupational stress, and, most importantly, increased job satisfaction.26,51 Positive
attitude and behaviors in the employees improve their job performance.52
In this study, the participants emphasized the role of ethical leadership in achieving patients’ satisfaction.
The ‘‘patient’s satisfaction’’ has a key role in the process of healthcare services. Our findings are in line with
Ahmadi et al.,53 who found that patients’ satisfaction reflects the capability and ability of the employees to
provide quality health services, so that professional development of nurses is achieved through focusing on
the patient’s satisfaction.54 Our results showed that ethical behavior leads to the patient’s satisfaction in a
direct and indirect manner. It is reasonably expected that an ethical leader who always gives high priority to
the patients and their satisfaction and does his or her best to respect the patient’s rights would reach
satisfaction in the patient. However, ethical behavior of the leader leads to satisfaction in nurses so that
high level of satisfaction in the employees is related to the sense of welfare, productivity, and the patient’s
satisfaction.49 Ethical care and valuing the patient are the signs of professional progress and growth.55 Not
only nurses should be trained to do the best performance but also they should be supported and encouraged
to do it. Effective leadership is needed to improve performance of the nurses.42 Several studies have
supported the significant relationship between leadership and satisfaction of the patient.41,42
‘‘Productivity’’ was another category extracted from the data. The nurses have a key role in the con-
tinuity of care and health promotion. That is, higher productivity in the nurses is critical for success of an
organization. Effective management leads to higher productivity,56 and high productivity is a sign of
maturity of the organization. Maturity is a critical element in the process of progress and development.57
This category was featured with two subcategories of ‘‘providing better services’’ and ‘‘inspiring ethical
behavior in the employees.’’ These findings are largely consistent with previous studies.29,42,43,58,59
An efficient and productive health system ensures its objective—that is, public health—only by
providing optimal services.60 The type of leadership is effective on quality and the way health services
are provided.61 Our results showed that ethical leaders motivate the nurses to provide better services
through demonstrating ethical behavior, exalted manners, and empathetic interactions. Such behaviors
also improve cooperative attitude and reduce the problems that the patient may be encountered with. The
results seem consistent with the findings of other studies that show that leadership style is associated with
the outcomes such as the patient’s satisfaction, rate of mortality, the patient health, and accidents and
subsequent problems.42 Also, Aiken and Patrician highlighted the role of nursing managers in creating a
professional work environment for the nurses that leads to more efficient care services. Such environment
also results in increased quality of services, automaticity and responsiveness of the nurses, and the
patient’s satisfaction in return.59
The participants acknowledged that seeing the leaders doing as they say, and treating the employees with
honesty, justice, trust, empathy, and respect, make the nurses believe in the leader and follow his or her
ethical guidelines. Brown et al.43 were the pioneer authors who introduced ethical leadership as the
demonstration of good behavior by implementing the ethical codes before the employees. As suggested
10 Nursing Ethics

by the studies, managers play pivotal role in providing a moral framework for the members of the orga-
nization62 and shaping group personality in the organization.63 Leaders with ethical behavior reflect an
image of trust and fairness and motivate their followers to achieve the same moral values and stan-
dards.29,43,58 There is a small chance that followers of these leaders would show unethical behaviors.64
The leaders can promote ethical behavior in the organization by demonstrating the ethical expectations,
following the policies and actions that empower ethical behavior, and hold accountable for the members of
the organization for their ethical deeds.8

Conclusion
Growth and progress in nursing fields (as the largest group of health service personnel) is one of the areas of
professional success in health service organizations. Results of this qualitative study showed that satisfac-
tion of all stakeholders and improvement of productivity depend on ethical leadership of the nurse leaders.
An ethical work environment could be created by paying attention to ethical matters in recruiting nurses,
preparing leaders to behave ethically, and adopting a systematic and objective approach to measure ethical
merits and help to inform the managers. Such environment supports organizational progress and growth.
The findings of this study help the managers to learn about the outcomes of their ethical behavior in the
organization and prepare the ground to improve productivity and satisfaction. This, in turn, leads to higher
quality of health services provided to the patients and improvement of quality of occupational life expe-
rienced by the leaders and nurses.

Future study recommendations

Given the dynamic nature of health service organizations, future studies may survey ethical behavior and
the factors effective on nursing. Similar studies can be conducted in other countries and cultures and
quantitative studies may compare the relationship between ethical leadership with the results of this study
including satisfaction of the patient and quality of healthcare.

Acknowledgements
This study is a part of nursing PhD dissertation. The authors thank the Research Department of Shahid
Beheshti University of Medical Sciences, the participants, and all the colleagues who kindly prepared the
ground for conducting the 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: This project was supported by Shahid Beheshti University of Medical Sciences,
Tehran, Iran.

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