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Applying IntegratedEthics in Nursing Practice
BARBARA L. CHANKO
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Describe what is meant by ethics quality
Discuss the levels of ethics quality throughout an organization
List the domains of ethics in health care
Describe the IntegratedEthics model and its three core functions: ethics consultation, preventive ethics, and ethical leadership
Indicate how IntegratedEthics can be applied in the work setting
As an RN, you may have felt a conflict over how you should weigh the values that are important to you as a person, as a professional, and as a member of the organization where you work in deciding about what is the right thing to do in a particular circumstance. Have you thought about the quality of ethics throughout the organization in which you are employed? As you read the following Case Scenario, think about how well your organization supports ethics and how you can actively participate in ethics activities by asking yourself the following questions.
From whom in the organization can I seek guidance when faced with an ethical concern that I cannot answer?
How can I help to close a practice gap involving an ethics standard?
Do I see leaders supporting an ethical environment and culture that benefits patients and staff ?
CASE SCENARIO RELATED TO AN OVERVIEW OF INTEGRATEDETHICS
Beatrice has been the nurse manager on the unit for 5 years. In that time she has evolved as a leader and it is clear that she takes her responsibility of creating a positive workplace very seriously. Personally, she attributes much of her growth to her conscious decision to implement the concepts and practices of IntegratedEthics® that she learned when she worked at a Department of Veterans Affairs medical center. The staff members on her unit know that while not perfect, it is a great place to work, and recognize that in large part it is because ethics matters to Beatrice.
Over the past few years, Beatrice has been working to integrate ethics into all aspects of the unit’s operations. Beatrice demonstrates to all staff that ethics is a priority, communicates clear expectations for ethical practice, practices ethical decision making, and supports the hospital’s overall ethics program. Staff members notice that she focuses on her responsibilities as a leader to promote a positive ethical environment and culture.
When anyone has an ethical concern about particular patient care situations or ethical concerns about general situations involving patient care or operations of the unit that he or she cannot resolve on his or her own, Beatrice is the first to suggest they call for an ethics consultation. Staff members have come to value the expertise that the ethics consultants bring to discussions about conflicts or uncertainty over values. They know that ethics consultants will analyze the situation; help foster consensus and resolve the conflict in an atmosphere of respect; honor participants’ authority and values in the decision-making process, and identify actions that are consistent with high ethical standards. The consultants do all this and they can be counted on to educate staff so that staff can become more skilled at handling the current and future ethical concerns. Knowing that ethical concerns will be responded to by the ethics consultation service makes staff members feel confident that they will not need to struggle alone with the inevitable ethical dilemmas that occur when providing health care.
Lately, Beatrice has been talking during staff meetings about some recurring ethical issues that she sees on the unit that create real gaps between what she knows is ethically the right thing to do and what staff sometimes do—these are ethics quality gaps. For example, she has noticed that informed consent and advance care planning practices are not being carried out in ways that are consistent with the best ethics practices that have been established in hospital policy. She knows that the nurses try their best but also that the organization’s systems and processes sometimes get in the way of doing what is right. Beatrice believes that there are ways to prevent these ethics quality gaps by looking upstream and fixing the systems problems that cause the concerns in the first place. She wants to get a group together to do “preventive ethics,” that is, performance improvement activities that reduce ethics quality gaps on a systems level.
Beatrice is excited to share what she knows and practices from IntegratedEthics so that everyone can participate and be a part of ensuring that the ethics quality on the unit is top notch. Alex, a relatively new nurse on the unit, has had some quality improvement experience and is intrigued to learn about Beatrice’s approach. Beatrice senses that Alex may be a budding ethics champion and encourages her to read about the IntegratedEthics Program at the Department of Veterans Affairs National Center for Ethics in Health Care (2015). The website contains publically available information that can be used to guide implementation of IntegratedEthics (IE), a comprehensive approach to managing ethics in health care organizations, as well as tools and resources that make it easy to move the program forward on the unit.
Nurses, along with other staff of a health care organization, have a duty to integrate values with the myriad rules that guide and direct actions meant to provide high-quality care to patients. Nurses promote quality in their everyday practice through leadership and quality improvement activities. The American Association of Colleges of Nursing (AACN) Quality and Safety Education in Nursing (QSEN) graduate competencies state, “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” (American Association of Colleges of Nursing, 2012, p. 2). QSEN competencies relevant to quality in nursing are presented in Table 12.1.
Nurses play a critical role in ensuring that high ethical standards are practiced and maintained as they are one of the core health professionals that work 24 hours a day, 7 days a week in many health care settings. Their work is most fruitful when it is done as part of an overall ethics program in an organization committed to ethics quality. Health care organizations that have strong ethics programs and staff committed to ethics quality reap many benefits for their patients, employees, and the organization itself. Box 12.1 lists examples from a brief business case for ethics that describe how doing the right thing is also the sensible and wise thing to do (National Center for Ethics in Health Care, 2014a).
Questions to Consider Before Reading On
1. How do I know when I have provided nursing care of high ethics quality?
2. How would I define ethics quality?
When most people in health care think of quality, they think of technical quality (e.g., clinical indicators that a procedure or action was properly performed according to standards) and service quality (e.g., patient satisfaction with the health care experience). But ethics quality is equally important in the care provided by the staff of a health care organization (Wynia, 1999, p. 296) including its nurses. For example, consider a patient who has had a peripherally inserted central venous catheter (PICC) line placed by the nurse. From a technical quality perspective, the care was perfectly executed by the nurse who maintained sterile technique, and from a service quality perspective, the patient experienced no pain and was perfectly satisfied with the professional manner and efficiency of the nurse who provided the care. So, one may think that the care was of high quality, right? Well, not necessarily. Imagine that the nurse never really informed—or even misinformed—the patient about the purpose of the PICC line and the risks, benefits, and burdens of having it placed. As informed consent is a standard, a norm, and an expectation in health care and for nursing practice, this would indicate a problem with the ethics quality of the care provided by the nurse. The IntegratedEthics model defines ethics quality in health care as, “Practices throughout an organization are consistent with widely accepted ethical standards, norms, or expectations for the organization and its staff” (National Center for Ethics in Health Care, 2013, p. 1).
Table 12.1
Quality in Nursing
KNOWLEDGE | SKILLS | ATTITUDES |
Describe strategies for improving outcomes at all points of care | Translate aims for quality improvement efforts Align the aims, measures, and changes involved in improving care | Commit to concepts of transparency, managing variability measurement and accountability |
Describe nationally accepted quality measures and benchmarks in the practice setting | Use a variety of sources of information to review outcomes, compare benchmarks of care, and identify potential areas for improvement (e.g., National Database of Nursing Quality Indicators; Hospital Compare; Centers for Medicare/Medicaid Services [CMS] indicators, The Joint Commission: ORYX, National Public Health Performance Standards and others) Participate in analysis of databases as sources of information for improving patient care Use quality indicators and benchmarks for improving system processes and outcomes | Commit to achieving the highest level of processes and outcomes of care Inspire others to achieve benchmark performance Model behaviors reflective of a commitment to high-quality outcomes |
Evaluate the relevance of quality indicators and their associated measurement strategies | Identify useful measures that can be acted on to improve outcomes and processes | Value the importance of the use of data in quality improvement |
Explain variance and its common causes in patient care process and outcomes including costs | Select and use quality improvement tools (e.g., run charts, control charts, root cause analysis, flow diagrams, and GANTT charts) to achieve best possible outcomes | Commit to reducing unwarranted variation in care |
Analyze ethical issues associated with continuous quality improvement | Participate in the design and monitoring of ethical oversight of continuous quality improvement projects Maintain confidentiality of any patient information used in quality improvement efforts | Value ethical conduct in quality improvement efforts Value the roles of others, such as IRBs, in assessing ethical and patient rights/informed decision making |
Analyze the impact of context such as access, cost, environment, workforce, team functioning, or community engagement on improvement efforts | Lead improvement efforts, taking into account context and best practices based on evidence Demonstrate commitment to process improvement | Value context (e.g., work environment, team functioning, social determinants) as an important contributor in quality care |
Understand principles of change management | Apply change management principles by using data to improve patient and systems outcomes | Appreciate that all improvement is change Demonstrate leadership in affecting the necessary change |
Evaluate the effect of planned change on outcomes | Design, implement, and evaluate small tests of change in daily work (e.g., using an experiential learning method such as Plan-Do-Study-Act) | Value planned change |
Analyze the impact of linking payment to quality improvement | Use benchmarks that carry financial penalties (e.g., serious reportable events) to improve care | Consistent with the National Quality Strategy, commit to achieving the highest quality of care in the practice setting (e.g., national strategy’s aims of better care, healthy people, and affordable care) |
Describe the intent and outcomes of public reporting | Use public reporting information to advance quality improvement efforts Appreciate that consumers will be more empowered to make decisions based on quality information | Value community engagement in quality improvement decision making |
Note: Quality improvement (QI) in the area of ethics quality focuses on ensuring that systems and processes regarding specific ethical standards are improved.
Source: American Association of Colleges of Nursing (2012).
Box 12.1
A Brief Business Case for Ethics
Doing the right thing brings business benefits by:
Increasing patient satisfaction. When organizations support ethical health care practices—for example, by encouraging clinicians to actively involve patients in decisions about their health care—patients do better clinically and say they are more satisfied with the care they receive (Kaplan, Greenfield, & Ware, 1989; Tierney, 2001).
Improving employee morale. Organizations that support ethical decision making—especially organizations whose ethics programs focus on achieving high standards instead of simply complying with policy or law (Paine, 2003)—can expect to have happier, more dedicated employees (Bischoff, DeTienne, & Quick, 1999; 1999 National Business Ethics Study, 1999).
Enhancing productivity. A strong corporate ethics culture can improve not only employee morale but also performance, and help improve an organization’s efficiency and productivity (Arthur Anderson Co., 1999; Biel, 1999; Verschoor, 1999). An effective ethics program also makes it easier to recruit and retain quality staff (Francis, 2001).
Conserving resources/avoiding costs. Effective ethics programs have been shown to improve quality of care and reduce length of stay and cost (Halloran, 1995). Supporting patients’ rights to forgo life-sustaining treatment meets an important ethical standard, and at the same time can have the effect of avoiding costs (Dowdy, Robertson, & Bander, 1998; Heilicser, Meltzer, & Siegler, 2000; Schneiderman et al., 2003).
Improving accreditation reviews. As of January 2016, The Joint Commission includes 16 standards explicitly pertaining to ethics, patient rights, and organizational responsibilities (RI.01.01.01–RI.02.01.01 and LD.04.02.03). A strong ethics program can help ensure that the organization meets or exceeds those standards (“Joint Commission Manual,” 2016).
Reducing risk of lawsuits. Organizations that make strong commitments to ethical health care practices, such as being honest with patients, can reduce the risk of litigation and liability (Kraman, & Hamm, 1999; Levinson, Roter, Mullooly, Dull, & Frankel, 1997; Vincent, Young, & Phillips, 1994).
Safeguarding the organization’s future. Lack of an effective ethics program can seriously jeopardize an organization’s reputation and even its survival (Gellerman, 2003). Creating structures and processes by which an organization can hold itself accountable to its core values and to ethical practices is an investment in the organization’s future.
LEVELS OF ETHICS QUALITY
Ethics quality should be evident, maintained, and improved throughout an ethical health care organization. The IntegratedEthics model developed by the U.S. Department of Veterans Affairs National Center for Ethics in Health Care (2007) uses the image of an iceberg (see Figure 12.1) to illustrate how ethical practices cut across three levels of the organization. In a highly ethical organization, there are strong practices at each of the three levels.
Figure 12.1, the IntegratedEthics iceberg, illustrates at the first level above the waterline, the decisions or actions of individual staff in their daily work at the bedside, in the clinic, in administration, or in the board room. The staff’s everyday decisions and actions are driven by the organization’s mission and values statements, policies and procedures, and personal and/or professional standards, and codes of ethics. When an individual or group has a question about what is the right thing to do in a given circumstance, they call upon the ethics consultation function for assistance in resolving the ethical concern.
At the second level just below the waterline in Figure 12.1, we can examine the systems and processes that guide behavior of the organizations’ staff. It is through value- and rule-based policies and procedures that the organization’s staff knows if they are doing the right thing in a consistent and measurable manner. When an individual or group notices or discovers that the systems and practices are not consistent with ethical standards, or there is a quality gap between what is being done and what should be done, they call upon the preventive ethics function to close the ethics quality gap.
At the third level, deep below the surface seen in Figure 12.1, nurses must carefully and consciously examine the environment and culture of the organization in which they practice nursing. Nurses must explore the values, understanding, assumptions, habits, and unspoken messages (what people in the organization know but rarely make explicit) as they are the foundation for everything else. What is it about some organizations that set them apart as a magnet or more desirable workplace for staff and care setting for patients? Each leader at every level of the organization has a responsibility to examine and improve the environment and culture. Leaders need to foster a positive environment and culture through what they say and do. The ethical leadership function supports leaders in this critical work.
Figure 12.1 IntegratedEthics iceberg.
Image courtesy of Uwe Kills. Used with permission.
Thus, ethics quality is the product of the interplay of factors at three levels: (a) decisions and actions, (b) systems and processes, and (c) environment and culture. Together, these three levels define the ethics quality of an organization. The IntegratedEthics iceberg model embraces a comprehensive approach to improving ethics quality by focusing on all three levels. The model is structured around three core functions, each of which targets a different level of ethics quality:
1. Ethics consultation—targets ethics quality at the level of decisions and actions
2. Preventive ethics—targets the level of systems and processes
3. Ethical leadership—targets the level of environment and culture
Questions to Consider Before Reading On
1. Which domains of health care (Box 12.2) are most prominent in my work-place?
2. How does the mission of my organization relate to each domain?
Box 12.2
Domains of Ethics in Health Care
1. Shared decision making with patients (how well the organization promotes collaborative decision making between clinicians and patients)
2. Ethical practices in end-of-life care (how well the organization addresses ethical aspects of caring for patients near the end of life)
3. Ethical practices at the beginning of life (how well the organization promotes ethical practices with respect to conception, pregnancy, and the perinatal period)
4. Patient privacy and confidentiality (how well the organization protects patient privacy and confidentiality)
5. Professionalism in patient care (how well the organization fosters behavior appropriate for health care professionals)
6. Ethical practices in resource allocation (how well the organization demonstrates fairness in allocating resources across programs, services, and patients)
7. Ethical practices in business and management (how well the organization promotes high ethical standards in its business and management practices)
8. Ethical practices in research (how well the organization ensures that its employees follow ethical standards that apply to research practices)
9. Ethical practices in the everyday workplace (how well the organization supports ethical behavior in everyday interactions in the workplace)
DOMAINS OF HEALTH CARE ETHICS
With the understanding that IntegratedEthics has three levels, let us think about the scope of the program. Within IntegratedEthics, the concept of ethics quality is very broad, crossing over clinical, organizational, and research ethics and encompassing the full range of ethical issues that all types of health care organizations including acute care hospitals, rehabilitation hospitals, outpatient facilities, nursing homes, home care organizations, and large health care systems encounter. IntegratedEthics defines for the organization domains of ethics in health care and specific topics within each content domain and recognizes that there may be additional domains that are relevant to an organization based on its particular mission (National Center for Ethics in Health Care, 2014b). For example, the Department of Veterans Affairs has special responsibilities by virtue of its role as a government organization, and for that reason has added the domain of “ethical practices in government service (how well the organization fosters behavior appropriate for government employees).” Additional domains derived from special mission-specific responsibilities might include, for example the following:
Ethical practices in mission integration (how well the organization manages the relationship between individual values and the values of Catholic health care)
Ethical practices in military medicine (how well the organization ensures that its employees follow ethical standards that apply to military medicine)
Ethical practices in occupational medicine (how well the organization manages conflicting ethical responsibilities to workers, employers, and the public)
A listing of the domains of ethics in health care is found in Box 12.2.
WHAT IS THE GOAL OF THE INTEGRATEDETHICS PROGRAM?
IntegratedEthics is a transformational idea that redefines ethics as it is practiced in the health care arena. The goal of IntegratedEthics is to move ethics into the organizational mainstream and to ensure that there is high ethics quality at all three levels of the organization. To achieve this goal, staff must coordinate ethics-related activities throughout the organization. This requires more than simply implementing the three core functions in a single work unit as is described in this chapter. It also requires strong leadership support, involvement of multiple programs, and clear lines of accountability as well as policy and evaluation. (A description of these requirements is beyond the scope of this chapter but further information is available at www.ethics.va.gov/integratedethics/index.asp.)
Questions to Consider Before Reading On
1. Do we have an ethics consultation team or committee in my organization?
2. How have or could I use this team or committee to resolve an ethical concern?
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