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Ethical Helps and Challenges Faced by Nurse Leaders in the Healthcare Industry

Cooper, Robert W. PhD; Frank, Garry L. PhD; Gouty, Carol Ann PhD, CNA; Hansen, Mary Mincer PhD, RN

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Author Information

Authors’ affiliations: Drake University, Des Moines, Iowa (Drs Cooper, Frank, and Hansen); Holy Cross Hospital, Chicago, Ill (Dr Gouty).

Corresponding author: Robert W. Cooper, PhD, 2389 NW 162nd Lane, Clive, IA 50325 (robert.cooper@drake.edu).

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Abstract

Professional healthcare providers are held responsible for technologic and financial decisions and also for the moral ramifications of their decisions. The authors report the findings of a survey of nurse leaders conducted to determine the key factors that provide help and present challenges as they seek to respond ethically to the dilemmas encountered in the course of their work. Implications for the healthcare industry and the nursing profession are discussed.

As ethics are considered in their decision-making, nurse leaders have revised nursing education to better prepare nurses for this responsibility. In addition, they have encouraged nurses at all organizational levels to contribute to the institutionalization of ethical responsibility throughout their organizations. Professional nursing associations have undertaken measures to improve their members’ ability to recognize and respond effectively to the ethical dilemmas encountered in their work. 1–7 To assist their staff, nurse leaders need to know the key factors that challenge nurses when making ethical decisions in the delivery of healthcare services. Organizational factors, as well as those in a provider’s personal and professional environments, must be identified. 8

This article reports the findings of a study conducted in February 2000 to learn more about factors that help and challenge nursing professionals in responding to the various ethical dilemmas they encounter in their work. Because managerial support is essential in creating an environment that encourages and rewards ethical decision-making in any organization, the authors surveyed 2000 of the approximately 4000 members of the American Organization of Nurse Executives (AONE). Survey participants were chosen by selecting every other name on the AONE membership list.

Each participant received a three-page questionnaire designed to collect information regarding the helpfulness of, and challenges presented by, various factors in dealing with ethical dilemmas encountered at work as well as information about the respondent and his or her organization. The questionnaire was developed by modifying a survey form that previously had been used in a number of studies of professionals in other fields and provided databases for extensive published research in those fields over the past decade. Survey modification was led by one of the authors who has been a nurse executive for a number of years and feedback regarding the revised form was sought from the local healthcare community.

Survey forms were mailed to the sample of AONE members with no followup. Responses were received from 426 participants (a 21.3response rate). The response rate is too low to permit generalizations to be made regarding the views of all nurse executives. The findings, however, are grounded in a sufficient number of responses to provide a sense of the key factors that help and hinder the ethical behavior of nursing professionals working in healthcare organizations (HCOs).

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Helps in Dealing With Ethical Dilemmas

A key portion of the survey form consisted of the 17 statements listed in Table 1 (hereafter referred to as “potential helps”). These statements reflect factors that might be helpful to nursing professionals when faced with ethical issues. Those surveyed were asked to rate each statement on a 5-point scale. If the factor was extremely helpful to them in responding to work-related ethical dilemmas, the participant responded with a 5, whereas a 1 meant that it was not helpful to the participant. If the particular item was either not available to them (eg, their organization does not have a statement on ethics) or not applicable to them, survey participants were asked to indicate a sixth option (NA) for that statement.

Table 1
Table 1
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Overall Findings

Table 1 shows the mean (average) ratings for each of the 17 potential helps based on the individual ratings (other than NA) given to each factor by all the nursing professionals responding to the survey. The Table also shows the rank of each factor based on the size of the factor’s mean rating. For example, potential help H7 (ie, ethics training provided by your organization) was rated 3.78 on average by all the survey respondents who did not circle NA and had the 16th highest mean rating among the 17 potential helps in the survey.

The information presented in Table 1 suggests several key points. Because all the factors had mean ratings greater than 3.0 (ie, the midpoint on the rating scale), the responding nurse leaders find all the resources listed to be helpful in resolving ethical dilemmas encountered in their work. As shown in Table 1, this finding is further supported by the very high percentages of respondents who rated each potential help factor as 3, 4, or 5.

The mean ratings and ranks in Table 1 also indicate that the nurses responding to the survey tended to rate their own personal moral values and standards (H16) as most helpful in dealing with ethical dilemmas at work. However, after this factor, the nurse leaders tended to view certain resources from their organizational environment as more helpful than those from their professional environment. The remaining top 10 potential helps in terms of dealing with ethical dilemmas relate to the nurse’s organizational environment.

Although two of the organization-related helps in the top 10 are formal organizational factors (H6 and H8), the other seven organization-related helps in the top 10 arise from the more informal organizational climate. The key factors related to organizational climate include the actions and responsiveness of an immediate boss as well as the ability to go beyond that boss if necessary, the organizational culture, management philosophy, management’s communication of appropriate ethical behavior, and help from coworkers. Also noteworthy is the fact that two of these factors (H11 and H14) deal with merely the absence of pressure to compromise one’s own ethical standards. This suggests that one way HCOs and their managers can assist nursing professionals is by neither explicitly nor implicitly pressuring them to go against their ethical values.

The resources related to the profession (H1 through H4) were found to be helpful to responding nurse leaders. Nevertheless, as shown in Table 1, those resources are generally rated lower than a number of the potential helps related to the organizational environment (H6, and H8–H15). An opportunity appears to exist for nursing professional associations to develop even more effective resources related to ethics. If such efforts are undertaken, the nursing professional associations may want to take into account that their members tend to look strongly to factors in the their organization’s environment for help in dealing with work-related ethical dilemmas.

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Findings for Nurse Leaders in Various Group Breakdowns

For almost all the helps, no statistically significant differences were found in the mean ratings (at the .05 level) when nurse leaders were grouped by position title, HCOs bed size, for-profit versus nonprofit HCOs, public versus private HCOs, and credentialed versus not credentialed by the American Nurses Credentialing Center. The few exceptions were:

* Vice presidents viewed H9 (a management philosophy in your organization that emphasizes ethics in operations) and H10 (clear communication of appropriate ethical behavior by management) as being significantly more helpful in dealing with ethical dilemmas in the course of their work than did directors.

* Respondents employed by for-profit HCOs viewed H17 (your family and friends who provide support and insight for you in resolving ethical conflicts) as being significantly more helpful in dealing with ethical dilemmas encountered at work than did respondents indicating that they worked for nonprofit HCOs.

* Respondents employed by private HCOs viewed H7 (ethics training provided by your organization) as being significantly more helpful in dealing with ethical dilemmas encountered at work than did respondents indicating that they work for public HCOs.

* Those respondents who are not credentialed viewed H15 (help from your coworkers in resolving your ethical dilemmas) as being significantly more helpful in dealing with ethical dilemmas encountered at work than did respondents who were credentialed.

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Challenges Encountered in Dealing With Ethical Dilemmas

When faced with ethical dilemmas in the course of their work, nursing professionals face a variety of challenges that can hinder their ability to behave ethically. As with helps, the potential challenges can be attributed to one’s personal, organizational, and professional environment.

Survey participants were presented with the 20 statements listed in Table 2 (hereafter referred to as “potential challenges”) that attempt to identify the key challenges to ethical decision-making faced by nursing professionals. Each statement was rated on a 5-point scale where 5 meant the factor presents a very significant challenge to their efforts to act ethically and 1 meant it does not present a challenge to them. If the particular item does not apply, survey participants were asked to indicate a sixth option (NA) for that statement.

Table 2
Table 2
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Overall Findings

Table 2 shows the mean (average) ratings for each of the 20 potential challenges based on the individual ratings (other than NA) given to each statement by all the nurse leaders responding to the survey. The Table also shows the rank of each statement based on the size of the statement’s mean rating. For example, potential challenge C11 (ie, a lack of ethics training in your organization) was rated 2.21 on average by all those survey respondents who did not circle NA, and had the fifth highest mean rating among the 20 potential challenges.

As indicated in Table 2, all the potential challenges had means less than 3.0 (the midpoint on the rating scale). Thus, the factors generally are not viewed as presenting particularly significant challenges to large percentages of the respondents. However, all but one of the potential challenges (C19) received a rating of 5 (presents a very significant challenge) from at least some of the respondents, and most of the challenges were rated 3, 4, or 5 by 2065171540r more of the survey respondents. This suggests that these challenges, although not viewed as widespread problems, are sufficiently pervasive that healthcare management should not ignore them. Nurse leaders and other healthcare managers need to be alert to identify and handle, on an individual basis, those situations in which reasonably significant challenges to ethical behavior exist. This finding also suggests a need to provide management-training programs to help managers develop skills in identifying and handling ethical challenges.

Several points are noteworthy. The two top-rated challenges deal primarily with competitive pressures. Although economic theory suggests that competition is good for business and its owners, perhaps competition’s impact from an ethical standpoint is not always favorable, especially when the rights of, and obligations to, other stakeholders in the healthcare arena (eg, patients, employees, and the general public) are taken into consideration.

The challenges rated third and fourth (C1 and C2) involve conflict between duty to one’s employer and duty to one’s employees and customers. The fifth-rated challenge deals with a lack of ethics training. If properly developed and delivered, ethics training could help nursing professionals deal more effectively with the effects of competition, the conflicts of duty that currently exist, and also with other ethical challenges likely to become more numerous and present more significant barriers to ethical behavior in the healthcare industry.

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Findings for Nurse Leaders in Various Group Breakdowns

Table 3 indicates the challenges for which statistically significant differences were found in the mean ratings (at the .05 level) when nurse leaders were grouped by position title, profit versus nonprofit HCOs, public versus private HCOs, and credentialed versus not credentialed by the American Nurses Credentialing Center.

Table 3
Table 3
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When challenge means for nurse leaders working for HCOs in four categories of bed size (<100, 100–200, 201–400, and >400 beds) were compared, statistically significant differences were found at the .05 level for only three factors. Respondents employed by HCOs with fewer than 100 beds found C3 (unethical demands made by co-workers), C9 (a lack of ethics policy in your organization), and C11 (a lack of ethics training in your organization) to present significantly greater challenges when they faced ethical dilemmas at work than did respondents employed by HCOs with 201 to 400 beds. The respondents employed by HCOs with fewer than 100 beds also found a lack of ethics policy to present a greater challenge to ethical behavior than did respondents employed by HCOs with 100 to 200 beds, and a lack of ethics training in their organization to be more of a challenge than did respondents employed by HCOs with 100 to 200 beds and more than 400 beds.

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Conclusion

Although a number of specific implications have been discussed in each section of this article, several general implications flow from the following key findings of the study:

* When faced with ethical dilemmas, nurse leaders tend to find certain aspects of their organizational environment to be more helpful than they find resources related to the professional environment.

* With two exceptions (H6 and H8), the organizational factors found to be most helpful tend to be those reflecting certain aspects of the informal organizational climate (ie, H9–H15) as opposed to more formal organizational mechanisms (eg, ethics training programs). The factors related to the organizational environment highlight the importance of one’s immediate boss and the ability to go beyond that boss, if necessary; the organization’s culture; management philosophy and communication of appropriate ethical behavior; and help from coworkers in helping nurse leaders respond effectively to ethical dilemmas arising at work.

* Many challenges to ethical behavior encountered by nurse leaders, although not viewed as widespread problems, are sufficiently pervasive that healthcare management should not ignore them.

* As a challenge to ethical behavior, a lack of ethics training ranked relatively high (5th of 20 potential challenges in Table 2). Moreover, ethics training provided by one’s organization was ranked 16th out of 17 potential helps studied (Table 1) in terms of its relative helpfulness to nurse leaders when faced with ethical dilemmas at work. When these two findings are viewed together, the opportunity, as well as the need, for improvement in the area of ethics training becomes evident. This finding adds support to the implications of the findings of several recent studies of nurses in the New England states that indicated that registered nurses have a high need for ethics education in order to practice ethically in today’s healthcare environment. 9–15

These findings have a number of implications for both the healthcare industry and the nursing profession. The finding that professionals working for HCOs tend to view certain factors in their organizational environment as more helpful than those related to their professional environment when faced with ethical dilemmas suggests several things. First, in dealing with employees who are professionals, HCOs must take the lead in providing an environment that encourages and rewards ethical behavior. HCOs cannot abdicate their responsibility in the area of ethics to the profession. Second, the findings suggest that opportunities often exist for nursing professional associations to improve the resources related to ethics they provide their members. The most effective way of doing so may be to focus on those efforts aimed at enhancing their members’ ability to contribute to an ethical organizational environment. For instance, professional associations might offer programs to educate members to identify and counsel subordinates facing ethical dilemmas or to assist them as managers to introduce ethical resources in their own organizations.

The findings that address the availability and relative helpfulness of various organization-related factors have implications for the nursing profession as well as for the healthcare industry, in general. First, it appears that one of the best things HCOs can do to encourage ethical behavior is to refrain from pressuring managers and employees to compromise their own personal values. Second, HCOs should ensure that managers are equipped not only to deal with their own ethical dilemmas, but also those encountered by their subordinates in the course of work. Finally, opportunities exist for many HCOs to either make available or improve the helpfulness of various formal organizational mechanisms related to ethics, especially ethics training programs. A study by the Ethics Resource Center 16 found that ethics programs appear to have the most positive effects in organizations that have three program components: codes of conduct, ethics training, and ethics offices. Additionally, codes of conduct alone often seem to have a negative effect on employee perceptions.

Although not viewed as presenting widespread problems, the study found that management should not ignore the many challenges faced by nurse leaders. This suggests that managers must be educated to identify and handle, on an individual basis, situations that challenge ethical behavior for them or those working for them. The obligation to prepare managers to identify and handle such ethical challenges is clearly the primary responsibility of the organization for which the nursing professional works.

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References

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© 2003 Lippincott Williams & Wilkins, Inc.

 

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