In the October/December 2013 issue of Advances in Nursing Science, the article “Barriers to Innovation: Nurses' Risk Appraisal in Using a New Ethics Screening and Early Intervention Tool”1 addresses the critically important yet thorny issue of ethics in health care. The authors are to be applauded for acknowledging the importance of this topic and for their broad-ranging discussion of the negative consequences of a work environment not fully supportive of nurses' voices in ethically ambiguous situations. These consequences can include compromised patient safety and quality of care, unnecessary suffering, unequal distribution of resources, and threats to the personal and professional well-being of nurses, to name but a few. A deep, effective understanding of such a complicated issue as ethics in health care requires an appropriate theoretical foundation—multilevel, multidimensional, and complex, with a strong focus on context. The authors underpin development of their ethical screening and early intervention tool with the model of the health care organization as ecosystem, and they highlight several elements of social ecology—normalization of values and power structures, interrelationships (not individuals) as central to system function, and the necessity of understanding how systems interrelate and interact to produce outcomes—as relevant to health care organizations.
However, the choice of this theoretical foundation to guide development and testing of the ethical screening and early intervention tool seems incongruous on several counts, given that, in a framework of ecological analysis, system thinking is essential.2 First, even though the authors acknowledge that interrelationships, power structures, and borders between systems are key elements of the ecosystem, their approach suggests a focus on the individual rather than on the system in which these relationships, processes, intersections, and structures are embedded and have become normalized. From the ecosystem perspective, it seems reasonable that change in one element would create change—both anticipated and unanticipated—in another. However, it also seems likely that the system would constrain the ability of the individual to act, since the traditions and values—“how we do it here”—of an institution are often deeply embedded and normative. In fact, this is what the authors discovered: nurses knew what they should do but were “caught” in the system.
The question that then arises is whether these constraints (eg, power imbalances, policy, the weight of the status quo) can truly be restructured in a sustainable way through the actions of individual nurses (or the sum of many of these actions) in the absence of system change. It seems unlikely, given that none of the 4 barriers to ethics-related action mentioned by the authors appears to be independent of an onerous ethical work environment. Next, viewing the nurse as the locus of ethical awareness and action may also obscure important dynamics of interrelationships and communities within institutions, which also have ethical lives and dispositions.3 If complex systems, such as those in health care, are separated into their component parts, our ability to understand them in a meaningful way becomes compromised.2
Furthermore, it is unclear why this nonpredictive ecosystem perspective would imply that a tool designed to foster ethical awareness and appropriate action would actually lead to action in the absence of an institutional culture of safety and support. In fact, the screening tool under discussion appeared to strengthen nurses' internal voices without affecting their external voices. Given this finding, might not such a tool further exacerbate nurses' moral distress by increasing the dissonance between internal and external voices? While I agree that the development of ethical awareness and action is beneficial both personally and professionally and should be encouraged and assisted, it may be more productive to conceptualize the escalation of ethical dilemmas as reflective of a faulty or dysfunctional system, rather than of a lack of agency on the part of individuals within the system. Perhaps then the landscape of the ecosystem could actually nurture nurses' sensitivity to emerging ethical issues, as well as empower them to act on what they already know.
What if, for example, the system were structured so that, instead of action being required to initiate an early ethics (or palliative care) consult, effort would have to be expended to ensure that a consult not happen if anyone were to document certain findings? How might this inversion of the status quo change the expectations of the individuals within the system and spare nurses the requirement that they commit to actions perceived as personally and professionally risky? Obviously, there are no panaceas, but such system-focused changes might resolve part of the difficulty and remove some of the onus from an already-overburdened workforce.
To conclude their article, the authors encourage the development of emancipatory knowledge as a way of improving ethical environments in health care. In this vein, using a system lens, we could ask: What is wrong with this picture of focusing on the skills and judgment of the individual? Who benefits from the continuing expectation that nurses shoulder this burden? What are the system barriers that, if lifted, would free nurses from this burden? And what system factors need to change in order for this to happen? As Pavlish et al pointed out, “Human behavior changes when structures surrounding them [humans] change.”4(p280) We owe it to ourselves to minimize individual burden and create change in the least distressing and most sustainable way possible.
—Celia M. Bridges, BA, BSN, RN
School of Nursing
University of Michigan
1. Pavlish CL, Hellyer JH, Brown-Saltzman K, Miers G, Squire K. Barriers to innovation: nurses' risk appraisal in using a new ethics screening and early intervention tool. Adv Nurs Sci. 2013;36:304–319.
2. McLaren L, Hawe P. Ecological perspectives in health research. J Epidemiol Community Health. 2005;59(1):6–14. doi:10.1136/jech.2003.018044.
3. Reiser S. The ethical life of health care organizations. Hastings Cent Rep. 1994;24:28–36.
4. Pavlish C, Brown-Saltzman K, Fine A, Jakel P. Making the call: a proactive ethics framework. HEC Forum. 2013; 25:269–283. doi:10.1007/s10730-013-9213-5.