CHAPTER SIX Leadership ethics in nursing and health care domains
INTRODUCTION
The primary mission of health care organisations today is to deliver safe, appropriate, high quality and viable health care serves to individuals and groups in the communities they serve. Whether a health care organisation will be able to fulfil its mission and remain economically viable (as well as accessible to its target patient populations) in today’s rapidly changing social-cultural climate, and whether it will be able to ‘plan for and respond appropriately to marketplace forces, while maintaining a coherent vision of its values and their meaning’, will depend ultimately on the ethics of its leadership (Spencer et al. 2000, p.10). Indeed, there is an emerging consensus that ethical leadership is crucial for the future survival, viability and flourishing of health care (Spencer et al. 2000) and, it should be added, the nursing services upon which health care depends.
Although leadership ethics is of obvious importance to those working in the fields of nursing and health care, curiously little has been written on the topic in the nursing, health professional or bioethics literature. One reason for this might be that many think that ethics in general, and leadership ethics in particular, is a matter of ‘practical knowledge, not theoretical knowledge [and] that practical knowledge and common sense (and exemplary moral character) are adequate for discussion on ethics in their particular field’ (Ciulla 1998c, p.5). However, leadership ethics in general and nursing leadership ethics in particular requires much more than practical know-how and commonsense. While these things are necessary and important to the realisation of the means and ends of ethical leadership in nursing and health care domains, they are not sufficient. Other characteristics, knowledge and behaviours are also required, as this chapter will attempt to show.
In the discussion to follow, brief attention will be given to:
clarifying the nature of leadership ethics in nursing and health care domains, and the relationship between ethical leadership and effective leadership;
LEADERSHIP ETHICS IN NURSING AND HEALTH CARE DOMAINS
In beginning this discussion, it is important to clarify that leadership ethics is distinct from—and ought to be distinguished from—other (albeit related) sub-fields of ethics such as business ethics, management ethics, health care ethics, medical ethics and nursing ethics. In contradistinction to these other sub-fields, leadership ethics is a relatively new field of inquiry that has as its focus a set of ethical issues that are distinctive to the field of leadership, hence the notion ‘leadership ethics’. According to Ciulla (1998c), leadership ethics may be defined as:
The study of ethical issues related to leadership and the ethics of leadership. The study generally consists of the examination of right, wrong, good, evil, virtue, duty, obligation, rights, justice, fairness, and so on, in human relationships with each other and other living things (Ciulla 1998c, p.4). [emphasis added]
A distinguishing feature of leadership ethics is the profound relationship that exists between ethical leadership and effective leadership. One author has even suggested that ‘ethics lies at the very heart of leadership’ and that without ethics there can be no leadership, only ‘mis-leadership’ of the kind exemplified by Adolf Hitler (Ciulla 1998b, p. xv). Ciulla explains:
Managers and generals can act like playground bullies and use their power and rank force to force their will on people, but this is coercion [tyranny], not leadership. Leadership is not a person or a position. It is a complex moral relationship between people, based on trust, obligation, commitment, emotion, and a shared vision of the good (Ciulla (1998b, p. xv). [emphasis added]
In several respects, ethical leadership is synonymous with effective leadership. This is because many of the key characteristics of ethical leadership (to be discussed in more detail in the next section) are also the characteristics of effective leadership. As discussed in the previous chapters of this book, leadership is first and foremost about vision and transformation. Improvement in any organisation or system requires transformation or change since the very nature of improvement involves ‘departure from the status quo’ (DuBrin 2000, p.5). A key and critical goal of any leader is to guide the people they work with (otherwise known as their constituents) to develop robust adaptation to new challenges and to foster in them an enduring resilience that will enable them to deal effectively (not merely cope) with other future challenges (Heifetz 1994).
trustworthiness (worthy of being trusted; that is, honest, reliable, and dependable) (adapted from DuBrin 2000, p.70; Ciulla 1998a).Effective leadership involves the ethical influence of other people to realise a vision and achieve positive and constructive change that is of moral benefit to stakeholders. In many important respects (on account of the moral importance of health itself), nursing and health care leaders have a special and perhaps greater obligation to influence transformational change in the organisations and systems in which they work, and thereby challenge and change the status quo—especially in regard to the provision of high quality health care services to the individuals, groups and communities they serve (Johnstone, 2002a; 2002c).
SEVEN KEY CHARACTERISTICS OF ETHICAL LEADERSHIP
According to DuBrin (2000), most people want their leaders to be ethical. An important question to be raised here is: What are the characteristics of ethical leadership?
There are at least seven key characteristics of ethical leadership. In summary, these are:
Moral conduct and adherence to ethical standards
Conduct is literally the manner in which a person behaves or, to put it more simply, a person’s behaviour. Moral conduct, by this view, refers to moral behaviour; that is, behaviour which accords with sound standards of ethics. Moral conduct thus presupposes the existence of—and the personal adoption of and strict adherence to—certain ethical standards of behaviour (Beauchamp & Childress 2001; Johnstone 1999).
Moral purpose (moral vision and commitment to achieving moral ends)
Purpose may be defined as the intention and determination to do something. Moral purpose, in turn, may be defined as the moral intention to achieve something moral; in this instance, a moral vision keyed to the achievement of certain desirable moral ends. According to Krause (1997):
In working to achieve his or her vision, the moral leader:
Moral accomplishment (achieving desirable moral outcomes)
Action may be defined as the state or process of doing something. Moral action, in turn, may be defined as something (that is, some physical process, preceded by an act of moral will; an occurrence effected by the volition of a human agent) that someone does in order to achieve a desirable moral outcome.
As stated above, moral action is not merely a thought about doing something. For instance, thinking that such-and-such is the right thing to do is not the same as actually doing it. Merely thinking: ‘I should develop a policy on conscientious objection to be implemented in my workplace’ is not the same as actually drafting a policy on conscientious objection, submitting it to the relevant authorities for approval, and overseeing its implementation in the workplace once approved. Moral action, in contrast to a mere thought of moral action, is the ‘deed done’. It is the physical process that occurs as a direct consequence of a given thought-to-action. Although moral action and moral thought are closely connected, it is the deed done that ultimately distinguishes a moral action from the mere thought of moral action (Johnstone 2002c).
Moral accomplishment (and the achievement of desirable moral ends) requires knowledge and skill. Not only must a moral leader know that (e.g. that a certain moral action is required) but also know how (e.g. how to go about achieving the desirable moral end). Knowing how, in turn, requires practical knowledge of applied ethics (see, for example, Beauchamp & Childress 2001; Johnstone 1999), not merely knowledge about leadership.
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