ETHICAL ISSUES FOR THE LEADER OF THE NEXT CENTURY
8. Respect: Treating all others with equal respect and concern
At the heart of ethical leadership is commitment to your personal values. Values are
“those things that are most important,” what you believe to be right, “more than words . . . the moral, ethical, and professional attributes of character” (NDU, n.d.). Values are both personal and organizational. Vision and mission must be grounded in values.
Quinn (2005) described the difference between a “normal” state of leadership and the
“fundamental” state of leadership. He asserted that when you are at your best, you are not trying to emulate anyone else. In a crisis, you draw from your fundamental values and abilities. Think about when you faced the most difficult trial of your life either at work or personally. You followed the instinct of your core values, and you found the best within
yourself. You responded beyond your own usual abilities and likely surprised others by your wisdom and strength. That is the state of fundamental leadership. Quinn described the contrasts: (1) Fundamental leadership is results centered rather than comfort cen- tered, as in a normal state. A focus on results invites you to move beyond a comfort zone to explore new possibilities and new outcomes. (2) Fundamental leadership is internally directed toward personal values rather than compliance with expectations of others.
(3) Fundamental leadership is others focused rather than self focused. And, (4) funda- mental leadership is externally open to needs and opportunities rather than internally closed to stay on the immediate task and avoid risk. The key is to know your values, set high standards, focus on others, be open to possibilities, and lead courageously.
One ironic ethical concern related to the nursing workforce is the appropriate re- sponse to a continuing nursing shortage. Halloran (2008) proposed that “Leaders in the nursing profession have pandered to cries of nurse shortages by preparing new en- trants with beginning skills to support the existing hospital and physician dominated health system.” He argued, “Were there to be investments in graduate education for clinical nurses who would compete for patients, more care would be given at less cost,”
that:
Nurses are too important to be used to shore up an existing, fragmented, expensive system.
Leadership is needed to see that patients have access to the services of nurses in primary care in more than token numbers. Nurses can contribute to the solution of health care financing by collaborating in the provision of primary care . . . or competing with doctors and hospitals for access to patients. As it is now, nurses are seen as part of the problem of financing health care in the United States. (Halloran, 2008, pp. 232–233)
The primary, essential, central moral principle ethics in nursing leadership is the doc- trine of intrinsic human dignity (Perkins, 2008). It is codified in an official code of ethics adopted by the American Nurses Association (2001, p. 7):
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
Leaders in health care are continually confronted with new and more complex ethical questions, but the core principle to protect human dignity remains at the center of the moral compass. Modern issues of disparities in access and care, vulnerable populations, end-of-life care and issues of assisted suicide, patients in persistent vegetative states, infectious diseases, chronic illness, and homeless and migrant populations will test the ethical decision making of all members of the healthcare system.
Leaders in health care encounter ethical issues that truly affect lives. Shale (2008) re- minded that although the entire reason for being for healthcare systems is to provide the best care for the individual, and leaders are confronted with the paradox of managing limited resources to provide care for entire populations, which may not always be con- sistent with serving the individual. Other sources of paradox and dilemmas pervade the work of the transformational leader. Curtin (2006) gave the simple example in hospital leadership:
A staff nurse has an obligation to request more help when staffing on [his or] her unit is inad- equate, and a right to expect that administration will respond to this need. [He or] she need not be concerned about the staffing on other units. The nurse manager, however, must judge the conflicting needs of other units to determine which has the greater need and allocate staff accordingly. [He or] she has an obligation not to base decisions on who complains the loud- est, but rather on a fair .. Such decisions do not deny the needs of the one, but rather recognize the greater need of the other.
Curtin (2006) further suggested that leaders facing difficult and ethic issues ask the fol- lowing questions: (1) What is the case? (2) What criteria should be used to make the deci- sion? (3) Who is best qualified to make the decision? (4) Is the decision a group decision?
(5) Who should benefit most from the decision? And she reminded that for the leader, issues of “professional standards, self-regulation, and self-discipline assume different”
and greater proportions and significance.
In a study by Redman and Fry (2003, p. 153), nurse leaders reported their most dif- ficult ethical issues. They included staffing patterns that reduce patient access to care, inappropriate prolonging of the process of dying, working with incompetent or unethi- cal colleagues, implementing mandated care practices that threaten quality, measures that do not consider patient quality of life, and caring for patients and/or families who are uninformed or misinformed about diagnosis, prognosis, treatments, or alternatives.
These reflect the challenging realities of current systems. Future leaders must resolve these difficult issues.
Beyond making specific decisions, the leader has the responsibility to build an ethical climate. The first step to create an environment of ethics is to model ethical behavior. It requires a commitment to integrate personal, professional, and organizational values throughout the work environment. Informal models of ethical behavior have been found to be more effective than formal policies (Cooper, Frank, Gouty, & Hansen, 2003). Next is to establish policies and procedures that reflect fairness and ethical values. Then, com- municate those values and policies throughout the organization. Finally, monitor all systems to know when and where ethical issues may arise in order to support ethical behavior and manage risk in decisions (NDU, n.d.).
Secretan (1986) suggested the primary values of mastery (or consistent action at the highest standard of which you are capable), chemistry (or “relating so well with others that they actively seek to associate themselves with you”), and delivery (or “identifying the needs of others and meeting them”). He further proposed leader behaviors to learn and seek wisdom, to empathize with the perspective of others, and to listen.
The challenges explored in this chapter certainly do not represent all major issues facing healthcare leadership. Perhaps, there is some topic you think that should have been discussed here. Perhaps, you are devoted to one of these or another cause just as important. Other significant issues related to patient populations include genetic test- ing issues care of the elderly, reaching underserved and uninsured children, the effects of poverty on health, access to care for mental health, palliative and end-of-life care, women’s health, and health care provider coverage for all. There are also other systems issues such as access in rural areas, issues related to niche providers, private and public systems, financing health care, system models, the role of government in health care, and a world of other concerns. The challenges described here represent but a sample of
issues that cross all populations of patients and concerns within systems at the moment.
All require the leader with personal values who sets high standards and aspires to wis- dom. Such leaders inspire trust and credibility.
It is most vexing that many of these challenges really ought not to be. For example, it is most unfortunate that we continue to discuss the need for and laud initiatives for patient-centered care. Shouldn’t it be self-evident in a modern healthcare system as rich in resources as that of our country that patient-centered care would be the very fiber and practice of our system—that it would already be integrated into every aspect of care?
You must be the leader to take us to that next most important level of caring. There are certainly other problems not listed here, but creating a longer list would not diminish the significance of these. What will you do as a leader to solve them?
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