Nursing Ethics as a Foundation in Nursing Practice: A Literature Review

Abstract


INTRODUCTION
The ethos of love, human charity, values of compassion, and dignity are integrated into nurses on an ongoing basis, so this is the ethics that is considered best and maintained by following external values such as laws, directives, norms, and rules [1].
Nursing ethics has a central role in the moral behavior of nurses towards patients, which significantly influences the improvement of patient health [2].Nursing ethics permeates all these nursing roles because nurses deal directly with patients.
They need to pay attention to ethical principles during nursing practice.The professional relationships of nurses in patient care and healthcare teams pose ethical issues unique to nursing [3].The problem of ethical behavior that occurs in the nursing process is a sense of injustice in nursing services, lack of attention and concern for patients, neglect of patient rights, lack of respect for patients, and high demands for professional ethics in every nursing service [4].In addition, ethical behavior problems in the provision of nursing services will impact the emergence of dissatisfaction with the nursing services provided.The patient will feel his needs are not being met and he is not getting attention from the nurse.In providing nursing services, it must refer to the nursing code of ethics as an ethical guide that cannot be negotiated [5].
The nursing code of ethics is part of health ethics that applies ethical values to maintaining public health services.According to the book Basic Nursing Science [6] The Therefore, this literature aims to explore and understand the purpose of nursing codes of ethics applicable to nursing practice.

Identify the research question
The  extraction fields for a systematic application of literature reviews [10].Table 1 provides a list of the included articles and the extracted data.From these data, three themes were identified: 1. Ethical Understanding

Collating, summarising, and reporting the results
Of the 15 articles identified, they were focused on nursing.All except seven studies were of a cross-sectional design.The remaining studies were qualitative through focus groups (three) or semi-structured interviews (one).There was a good spread of international data, with data originating from 9 individual counties.
The United States had the most relevant studies (three), followed by Iran (three) and Turkey (three).The remaining countries all had one result, as shown in Table 1.

RESULTS
This literature review consists of fifteen journals in total, in accordance with inclusion and exclusion criteria, and provides an overview of nursing ethics as a foundation for the implementation of nursing practice.Furthermore, this literature review is divided into three sub-chapters that will discuss the understanding of ethics, integrity and moral responsibility, and the importance of codes of ethics in nursing practice.

Ethical understanding
Ethics has internal and external dimensions.
External ethics is about norms and morals, and internal ethics is guided by personal values that form gradually over time.In care and nursing, external ethical dimensions still seem to have a dominating position, often external ethical norms and rules governing public health practice [1], [16].Yet external ethics alone do not seem to be enough to perform the nursing task.Ethics is not just about good deeds but also about the spirit in which good deeds are done.When we look at ethics as an ethos, there is evidence of movement between the internal and external sides.

Integrity and moral responsibility
Integrity and responsibility are at the heart of nursing ethics.The value of honesty in delivering truth, respect, compassion, generosity, loyalty, objectivity, benevolence, and wisdom is a form of responsibility and integrity [7].[23].Virtue is a valuable personal and professional asset [23].Nurse responsibility shows that the professional nurse displays performance carefully, and conscientiously and the nurse's activities are reported truthfully [2].Patients feel confident that responsible nurses have the abilities, knowledge, and expertise relevant to their discipline and work align with the code of ethics [13], [24].Nurses also should uphold and abide by the ethical principles that guide the nursing profession.[25], [26], [27].

The importance of nursing codes of ethics in nursing practice
Every day in nursing practice, situations requiring decisions and actions include ethical dilemmas such as the most common and near-miss mistakes, delegation, end-oflife care, technology use, and burnout in completing these challenges well while contributing to safe, compassionate, and quality care.Nurses are expected to be able to solve ethical problems using a code of ethics.
The code of ethics is used not only as justification but also as disciplinary action [28].Nursing code of ethics as a relevant source in service practice [17].Nurses must respect patient rights, focus on patients, provide humanistic nursing care, and maintain human dignity [8].Human dignity represents the essence of nursing care, meaning respect for the inherent value of each individual [29], [21].

DISCUSSION
Ethics ontologically suggests that ethics is actually about ethos.Ethos is formed through culture and history, a fusion of internal and external ethics.Ethics is not just about good deeds but also about the spirit in which good deeds are done [1].Internal ethics are individual characteristics such as conscience, positive energy related to others, self-control skills in conflict situations, the ability to communicate with patients and other health professionals, and responsibility for their duties [2], [11].For example, when a nurse is face-to-face with a patient, the nurse must be compassionate and intuitive when doing "patient reading" and thinking about which ethical approach is suitable for that patient, how I can value their views on health, and how I can best care for the patient.External ethics, such as appropriate, flexible support systems and effective rewards and punishments, can help enhance the ethical experience.Factors of educational and cultural development rethink behavior, develop a culture that focuses on ethics, and provide specialized practical and theoretical training in ethics [12].Internal and external ethics are fundamentally different.In the end, internal ethics become more dominant to maintain human dignity [21].
Integrity and responsibility are at the heart of nursing ethics.Nurse responsibility shows that the professional nurse performs carefully and conscientiously and reports the nurse's activities truthfully [2].Patients feel confident that responsible nurses have knowledge, abilities, and skills relevant to their discipline and are working to align with the code of ethics [13], [14].[12] Stressing that students who want to enter the nursing profession must be cognitively examined, their thinking skills in analyzing conflicts, and the ability to communicate with patients and other health professionals.According to Risnawati and Amir [18], The problem that often occurs is interpersonal communication.This is important because the health care system requires nurses who can thrive in their relationships with multidisciplinary professionals.
Poor interpersonal communication relationships will impact improving ethics [15].
Problems with adherence to the code of ethics also reveal that nurses are incompetent concerning the practice and application of the code of ethics [30], [31].Nursing ethics can serve as a valuable framework for nursing [5].
Nursing ethics reflects their understanding of how services should be provided in providing more humanistic healthcare [20], [16].nursing world [20].Nurses must maintain behavior with patients and then communicate well with health workers, which can lead to the application of professional ethics [2], [33].
A code of ethics that does not work will have an impact on the quality of service [22].
Therefore, nursing ethics is the ethics that nurses use and embody when performing their actions committed to quality nursing care [34], [35].

LIMITATIONS AND STRENGTH
The study was not without its limitations.A Ethics is ontologically more about what happens to relationships between people.The focus of ethics shifts from morals (right or wrong) to ethos (values).Ethos is based on dignity and virtue.Dignity is the difference and uniqueness of another person in a caring relationship.Virtue is a picture of good character and qualities.Virtue answers the question, who should I be?The desired answer must be "good human being.".Virtue is strongly influenced by ethos.Ethos is the foundation of human values formed internally through one's values.When humans connect with their ethos, there is a sense of home.The feeling of being at home gives man courage, joy, warmth, and inner strength.Ethos is manifested through human action.A sense of home is the essence of virtue, where the willingness to serve, take responsibility, give what is good, and do something wholeheartedly for the patient becomes real.
Council for Nurses (ICN) adopted the code of ethics for the first time in 1953.In Indonesia, the nursing code of ethics was prepared by the Indonesia National Nurse Association (INNA) through the INNA National Conference in Jakarta on November 29, 1989; it consists of 5 chapters and 17 articles.A code of ethics establishes standards of behavior consistent with what the profession, other professionals, and society expect of a nurse [3].The nursing code of ethics reflects the collective values of the profession, but it is still poorly understood.Although practitioners value and understand their codes of ethics, research shows that such codes are rarely used in clinical practice.This happens forvarious reasons, such as lack of knowledge, conflicts in the workplace, and institutional obstacles[7].Nursing codes of ethics have been designed to meet the need for ethical principles and standards and appropriate guidelines to assist when making decisions and facing moral challenges.These codes are intended to act as standards in the nursing profession[8].The purpose of the nursing code of ethics is that nurses, in carrying out their duties and functions, always respect the dignity and dignity of patients as human beings and as a guideline in nurse behavior when carrying out their work profession to avoid things that violate the code of ethics.

Figure 1 .
Figure 1.Articles were included if they met all the following criteria: 1. Examined the defined health professionals (nurses) 2. Examined a formal professional code from a regulatory or national body 3. Examined the use, understanding, or awareness of the code (or synonyms of these concepts); 4. Empirical studies (of any study design including qualitative, quantitative, or mixed methodologies Excluded were articles not in English and Bahasa, about codes written by employers/ institutions, commentaries and editorials (or other non-empirical evidence), and were solely about students or existing literature reviews.The date limit was set from 2014-2023 to include all relevant literature.The database and hand searching were conducted

2. Integrity and moral responsibility 3 .
The importance of using a nursing code of ethics These themes were noted to be recurring throughout the articles and relevant to the research question.A single author (R.C-D) charted the data and identified themes.Note that the total number of themes allocated exceeds the included articles, as most had multiple themes allocated.

Fig. 1 .
Fig. 1.Literature Search Flow Chart Diagram Humanistic nursing service is demonstrated by nurses who view patients as friends, let patients talk, and invite them to engage in their care.Nurses have the time and willingness to see and listen to patients[32],[19].Nursing services are an integral part of health services based on science, and nursing must carry out its duties following the nursing code of ethics.Code of ethics assessments emphasize nurses' responsibilities in providing for patient needs, an environment in which values, beliefs, human rights, and dignity are respected, and nurses must understand and apply nursing codes of ethics to guide behavior.To this day, codes of ethics are considered an essential part of the nurse ethics knowledge base throughout the broad view is important to get as much depth of the topic as possible.The study was limited by the lack of representation from some countries, which may have different perspectives due to workplace and cultural differences.The strength of this research is that it is necessary to create or add lessons on understanding the nursing code of ethics in the educational curriculum and hospitals so that in-house training schedules can be made for nurses to increase awareness and understanding of the nursing code of ethics.Educators should be able to provide lessons about the nursing code of ethics and provide back that understanding before doing a practicum at work.Nurse practitioners should increase awareness about the importance of the nursing code of ethics through continuous learning from in-house training and related seminars.IMPLICATIONS Our research can be used as input in patient care services for nursing sessions and discussions with other health workers when explaining nursing ethics as a cornerstone in nursing practice.This provides more diverse research results and more exposure to participants with different backgrounds to give an overview.CONCLUSION Ethics is not just about good deeds but also about the spirit in which good deeds are done.Internal ethics are individual traits such as conscience, positive energy relating to others, self-control skills in conflict situations, and communication skills.Nursing ethics is ethos.Internal ethics dominate to maintain the dignity of the patient.Internal and external ethics are interrelated.Integrity and moral responsibility are at the heart of nursing ethics.Nurses must have an understanding of ethics for self-development and nursing services.The nursing code of ethics as a framework and relevant source refers to the system of rules and principles to realize its responsibility to society.Applying the code of ethics in nursing practice impacts improving the quality of nursing care and service to guarantee patient safety.

Table 1
Summary of the literature