1 Colegio de San Agustin-Bacolod College of Health & Allied Professionals.

HEALTHCARE ETHICS

MODULE 2:
ETHICS IN NURSING
LEADERSHIP
INTRODUCTION

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). 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).

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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).

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).

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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

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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).
https://nursekey.com/applying-ethics-to-the-leadership-role-3/
Worth some thoughtful reflections..

“The nurse director/manager position is critical to organizational

success, patient outcomes, and nurse empowerment”
In the current Pandemic, what challenges do you thnk a NURSE
LEADER faces to be able to achieve success, outcomes &
empowerment ing the workplace?

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Ethical Model
An Ethical Model for Reflection: Questions to Consider
Frameworks or models can help people order their approach to an ethical problem or concern,
and they can be a useful tool to guide nurses in their thinking about a particular issue or question.
When it is appropriate, colleagues in nursing and other disciplines, ethics committees, ethicists,
professional nurses associations and colleges of nurses and other experts will be included in
discussions of ethical problems. Legislation, standards of practice, policies and guidelines of
nurses’ unions and professional associations and colleges may also be useful in ethical reflection
and decision-making.
Ethical reflection (which begins with a review of one’s own ethics and judgment) is required to
determine how a particular value or responsibility applies in a particular nursing context. There
is room within the profession for disagreement among nurses about the relative weight of
different ethical values and principles. More than one proposed intervention may be ethical and
reflective of good ethical practice. Discussion and questioning are extremely helpful in the
resolution of ethical problems and issues.
Ethical models can facilitate discussion among team members by opening up a moral space for
everyone to participate in the conversation about ethics. There are many models for ethical
reflection and for ethical decision-making in the health-care ethics literature, and some of these
are noted in this section.

Oberle and Raffin Model

Questions for Ethical Reflection
1. Assessing the ethics of the situation, relationships, goals, beliefs and values
• What relationships are inherent in the situation?
• Who is significant in this care situation, and how could they be involved?
• Are my relationships with others in this care situation supportive and nurturing?
• What are the goals of care in this situation?
• Are these goals shared by the person in care, the nurse and others?
• What are my beliefs and values?
• What values in the Code are inherent in this situation?
• What values are important for others in the situation, including other health-care providers?

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• Do the individuals involved in the situation have different values? Do the differences create
conflict?
2. Reflecting on and reviewing potential actions: Recognizing available choices and how these
choices are valued
• What expectation does the person/family/community have for care?
What actions do the person/family/community think will do the most good? Have I helped this
person/family/community become clear about what they value and the actions they think will be
taken?
• What action(s) do I think will do the most good? What do other health-care providers think?
• What action(s) will cause the least amount of value conflict and/or moral distress? What are the
potential consequences of the actions? How will key persons be affected?
• What values does society view as important in this situation? What are societal expectations of
care?
• What economic and political factors play a role in the person’s care? What actions are possible
given the existing resources and constraints?
• What legislation applies to this situation in terms of my obligations, the institution’s obligations
and the obligations of other health-care providers? Are there legal implications for different
actions?
3. Selecting an ethical action: Maximizing the good
• What do I believe is the best action?
• Can I support the patient’s/family’s/community’s choice? The choice of other care providers?
If not, what actions do I need to take?
• Are there constraints that might prevent me from taking ethical action?
• Do I have the kind of virtues required to take ethical action? Do I have the necessary
knowledge and skill?
• Do I have the moral courage to carry out the action I believe is best? Will I be supported in my
decision?
4. Engaging in ethical action
• Am I acting according to the Code? • Am I practising the way a reasonably prudent nurse
would practise in this situation?
• Am I acting with care and compassion in my relationships with others in this situation?
• Am I meeting professional and institutional expectations in this action?

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5. Reflecting on and reviewing this ethical action

• Did I report it through the appropriate channels?
• Were the outcomes of this action acceptable?
• Was the process of decision-making and action acceptable? Did all involved feel respected and
valued?
• How was the person/family/community affected? How were the care providers affected?
• Were harms minimized and was good maximized?
• What did I do well?
• What might have been done

MORAL DECISON MAKING

MORAL RESILIENCY
BY : Vicki Lachman, MIDSURG Nursing, March-April 2016, VOL 25, No.2
Morally resilient people also have developed self-confidence by confronting such situations so
they can maintain their self-esteem, no matter what life delivers. Finally, the ability to adapt to
changing circum- stances with a sense of humor is at the heart of their flexibility. Morally
resilient nurses are not naïve about the price of moral integrity. They know it does not come
without pain of dealing with adversity, but they believe the virtue of moral courage is necessary
to meet the eth- ical obligations of their profession (ANA, 2015b).
What Is Moral Resilience? The Merriam-Webster Dictionary (2015b) defined moral as
“concerning or relating to what is right and wrong in human behavior; considered right and good
by most people: agreeing with a standard of right behavior” (para. 1). Though the term moral
resilience was used in numerous publications, no definition was offered (Monteverde, 2014;
Rushton et al., 2015; Rushton & Kurtz, 2015). This author defines moral resilience as the ability
and willingness to speak and take right and good action in the face of an adversity that is
moral/ethical in nature. Lessons learned from military combat situations are instructive in further
understanding the application of moral resilience to nursing clinical situations (American Nurses
Association [ANA], 2015a; Litz et al., 2009).

Why Is Moral Resilience Key in Dealing with Moral Complexity?

Litz and colleagues (2009) defined moral injury as an injury suffered as a result of “perpetrating,
failing to pre- vent, or bearing witness to acts that transgress deeply held moral beliefs and
expectations” (p. 296). The harm done by moral injury comes from its ability to “shatter an
individual’s beliefs about the purpose and meaning of life, challenge belief in God, induce moral
conflict, and even precipitate an existential crisis” (p. 296). Service members, as well as nurses,
may experience moral injury from two sources. First, they may witness or do something that

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violates their moral code. For example, the nurse failed to prevent the intervention in the futility
case, creating a moral conflict that left her with moral residue. Second, individuals may become
so entrenched in the culture in which they work that their moral code begins to incorporate
elements of their host culture (Markus & Kitayama, 2003; Monteverde, 2014; Snow, 2009;
Zimbardo, 2007). What becomes normal clinical practice can violate compassionate, evidence-
based care of patients in some unit/organizational cul- tures. Extensive arguments have been
offered by situa- tional philosophers and social psychologists that moral character will be traded
for situational acceptance. Monteverde (2014) and Erdil and Korkmax (2009) called for new
ethics education for nurses; both identified the influence of the so-called hidden or informal
curricu- lum to which students are exposed during clinical prac- tice. Practicing nurses are
exposed to the same organiza- tional culture that deals compassionately with difficult patients,
confronts patient safety issues, supports patient advance directives, or does not. Resilient people
employ transformational coping strategies of understanding and contextualizing the cir-
cumstances of the situation. They see the reality of the culture in which they work and
sometimes must take action that does not support the cultural norm. They couple this with
situation-focused problem solving to reframe the event in terms of a challenge over which they
have some level of control. Resilience is cultivated when nurses are able to frame their
experiences contex- tually in environments with different, even competing moral systems while
maintaining a healthy sense of commitment, control, and challenge.

Moral resilience is the ability to deal with an ethically adverse situation without
lasting effects of moral dis- tress and moral residue. This requires morally coura-
geous action, activating needed supports and doing the right thing

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Van Den Berg (2004) defined prestige resilience as “the set of reactive attitudes, which allows a
person to cope with the per- manent public presence of cultural others, without harming or
denying her own identity” (p. 197). According to Litz and co-authors (2009), …the idea is not to
try and fix the past, but rather to draw a firm line around the past and its related associations, so
that the mistakes of the past do not define the present and the future and so that a pre-occupation
with the past does not prevent possible future good. (p. 704) Do morally resilient nurses manage
moral distress sit- uations in clinical practice differently, avoiding moral residue that erodes their
moral integrity? As Epstein and Hamric (2009) noted in their research, the answer to this
question is unknown. Mealer and colleagues (2012) commented, “…future research is needed to
better understand coping mechanisms employed by highly resilient nurses and how they maintain
a healthier psy- chological profile” (p. 292). This author believes research on the development of
resilience could yield promising ways to combat moral distress and moral residue, as well as
better understand the development of moral courage and moral resilience (Mealer et al, 2012;
Monteverde, 2014; Moore, 2014; Rushton et al., 2015; Wagnild, 2014). Because resilience can
be learned, an individual needs to understand what characteristics are most important to develop.

What Other Attributes Needed to Build Moral Resilience?

Using the work of Conner and Davidson (2003) from the development of their resilience scale
(CD-RISC), Wagnild’s (2014) work on the True Resilience Scale Survey (TRS), and other
references in this article, this author adds to the Earvolino-Ramirez (2007) concept analysis of
resilience six attributes most relevant to moral resilience. Considerable overlap exists in
characteristics, and the fol- lowing statements from the resilience scales address the importance
of clarity of beliefs:
• “I stay true to myself even when I’m afraid to do so.” (TRS)
• “My deeply held values guide my choices.” (TRS)
• “I make decisions that are consistent with my beliefs.” (TRS)
• “I know what’s most important to me and this knowledge guides my life.” (TRS)
• “Make unpopular decisions.” (CD-RISC)
• “Can handle unpleasant feelings.” (CD-RISC) In the case, the nurse did not stay true to the
personal belief of patient advocacy and was left with the moral residue of guilt. All authors on
resilience address the importance of perseverance. Below are three quotations from the two
scales and a book that reflect its importance for moral resilience.
• “Even if I don’t feel like it, I do what I need to do.” (TRS)
• “Best effort no matter what.” (CD-RISC)
• “Perseverance means you don’t give up easily on any- thing.” (Wagnild, 2014, p. 13) These
behaviors, plus the six attributes mentioned by Earvolino-Ramirez (2007), are the traits that
should be developed by nurses for moral resilience.

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What Can Leaders Do to Increase Moral Resilience in the Workplace?

The resilience of leaders influences the resilience of the people they lead. Allison-Napolitano
and Pesut (2015) created a model for resilient leaders and dis- cussed the subject in depth. What
follows are three ways leaders can influence moral resilience in a constantly changing, morally
complex health care system. 1. Engage in interprofessional dialogue in truly com- plex cases in
a seminar format. This allows members to explore their peers’ methods for engaging in the case.
The focus of this effort is on enabling members to revisit past trauma to develop appreciation of
the appropriate context in which trauma occurred by countering the tendency to universalize, and
regain a sense of themselves as competent moral agents. 2. Leaders and staff formulate policies
and priorities that reinforce the requirement to verbalize concerns in morally complex cases,
without the possibility of retribution. 3. Leaders routinely consider the directives they give. Their
talk and actions need to be synchronous with a culture that supports an ethical work environment.
The advice and counsel they offer, the stories they tell, and perhaps most importantly the
examples they provide may indeed alter the manner in which individuals interpret and make
sense of their experi- ences in morally complex cases.

Problem-based learning (PBL)

an instructional method in which students learn through
facilitated problem solving. In PBL, student learning centers on
a complex problem that doesnot have a single correct answer.

Students work in collaborative groups to identify what they need

to learn in order to solve a problem. They engage in self-directed
learning (SDL) and then apply their new knowledge to
theproblem and reflect on what they learned and the
effectiveness of the strategies employed.

In our MODULE 2, we shall endeavor to move further understanding ETHICS in the context of
leadership in Nursing Practic. We will have less lecture times this week and more on
collaborative activities and concept engagement.

MODULE 2. NCM 108 Endterm Coverage Eden Shiz Parpa, RN,MAN