Choosing a Leadership Style (Marquis & Huston, 2012)
DISPLAY 4.6 Strategies Leader-Managers Can Use to Promote Ethical Behavior as the Norm
1. Separate legal and ethical issues.
2. Collaborate through ethics committees.
3. Use institutional review boards appropriately.
4. Foster an ethical work environment.
Separate Legal and Ethical Issues
Although they are not the same, separating legal and ethical issues is sometimes difficult. Legal controls are generally clear and philosophically impartial; ethical controls are much less clear and individualized. In many ethical issues, courts have made a decision that may guide managers in their decision making. Often, however, these guidelines are not comprehensive, or they differ from the manager’s own philosophy. Managers must be aware of established legal standards and cognizant of possible liabilities and consequences for actions that go against the legal precedent.
In general, legal controls are clearer and philosophically impartial; ethical controls are much less clear and individualized.
Legal precedents are frequently overturned later and often do not keep pace with the changing needs of society. In addition, certain circumstances may favor an illegal course of action as the “right” thing to do. If a man were transporting his severely ill wife to the hospital, it might be morally correct for him to disobey traffic laws. Therefore, the manager should think of the law as a basic standard of conduct, whereas ethical behavior requires a greater examination of the issues involved.
The manager may confront several particularly sensitive legal–ethical issues, including termination or refusal of treatment, durable power of attorney, abortion, sterilization, child abuse, and human
experimentation. Most health-care organizations have legal counsel to assist managers in making decisions in such sensitive areas. Because legal aspects of management decision making are so important, Chapter 5 is devoted exclusively to this topic.
Collaborate Through Ethics Committees
The new manager must consult with others when solving sensitive legal–ethical questions because a person’s own value system may preclude examining all possible alternatives. Many institutions have ethics committees to assist with problem solving in ethical issues. These ethics committees typically are interprofessional and are organized to consciously and reflectively consider significant and often difficult or ambiguous value issues related to patient care or organizational activities. Ethics committees are a core element of collaborative ethical decision making and should include representatives of all stakeholders, including patients when they are involved in the ethical issue.
Use Institutional Review Boards Appropriately
IRBs are primarily formed to protect the rights and welfare of research subjects. They provide oversight to ensure that individuals conducting research adhere to ethical principles that were articulated by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The primary role of the manager regarding IRBs is to make sure that such a board is in place in the organization where the manager works and that any research performed within his or her sphere of responsibility has been approved by such a board.
Foster an Ethical Work Environment
Perhaps the most important thing a leader-manager can do to foster an ethical work environment, however, is to role model ethical behavior. Indeed, Storch, Makaroff, Pauly, and Newton (2013) note that “role modeling ethical management practice is one of the most forceful ways to promote ethics in practice” (p. 150) and that it can foster nurses’ ability to embed ethics into health-care and nursing practice.
Likewise, working as a team with a standard for behavior can promote a positive ethical climate. Other important interventions include encouraging staff to openly discuss ethical issues that they face daily in their practice. This allows subordinates to gain greater perspective on complex issues and provides a mechanism for peer support.
Integrating Leadership Roles and Management Functions in Ethics
Leadership roles in ethics focus on the human element involved in ethical decision making. Leaders are self- aware regarding their values and basic beliefs about the rights, duties, and goals of human beings. As self- aware and ethical people, they role model confidence in their decision making to subordinates. They also are realists and recognize that some ambiguity and uncertainty must be a part of all ethical decision making.
Leaders are willing to take risks in their decision making despite the fact that negative outcomes can occur even with quality decision making.
In ethical issues, the manager is often the decision maker. Because ethical decisions are so complex and the cost of a poor decision may be high, management functions focus on increasing the chances that the best possible decision will be made at the least possible cost in terms of fiscal and human resources. This usually requires that the manager becomes expert at using systematic approaches to problem solving or decision making, such as theoretical models, ethical frameworks, and ethical principles. By developing expertise, the manager can identify universal outcomes that should be sought or avoided.
The integrated leader-manager recognizes that ethical issues pervade every aspect of leadership and management. Rather than being paralyzed by the complexity and ambiguity of these issues, the leader- manager seeks counsel as needed, accepts his or her limitations, and makes the best possible decision at that time with the information and resources available.
Edmonson (2015) concludes that organizations and health-care systems today are in great need of moral leadership and that the influence of morally courageous nurses, regardless of position, will be critically needed to transform health-care and care systems to safeguard patients. “As nurse leaders in the healthcare system and in specific facilities, we need to demonstrate moral courage and create environments that promote morally courageous acts so as to keep us centered on the very thing that drew us into healthcare, namely the patient, the families, and the communities we serve” (Edmonson, 2015, Conclusion section para. 1). Barlem and Ramos (2015) concur, arguing that “instead of questioning the reason nurses experience moral distress according to certain situations and contexts, it is more important to question the reasons why nursing professionals allow themselves to accept certain contexts as unchangeable or natural, renouncing the possibility to ethically resist situations that bring about moral distress” (p. 613).
KEY CONCEPT
Ethics is the systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and
the study of what a person’s life and relationships should be—not necessarily what they are.
In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse-managers involves some ethical component. Multiple advocacy roles and accountability to the profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.
Many systematic approaches to ethical problem solving are appropriate. These include the use of theoretical problem-solving and decision-making models, ethical frameworks, and ethical principles.
Outcomes should never be used as the sole criterion for assessing the quality of ethical problem solving because many variables affect outcomes that have no reflection on whether the problem solving was appropriate. Quality, instead, should be evaluated both by the outcome and by the process used to make the decision.
If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, then, regardless of the outcome, the manager should feel comfortable that the best possible decision was made at that time with the information and resources available.
Four of the most commonly used ethical frameworks for decision making are utilitarianism, duty- based reasoning, rights-based reasoning, and intuitionism. These frameworks do not solve the ethical problem but assist individuals involved in the problem solving to clarify their values and beliefs.
Principles of ethical reasoning explore and define what beliefs or values form the basis for our decision making. These principles include autonomy, beneficence, nonmaleficence, paternalism, utility, justice, fidelity, veracity, and confidentiality.
Professional codes of ethics and standards for practice are guides to the highest standards of ethical practice for nurses.
Sometimes, it is very difficult to separate legal and ethical issues, although they are not the same.
Legal controls are generally clear and philosophically impartial. Ethical controls are much more unclear and individualized.
Additional Learning Exercises and Applications
LEARNING EXERCISE
4.7
The Impaired Employee
B
everly, a 35-year-old, full-time nurse on the day shift, has been with your facility for 10 years. There are rumors that she comes to work under the influence of alcohol. Staff report the smell of alcohol on her breath, unexcused absences from the unit, and an increase in medication errors. Although the unitsupervisor had heard rumors that Beverly was chemically impaired, she was unable to observe directly any of these behaviors.
After arriving at work last week, the supervisor walked into the nurses’ lounge and observed Beverly covertly drinking from a dark-colored flask in her locker. She immediately confronted Beverly and asked her if she was drinking alcohol while on duty. Beverly tearfully admitted that she was drinking alcohol but stated this was an isolated incident and begged her to forget it. She promised never to consume alcohol at work again.
In an effort to reduce the emotionalism of the event and to give herself time to think, the supervisor sent Beverly home and scheduled a conference with her for later in the day. At this conference, Beverly was defensive and stated, “I do not have a drinking problem, and you are overreacting.” The supervisor shared data that she had gathered supporting her impression that Beverly was chemically impaired. Beverly offered no explanation for these behaviors.
The plan for Beverly was an immediate suspension from work, referral to the State Board of Nursing
Diversion Program and a requirement that she complete the program as they directed her before she could return to work. Beverly again became very tearful and begged the supervisor to reconsider. She stated that she was the sole provider for her four small children and that her frequent sick days had taken up all available vacation and sick pay. The supervisor stated that she believed her decision was appropriate. Four days later, the supervisor read in the newspaper that Beverly committed suicide the day after this meeting.
A S S I G N M E N T:
Evaluate the problem solving of the supervisor. Would your actions have differed if you were the manager? Are there conflicting legal and ethical obligations? To whom does the manager have the greatest obligation—patients, subordinates, or the organization? Could the outcome have been prevented? Does this outcome reflect on the quality of the problem solving?
LEARNING EXERCISE
4.8
Everything Is Not What It Seems
Y
ou are a perinatal unit coordinator at a large teaching hospital. In addition to your management responsibilities, you have been asked to fill in as a member of the hospital promotion committee, which reviews petitions from clinicians for a step-level promotion on the clinical specialist ladder. You believe that you could learn a great deal on this committee and could be an objective and contributing member.The committee has been convened to select the annual winner of the Outstanding Clinical Specialist Award. In reviewing the applicant files, you find that one file from a perinatal clinical specialist contains many overstatements and several misrepresentations. You know for a fact that this clinician did not accomplish all that she has listed because she is a friend and close colleague. She did not, however, know that you would be a member of this committee and thus would be aware of this deception.
When the entire committee met, several members commented on this clinician’s impressive file.
Although you were able to dissuade them covertly from further considering her nomination, you are left with many uneasy feelings and some anger and sadness. You recognize that she did not receive the
nomination and thus there is little real danger regarding the deceptions in the file being used inappropriately at this time. However, you will not be on this committee next year, and if she were to submit an erroneous file again, she could be highly considered for the award. You also recognize that even with the best of intentions and the most therapeutic of communication techniques, confronting your friend with her
deception will cause her to lose face and will probably result in an unsalvageable friendship. Even if you do confront her, there is little you can do to stop her from doing the same in future nomination processes other than formally reporting her conduct.
A S S I G N M E N T:
Determine what you will do. Do the potential costs outweigh the potential benefits? Be realistic about your actions.
LEARNING EXERCISE
4.9
The Valuable Employee
G
ina has been the supervisor of a 16-bed intensive care unit (ICU)/critical care unit (CCU) in a 200-bedurban hospital for 8 years. She is respected and well liked by her staff. Her unit’s staff retention level and productivity are higher than any other unit in the hospital. For the last 6 years, Gina has relied heavily on Mark, her permanent charge nurse on the day shift. He is bright and motivated and has excellent clinical and managerial skills. Mark seems satisfied and challenged in his current position, although Gina has not had any formal career planning meetings with him to discuss his long-term career goals. It would be fair to say that Mark’s work has greatly increased Gina’s scope of power and has enhanced the reputation of the unit.
Recently, one of the physicians approached Gina about a plan to open an outpatient cardiac rehabilitation program. The program will require a strong leader and manager who is self-motivated. It will not only be a lot of work but will also provide many opportunities for advancement. He suggests that Mark would be an excellent choice for the job, although he has given Gina full authority to make the final decision.
Gina is aware that Lynn, a bright and dynamic staff nurse from the open-heart surgery floor, also would be very interested in the job. Lynn has been employed at the hospital for only 1 year but has a proven track record and would probably be very successful in the job. In addition, there is a staffing surplus right now on the open-heart surgery floor because two of the surgeons have recently retired. It would be difficult and time-consuming to replace Mark as charge nurse in the ICU/CCU.
A S S I G N M E N T:
What process should this supervisor pursue to determine who should be hired for the position?
Should the position be posted? When does the benefit of using transfers/promotions as a means of reward outweigh the cost of reduced productivity?
LEARNING EXERCISE
4.10
To See or Not to See
F
or the last few days, you have been taking care of Mr. Cole, a 28-year-old patient with end-stage cystic fibrosis. You have developed a caring relationship with Mr. Cole and his wife. They are both aware of the prognosis of his disease and realize that he has only a short time left to live.When Dr. Jones made rounds with you this morning, she told the Coles that Mr. Cole could be
discharged today if his condition remains stable. They were both excited about the news because they had been urging the doctor to let him go home to enjoy his remaining time surrounded by things he loves.
When you bring in Mr. Cole’s discharge orders to his room in order to review his medications and other treatments, you find Mrs. Cole assisting Mr. Cole as he coughs up bright red blood. When you confront them, they both beg you not to tell the doctor or chart the incident because they do not want their discharge to be delayed. They believe that it is their right to go home and let Mr. Cole die surrounded by his family.
They said that they know that they can leave against their physician’s wishes and go home AMA (against medical advice), but if they do, their insurance will not pay for home care.
A S S I G N M E N T:
What is your duty in this case? What are Mr. Cole’s rights? Is it ever justified to withhold
information from the physician? Will you chart the incident and will you report it to anyone? Solve this case, justifying your decision by using ethical principles.
LEARNING EXERCISE
4.11
The Untruthful Employee (Marquis & Huston, 2012)
Y
ou are the registered nurse (RN) on duty at a skilled nursing facility. Judy, a 35-year-old, full-time nurse’s aide on the day shift, has been with the skilled nursing facility for 10 years. You have worked with Judy on numerous occasions and have found her work to be marginal at best. She tries to be extra friendly with the staff and occasionally brings them small treats that she bakes. She also makes a point of telling everyone how much she needs this job to support her family and how she loves working here. She has a disabled daughter who relies on her hospital-provided health insurance to have her health care needs met.Most of the other staff seem willing to put up with Judy’s poor work habits, but lately you have felt that her work has shown many serious errors. Things not reported to you that should have been, intake and output volumes that are in error, strange recordings for vital signs, and so on. She has tried to cover up such errors, with what you suspect are outright lies. She claims to have bathed patients who have not appeared bathed and has said some patients have refused to eat when you have found that they were willing to eat for you. Although the chief nursing officer acknowledges that Judy is only a marginally adequate employee, she has been unable to observe directly any of the behaviors that would require disciplinary action and has told you that you must have real evidence of her wrongdoing in order to for her to take action.
During morning report, you made a specific request to Judy that a confused patient, Mr. Brown, assigned to her, be assisted to the bathroom and you told her that someone must remain in the room to assist him when he is up, as he fell last evening. You also told Judy that when in bed, Mr. Brown’s side rails were to be up at all times. Later in the morning, you take Mr. Brown his medication and notice that his side rails are down and after pulling them up and giving him his medicine, you find Judy and talk with her. She denies leaving the side rails down and insisted someone else must have done it. You caution her again about Mr.
Brown’s needs. Thirty minutes later, you go by Mr. Brown’s room and find his bed empty and discover he is in the bathroom unattended. As you are assisting Mr. Brown back to bed, Judy bursts into the room and pales when she sees you with her patient. At first, she denies that she had gotten Mr. Brown up, but when you express your disbelief, she tearfully admits that she had left him unattended but stated that this was an isolated incident and begged you to forget it. When you said that it was her lying about the incident that