8
Applying Ethics to the Leadership Role
CATHERINE ROBICHAUX
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Identify prominent leadership theories in nursing
Describe components of ethical leadership and their relation to leadership theories used in nursing
Discuss the behaviors and responsibilities of ethical leaders at the micro-, meso-, and macro-levels
Identify and apply strategies to develop ethical leadership
All nurses are leaders in their roles as health care providers and advocates, meeting the needs of patients and families directly or indirectly from the classroom to the bedside and boardroom, as managers, executives, educators, or researchers. At the bedside, nurses communicate and collaborate with the patient, family, and health care team regarding the provision of safe, quality care. At the department and unit levels, nurse leaders engage nurses in decision making about patient flow and staffing, quality improvement activities, and continuous learning opportunities to improve overall care delivery. Nurse managers strive to ensure that appropriate staffing and other resources are in place to achieve safe care and optimal patient outcomes (Thompson, Hoffman, & Sereika, 2011; Tregunno et al., 2009). At the organizational level, nurse executives contribute to strategic directions through their participation in senior level decision making and their ability to influence how nursing is practiced and valued (Marquis & Huston, 2014; Wong, Spence Laschinger, & Cziraki, 2014). Academic faculty, nurse educators, and researchers assist in guiding students and developing the discipline. At the national and international level, nurse leaders participate in health care reform and policy formation. So regardless of your nursing role as a formal or informal leader, you will encounter ethical issues and will have ethical responsibilities associated with your role.
CASE SCENARIO
Sandy has worked in the labor and delivery unit of a large, academic medical center for 5 years. Recently there has been increased staff turnover and several new graduates have been hired for the 7 a.m. to 7 p.m. shift. In postpartum care, the nurse to mother-baby couplet ratio has been one nurse to four stable couplets with alterations based on acuity. For the past 2 weeks, Sandy has had several assignments of five couplets in which mothers had been immediate postoperative cesarean section or the baby was late preterm and at risk for complications. In addition, Sandy is serving as preceptor for two of the new graduates who also have patient assignments. As an active member of Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Sandy is aware of the recommendations for staffing of perinatal units (AWHONN, 2010) and realizes that these assignments jeopardize patient care and nurse professional integrity and licensure. She also knows that in her state, Texas, the Board of Nursing has a safe harbor regulation that can be invoked without employer retaliation when a nurse believes an assignment is unsafe (Texas Board of Nursing, 2013).
At the end of the shift, she discusses her concerns with the charge nurse, Irene, who states, “You better get used to it because I don’t think they will be hiring any experienced nurses soon.” Sandy informs the charge nurse that she intends to invoke safe harbor on her next shift if such unsafe patient assignments continue.
Questions to Consider Before Reading On
1. How would you respond to a similar situation in your workplace if you were Sandy?
2. How would you respond as the charge nurse?
LEADERSHIP IN NURSING
There are many definitions, types, and theories of leadership. One definition states that leadership is “the process through which an individual attempts to intentionally influence another individual or a group in order to accomplish a goal” (Pointer, 2006, p. 125). A distinction is often made between leadership and management or administration. While the latter may be positional roles, “leadership” is a qualitative statement of personal or individual ability. This difference suggests that while management is about tasks, leadership is about perception, judgment, and philosophy. In nursing, however, the two may overlap and be similar in that they involve determining what has to be done, collaborating to attain the goal, and ensuring that it is accomplished. As leaders in diverse roles, nurses establish a direction and motivate others to achievement through trust, credibility, and relationships. Thus, leadership is a set of knowledge, skills, and attitudes that can be used by all nurses. Effective leadership at the management and administration levels is also associated with a healthy work environment, improved patient safety and satisfaction, and decreased nurse turnover rates, among other factors (Laschinger & Smith, 2013; Zook, 2014).
The American Association of Colleges of Nursing (AACN) documents on baccalaureate (2008) and master’s essentials (2011) support the development of leadership competencies in all nurses. Scott and Miles (2013) state that “if nurses are to make an impact on the advancement of patient care and the promotion of patient safety, then leadership must be considered an integral dimension of nursing education across the continuum” (p. 78). In the baccalaureate document, essential II states that “knowledge and skills in leadership, quality improvement, and patient safety are necessary for the provision of high-quality health care” (p. 3). This document also states that “Leadership skills . . . that emphasize ethical and critical decision making, . . . effective working relationships, . . . , and developing conflict resolution strategies” are needed. In addition, “The baccalaureate program prepares the graduate to engage in ethical reasoning and actions to provide leadership in prompting advocacy, collaboration, and social justice as a socially responsible citizen” (p. 12). Of the nine essentials for master’s-prepared nurses, two contain the word “lead” and most imply the use of leadership knowledge, skills, and attitudes.
The American Association of Colleges of Nursing (AACN) Quality and Safety Education in Nursing (QSEN) graduate competencies state that “graduate nurses will be the future leaders in practice, administration, education, and research. It is essential that these nurses understand, provide leadership by example, and promote the importance of providing quality health care and outcome measurement” (author’s emphasis; AACN, 2012, p. 2). Those QSEN competencies relevant to leadership in nursing are presented in Box 8.1.
Question to Consider Before Reading On
1. How do you or other nursing leaders in your workplace demonstrate the QSEN competencies in Box 8.1?
Box 8.1
Ethics in the Leadership Role—Relevant QSEN Competencies
Understand principles of change management (Knowledge)—Demonstrate leadership in affecting necessary change (Attitudes).
Analyze human factors safety design principles as well as commonly used unsafe practices (Knowledge)—Demonstrate leadership skills in creating a culture where safe design principles are developed and implemented (Skills).
Analyze the impact of team-based practice (Knowledge)—Be open to continually assessing and improving your skills as a team member and leader (Attitudes).
Source: American Association of Colleges of Nursing (2012); Cronenwett et al. (2007).
LEADERSHIP THEORIES
Although numerous leadership theories exist, transactional, transformational, and authentic leadership are popular models in nursing literature and education. These theories have several similar or overlapping components or behavioral attributes and it has been suggested that authentic leadership evolved from transformational leadership (Tonkin, 2013). An in-depth discussion of these theories is beyond the scope of this chapter; however, transactional leaders focus on achieving goals through clarifying expectations and, at times, offering recognition and rewards. In contrast, transformational nurse leaders stimulate and inspire others to achieve through charisma, and authentic leaders accomplish the same through honesty and consistency.
A transactional leader is focused on the maintenance and management of ongoing, day-to-day functions. She or he may work within the existing organizational culture as a direct care provider or charge nurse and demonstrate effective, stable leadership (Huber, 2014). The transformational nurse leader encourages others to collaborate rather than compete with each other, inspiring a sense of being connected to a higher purpose. Authentic nurse leaders endeavor to speak the truth, be transparent in their actions, and encourage and mentor others to achieve higher levels of performance. Transformational and authentic leadership may be necessary for organizational culture change in circumstances of growth, change, and crisis and is future oriented (Clark, 2009; Huber, 2014). These leadership approaches or styles are not mutually exclusive; behaviors or characteristics associated with one or more may be appropriate or used in another given situation.
While leadership has been explored extensively across disciplines, the role of ethics in leadership or ethical leadership has received focused attention only within the last 15 years and primarily in the business literature (Storch, Makaroff, Pauly, & Newton, 2013). This current interest is undoubtedly related to recent and ongoing scandals in business, government, sports, nonprofits, religious, and health care organizations (Dinh, Lord, Gardner, Meuser, & Hu, 2014; Sama & Schoaf, 2008). In nursing, Nightingale and other early nurse leaders gave specific attention to ethics, with chapters, articles, and books written about the ethical behavior and responsibilities of nurse leaders (Aikens, 1916/1935; Ulrich, 1992). Makaroff, Storch, Pauly, and Newton (2014) note, however, that attention to ethics and nursing leadership has waned over the last two decades perhaps contributing to a deficient ethical climate and pervasive moral distress among nurses. These authors (Makaroff et al., 2014) and others (Edmonson, 2015; Gallagher & Tschudin, 2010; Keselman, 2012) call for renewed attention to ethics in nursing education and leadership. This attention is especially significant in the current health care environment as ethical leaders may influence peer/employee ethical conduct in situations that may have great impact on patient outcomes, safety, and quality care (Keselman, 2012; Piper, 2011; Piper & Tallman, 2015).
Question to Consider Before Reading On
1. Identify a nurse leader in your current workplace. Does he or she demonstrate characteristics or behaviors associated with one or more leadership theories in Figure 8.1?
Figure 8.1 Ethical leadership behaviors integrated into leadership styles in nursing.
Sources: Fox, Crigger, Bottrell, and Bauck (2007); Huber (2014).
CASE SCENARIO (CONTINUED)
Returning to the Case Scenario, Sandy thinks about Irene’s comment that she “better get used” to continued short staffing in the postpartum unit. She wonders if the charge nurse is aware of current research on the potential adverse outcomes for both mothers and infants that can occur from inadequate nurse staffing (Bingham & Rule, 2015). Sandy is certain that Irene realizes that providing safe care is the primary ethical and legal obligation of the hospital and all health care providers. She reviews the components of the ethical decision-making framework presented in Chapter 2. Sandy recognizes that the present staffing situation may both harm the patients, violating the principle of nonmaleficence, and is inconsistent with her perception of good nursing (virtue ethics). Sandy decides to bring copies of the Code of Ethics (2015) and AWHONN (2010) staffing guidelines to review with Irene before her shift begins in the morning.
ETHICAL LEADERSHIP
Ethical behavior is certainly a characteristic of transactional, transformational, and authentic leaders. These nurses are individuals of integrity who engage in ethical decision making and are role models for others. A distinction is made, however, in that in ethical leadership at all levels, nurses proactively influence others through personal conduct, communication, and expectations. As Zheng et al. (2015) note, the difference between ethical leadership and other forms of leadership is one of breadth. Although all leadership theories contain moral components, ethical leaders focus explicitly on ethical obligations and guidelines and hold others accountable to do the same. As a result, these nurse leaders may influence ethical conduct and accountability by encouraging critical thinking and questioning regarding situations with ethical content.
In a meta-analysis of the effects of ethical leadership, Ng and Feldman (2015) suggest that the behaviors and expectations of ethical leaders go beyond merely increasing sensitivity to ethical issues and standards. Peers and employees trust ethical leaders and display more positive attitudes and greater job performance because of this heightened trust. Figure 8.1 illustrates behaviors associated with ethical leadership that may be incorporated into transactional, transformational, and authentic leadership styles. These behaviors are discussed in more detail in the section on developing ethical leadership.
The specific elements of ethical leadership and associated attributes of an ethical leader in nursing and other disciplines remain an ongoing area of inquiry. Storch et al. (2013) provide an initial framework for considering the responsibilities of ethical nurse leaders at the macro-, meso-, and micro-levels both within and outside their organizations (Figure 8.2).
Figure 8.2 Nursing ethical leadership responsibilities at micro-, meso-, and macro-levels. Ethical leadership behaviors cross all levels.
Questions to Consider Before Reading On
1. Figure 8.2 illustrates the responsibilities of ethical nurse leaders at three different levels. In addition, it depicts how ethical leadership behaviors cross all levels. How would you demonstrate these responsibilities and behaviors in your current workplace?
2. Can you identify a nurse leader with whom you have worked who demonstrates these behaviors and responsibilities at the macro-level?
The terms “macro,” “meso,” and “micro” reflect the environment of practice rather than the magnitude of influence of the ethical nurse leader. In addition, a nurse may be an ethical leader in several levels, for example, a staff nurse or nurse manager who is also a member of the institutional ethics committee or professional organization(s).
At the macro-level, ethical nursing leaders are spokespersons, political strategists, researchers, and advocates for social justice and health care reform. These leaders also ensure that nurses’ views on and experiences of ethical issues are heard and represented in various national and international forums. For example, Marla Weston, Chief Executive Officer, American Nurses Association, has championed federal legislation regarding safe nurse staffing presently under review in the U. S. Senate, the Registered Nurse Safe Staffing Act of 2014 (ANA, 2014). Carol Pavlish, Associate Professor, UCLA School of Nursing, and colleagues have conducted extensive research on moral distress in nursing (2013, 2015a, 2015b), developed an early intervention tool to mitigate its deleterious effects (2014, 2015c), and an evidence-based action guide for nurse leaders (2016). Pavlish and her co-investigators have also explored gender-based violence in South Sudan and Rwanda and identified the global advocacy role of nursing in supporting these vulnerable populations (Pavlish, Ho, & Runkle, 2012).
At the meso-, or organizational, level, the nurse executive “serve(s) as the conscience of the health-care team” by avoiding compromises that lead to decreased standards of care or negate nurses’ contributions (Storch et al., 2013, p. 4). These nurse leaders interpret nursing concerns clearly and support research and guidelines for ethical practice and quality patient care. In addition, as exemplified by Donna Casey, they ensure that ethics resources are available and used by nurses. Ms. Casey, Director of Patient Care Services, Cardiovascular and Critical Care at Christiana Care, participates in and mentors nurses in preventative ethics strategies. She has also integrated the Code of Ethics into the performance appraisal and peer review process to “help nurses make a clear connection between their ethical obligations and what they do at the bedside” (Trossman, 2013). A selected example of the Registered Nurse III competencies and associated ethical obligations contained in the Christiana Care performance review tool is presented in Box 8.2.
Nursing directors and nurse managers are leaders at both the organizational and unit levels. They are called on to foster healthy work environments and create a climate of caring and connectedness. These frontline leaders must also recognize the importance of meeting nurses’ needs in order to meet client needs, and provide meaningful participation in decision making. The nurse director/manager position is critical to organizational success, patient outcomes, and nurse empowerment (Duffield, Roche, Blay, & Stasa, 2011; Lucas, Laschinger, & Wong, 2008; Wong et al., 2010). Over the past two decades, this role has become increasingly complex as these nurses may lead one or more units and have increased responsibility for budget, staffing, and regulatory compliance (Hewko, Brown, Fraser, Wong, & Cummings, 2014; Kath, Stichler, & Ehrhart, 2012; Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010). These responsibilities and others may create tension between personal values, the ethical obligations of the profession, and working within the priorities and needs of the organization.
The challenging position of the frontline nurse manager or leader in ethical situations was explored by several researchers (Aitamaa, Leino-Kilpi, Puukka, & Suhonen, 2010; Pavlish et al., 2015b; Porter, 2010). Many issues identified by the nursing leaders in these studies are similar to those reported by direct care nurses. However, they occur at multiple levels as presented in Box 8.3, and reflect the nurse manager/leader’s complex role in navigating diverse perspectives. Rather than taking a proactive stance or intervening early in these situations, Pavlish and colleagues (2015b) reported that the nurse leaders in their investigation often waited until the conflicts escalated. Reasons for the delay included perceptions that intervening could be risky, harm relationships, and/or jeopardize their ability to accomplish other initiatives. Although many participants believed that system-level issues contributed to ethical conflicts, few identified approaches to operate at the organizational level to change those contributing factors. Pavlish and colleagues concluded that the frontline nurse manager or leader may need to develop “more awareness, skill, and confidence in working with institutional level ethics” (p. 317).
Box 8.2
Registered Nurse III Performance Review Tool Selected Competencies
ADVOCACY/MORAL AGENCY
PATIENT ASSESSMENT/ETHICAL PLAN OF CARE
Works on another’s behalf to help resolve ethical and clinical concerns within the clinical setting for patients and families when they cannot represent themselves.
Cultivates an environment that is supportive of colleagues’ development in ethical reasoning and advocacy.
Represents the patient when the patient cannot represent self. Seeks available resources to help understand, formulate, and implement ethical decisions.
PATIENT/FAMILY SATISFACTION/ETHICAL INVOLVEMENT
Supports ongoing initiatives and implements new initiatives that improve patient satisfaction and foster ethical decision making.
Assumes a leadership role to provide support to other members of the team seeking resolution to patient satisfaction concerns or ethical solutions.
Empowers the patient and family; knows what rules or guidelines can be suspended or modified to allow patients and families to represent themselves or meet their moral needs.
Serves as a resource and a patient advocate. Is alert to and takes appropriate action regarding incompetent, unethical, illegal, or impaired practice by any member of the health care team.
PROFESSIONALISM IN NURSING—EXEMPLARY PROFESSIONAL PRACTICE
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth (ANA Code of Ethics, 2015).
Attended a local or national nursing conference
Submitted an article for publication in a nursing or medical journal within the current review year
Active member of the unit or hospital nursing Quality and Safety Council
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