Discussion: Ethics And Healthcare Delivery
Undisputedly, the United States’ health care sys- tem is in the midst of unprecedented complexi- ty and transformation. In 2014 alone there were
well over thirty-five million admissions to hospitals in the nation,1 indicating that there was an extraordinary number of very sick and frail people requiring highly skilled clinicians to manage and coordinate their com- plex care across multiple care settings. Medical advances give us the ability to send patients home more efficiently than ever before and simultaneously create ethical ques- tions about the balance of benefits and burdens associ- ated with these advances. New treatments for cancer or complex heart disease may prolong life until the disease becomes irreversible while causing significant morbidity that undermines functional status, independence, and quality of life in ways that patients find unacceptable. Some patients and families voice concerns about access to treatments and about the quality and safety of the care they or their loved ones receive.
Every day on every shift, nurses at the bedside feel these pressures and the intense array of ethical issues that they raise. A staggering 17.5 percent of trained nurses are leaving their roles or the profession after less than one year of service,2 and increasing levels of moral distress and burnout contribute to their decisions.3 Meanwhile, research supports the common-sense understanding that patients and health care organizations fare better when nurses are not harried, are supported in their work en- vironments, and are able to practice high-quality, ethical care.
At the same time, administrators, policy-makers, and regulators struggle to balance commitments to patients, families, staff members, and governing boards. Health care organizations are compelled by laws, regulations, and accrediting bodies to pursue externally reported measures of effectiveness that can put their mission and values at risk. While health care systems declare their commitment to core ethical values, many clinicians struggle to understand institutional priorities, budgets, policies, and decisions seemingly inconsistent with their values as professionals.
Increasingly clinicians find their ability to provide compassionate care at odds with the intensifying focus on matters such as clinical pathways aimed at standard- izing care, cost-cutting efficiencies, electronic medical records, and hospital policies and procedures.4 Arguably, each of these have merit in the current system, but what is not accounted for are the unintended consequences of diverting attention from the core ethical values of the professions. For example, the advent of the EMR requires clinicians to focus on documentation rather than being fully present during patient encounters. An emphasis on clinical pathways increases the risk of reducing patient symptoms and diseases to what fits a rote application of protocols rather than providing individualized care, and demands to expedite patient flow in hospitals—shorten- ing stays, for instance—can imperil respect for patient readiness to assume responsibility for complex treatment protocols. Although pressed to meet fiduciary responsi- bilities to the institutions in which they practice, most clinicians remain committed to their ethical responsibili- ties to reduce harms, promote patient-focused goals, and provide high-quality care. These ethical responsibilities and the fiduciary, regulatory, and community service goals of health care institutions are not mutually exclu-
Creating a Culture of Ethical Practice in Health Care Delivery Systems
By cynDA hylTon ruShTon
Cynda Hylton Rushton, “Creating a Culture of Ethical Practice in Health Care Delivery Systems,” Nurses at the Table: Nursing, Ethics, and Health Policy, special report, Hastings Center Report 46, no. 5 (2016): S28-S31. DOI: 10.1002/hast.628
S29SPECIAL REPORT: Nurses a t the Tab le : Nurs ing , E th ics , and Hea l th Po l i cy
sive; they must go hand in hand. If they do not, our health care system will continue to lose valued professionals to moral distress, risk breaking the public’s trust, and poten- tially undermine patient care.
At this critical juncture in health care, we must look to new paradigms, tools, and skills to confront contemporary ethical issues that impact clinical practice. The antidote to the current reality is to create a new health care para- digm grounded in compassion and sustained by a culture of ethical practice.
What Is a Culture of Ethical Practice?
Imagine, for a moment, a health care system where pa- tients and the clinicians who care for them are able to
navigate the often uncertain and frightening territory of illness, recovery, and death with dignity, respect, and in- tegrity. A culture of ethical practice is comprised of the values, norms, and structures that support moral agency and integrity. It transforms clinical practice from a system punctuated by moral distress and burnout to one of mor- al resilience.5 Consonant with a person-centered model of health care, the voices of patients, their families, and members of the health care team are engaged and respect- ed. The culture aligns individual and organizational val- ues, decision-making practices, and priorities to create an environment where ethical values are used as benchmarks to assess alignment, progress, and gaps. Threats to patient safety are identified without reprisal against or reprimand of the party who reports them; financial incentives and expenditures are driven by ethical values, not by compli- ance or data alone. The alignment between the values of the organization and those of the individuals who practice within it results in a shared commitment to quality, safe, and ethically grounded care.
Why Is Nursing Central to a Culture of Ethical Practice?
The voice of nursing is essential to illuminate the in- timate, complex, and subtle contours of the ethical
conflicts that arise in daily practice. The 3.2 million nurses in the United States represent the largest segment of the health care workforce and are the professionals who are
most consistently involved at the bedside. Whether they care directly for patients or work in education, innovation, discovery, or policy development for the profession, nurses are repeatedly identified as the most trusted professionals in health care.6 The public’s trust in their integrity creates a profound responsibility and opportunity for nurses to recognize and address ethical issues. In diverse and rap- idly changing practice environments, one core principle holds constant: nurses’ desire to serve their patients, their patients’ families, and their communities while fulfilling nursing’s values.
As the de facto integrators of the health care system, nurses work to provide competency-based care, enact goals of care across care settings, and navigate divergent treatment plans and organizational policies. Their exper- tise is vital in designing effective care delivery models and promoting patient outcomes. As in the U.S. Ebola experi- ence, nurses are often the first to recognize unsafe situa- tions. Practicing at the point of care, nurses are intimate witnesses to the pain, suffering, and hope of the people they serve. Without nurses, the entire health care system would collapse.
Yet many systems fail to fully leverage the knowledge, skills, and abilities of nurses.7 As a prime budgetary line item, nursing is often the first place cuts are proposed. Chief nursing officers across the country report that they are asked to justify nurse-patient ratios and implement “across-the-board” cuts without accounting for the con- tributions nurses make to patient outcomes. In part, this reflects the vestiges of antiquated hierarchical systems that obscure the value of a profession that is still predominately female and, even within nursing itself, relegates nursing to “following doctors’ orders” or constrains the nursing role. Too often, power disparities, different knowledge para- digms, and divergent views of treatment plans fuel conflict and undermine teamwork.
What Is Nursing Leadership Doing to Create a Culture of Ethical Practice?
The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (2015)8
outlines nurses’ ethical obligations to care for every per- son with respect, dignity, compassion, and fairness. It also
Creating a culture of ethical practice involves major shifts within organizations —from silence to giving voice to all stakeholders,
from hierarchy to collaboration, from disparity to fairness, from victimization to principled moral agency.
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mandates that nurses have an obligation to contribute to a culture that supports ethical practice and preserves the integrity of the profession and the well-being and integrity of the individual nurse. Contributing to a culture of ethical practice is not optional: it is required of all nurses.
In 2014, the National Nursing Ethics Summit,9 con- vened by the Johns Hopkins University Berman Institute of Bioethics and the School of Nursing, identified sustain- ing a culture of ethical practice as a unifying theme. Its recommendations are reflected in the “Blueprint for 21st Century Nursing Ethics” (http://www.bioethicsinstitute. org/nursing-ethics-summit-report). The pledge, signed by the summit’s strategic partners and other nursing organi- zations representing more than 700,000 individuals, calls for solidarity in working together to create a culture where nurses and all health care professionals can practice ethi- cally. It was recognized that there is a vital interplay among nurses’ competence in ethics, the environments where they practice, and the culture that either supports or constrains integrity and ethical behavior. This means that there is a need for ongoing education to build ethical competence; unbridled access to ethics resources, such as ethics con- sultants; representation at all levels of organizational op- erations and governance; and the development of a robust organizational ethics infrastructure.
Many of the summit’s goals are exemplified by nursing leadership at Massachusetts General Hospital. To create the ethics infrastructure, the chief nurse and senior vice presi- dent for patient care designed and implemented what the hospital calls a “Collaborative Governance” communica- tion and decision-making structure. Within this structure is an Ethics in Clinical Practice Committee, which brings together, from across the organization, nurses and other health professionals from the interprofessional team in di- rect care roles for the purposes of sharing ethically challeng- ing experiences in their practice; learning the language of ethical discourse; teaching clinicians, patients, and families about advance-care planning; and making recommenda- tions for policies that can positively affect ethical care in the organization. Additionally, they are charged with im- plementing and evaluating a clinical ethics residency for nurses supported by the health resources services admin- istration,10 conducting regular ethics rounds on clinical units, and developing evidence-informed policies aimed at supporting patient care and professional integrity.11
Other efforts are under way, including those at organi- zations that have achieved Magnet status, granted by the American Nurses Credentialing Center.12 As Magnet orga- nizations, these institutions are recognized for their support for nurses that allows them to practice at the full extent of their training and to contribute meaningfully to organi- zational priorities, policies, and research agendas.13 They acknowledge that the pathway to positive patient experi- ence and beneficial outcomes (including the bottom line) is to seek a balanced approach that identifies efficiencies, retools business practices and business lines, and reduces nonlabor costs rather than making across-the-board cuts of nursing personnel and support staffs. Embedded in the
Ten Actions Health Care Organizations Can Take to Support a Culture of Ethical Practice
1. Foster individual, professional, and organizational commitment to ethical values with accountability across all stakeholders, from trustees and governing boards to leadership and frontline staff; identify ethical practice as a core value.
2. Commit to a culture of ethical practice as a priority by monitoring progress on the organization’s performance dashboard and allocating a proportion of the budget to ethics infrastructure.
3. Develop and sustain institutional roles and mecha- nisms, such as ombudsmen and surveillance and re- porting systems, that make it safe for nurses and others to speak up about unethical practices.
4. Develop conscientious objection and refusal policies that go beyond the Joint Commission’s regulations* to create meaningful and accessible mechanisms and ad- vocate their widespread use.
5. Develop mechanisms to engage staff members in cocreating system solutions for problems that may un- dermine their ability to practice ethically.
6. Invest in interprofessional ethics committees and clinical consultation services led or co-led by nurses, with unbridled access by all members of the interpro- fessional team, patients, and families.
7. Establish nonnegotiable, no-opt-out accountability norms for leaders, clinicians, and staff members to pre- vent or remediate instances of reprisal, disrespect, or dismissal of ethical concerns.
8. Allocate resources to support interprofessional attain- ment of ethical competence, self-regulatory capacities, communication and teamwork, conflict management, personal health and well-being, and related goals.
9. Provide mechanisms and resources for recognizing and addressing moral distress among members of the interprofessional team to promote moral resilience.
10. Collaborate with interprofessional societies, mem- ber organizations, community and health care net- works, policy-makers, and regulatory bodies to devise policies that support a culture of ethical practice.
*Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Hospitals (Chicago, IL: Joint Commission Resources, 2015).
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Magnet standards are requirements for evidence of nursing leadership in addressing clinical and organizational ethical concerns and policies.
What Guides the Path Forward?
To move forward, we need more nurses in leadership of all levels, in roles equal in authority to those of other
executive leaders and clinicians, on governing boards, key committees, and organizational initiatives and in policy development. Organizationally, nursing must have access and report directly to the chief executive officer, particu- larly with regard to quality and safety and ethical concerns.
Second is a full-spectrum approach to intentionally de- sign systems and processes that systematically shift under- lying structures, norms, and policies to produce the desired results.14 Such an approach engages all stakeholders to ar- ticulate the values that make up their moral compass; it le- verages those shared values as the foundation for designing new ways of communicating, working together, resolving conflicts, and addressing the root causes of misalignment in the current system. A culture of ethical practice priori- tizes ethics as central to the organization’s mission and op- erations and creates mechanisms that allow individuals to recognize and speak up about ethical concerns and to take principled action to address them. Building such a culture requires that an organization establish norms and account- ability for ethical dialogue and action, invest in resources to support clinical and leadership decision-making and conflict management, and design systems to detect and ad- dress ethical issues through processes such as quality im- provement, root-cause analysis, and ethics rounds. These and other interdisciplinary and cross-organizational efforts require strong impact evaluations and dissemination plans.
Creating a culture of ethical practice involves major shifts within organizations, including shifts from silence to giving voice to all stakeholders, from hierarchy to col- laboration, from disparity to fairness, from victimization to principled moral agency. When the culture shifts, indi- vidual behaviors also change in ways that make it possible to discover the root causes (commonly, patterns of behavior and decision-making) of system misalignment and to cre- ate a plan to address them, using techniques and interven- tions such as those listed in table 1.
By aligning the values of the organization and the indi- viduals who practice within it, the full spectrum approach ends partial solutions and decisions based on efficiency
measures alone and creates a shared commitment to safe, quality, ethically grounded care.
Individually, nurses are positioned to leverage their ethi- cal commitments to produce meaningful change in their daily practice. Collectively, nurses stand ready to collabo- rate with interprofessional colleagues and health system leaders to create a culture of ethical practice, as the ANA Code of Ethics for Nurses and the National Nursing Ethics Summit attest.
1. American Hospitals Association, “Fast Facts on U.S. Hospitals,” January 2016, at http://www.aha.org/research/rc/stat-studies/fast- facts.shtml.
2. C. T. Kovner et al., “What Does Nurse Turnover Rate Mean and What Is the Rate?,” Policy, Politics, and Nursing Practice 15, nos. 3-4 (2014): 64-71.
3. K. M. Gutierrez, “Critical Care Nurses’ Perceptions of and Responses to Moral Distress,” Dimensions of Critical Care Nursing 24 no. 5 (2005): 229-41.
4. J. Summer and J. Townsend-Rocchiccioli, “Why Are Nurses Leaving Nursing?,” Nursing Administration Quarterly 27, no. 2 (2003): 164-71.
5. C. Rushton, “Moral Resilience: A Capacity for Navigating Ethical Challenges in Critical Care,” AACN Advanced Critical Care 27, no. 1 (2016): 111-19.
6. Gallup, “Americans Rate Nurses Highest on Honesty, Ethical Standards,” December 2014, http://www.gallup.com/poll/180260/ americans-rate-nurses-highest-honesty-ethical-standards.aspx.
7. Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health (Washington, D.C.: National Academies Press, 2010).
8. American Nurses Association, Code of Ethics for Nurses with Interpretative Statements (Silver Spring, MD: American Nurses Association, 2015).
9. National Nursing Summit, “A Blueprint for 21st Century Nursing Ethics: Report of the National Nursing Summit,” January 2016, http://www.bioethicsinstitute.org/nursing-ethics-summit- report.
10. P. J. Grace et al., “Clinical Ethics Residency for Nurses: An Education Model to Decrease Moral Distress and Strengthen Nurse Retention in Acute Care,” Journal of Nursing Administration 44 (2014): 640-46.
11. A. M. Courtwright et al., “Experience with a Hospital Policy on Not Offering Cardiopulmonary Resuscitation When Believed More Harmful than Beneficial,” Journal of Critical Care 30, no. 1 (2014), 173-77.
12. American Nurses Credentialing Center, 2014 Magnet Application Manual (Silver Spring, MD: American Nurses Credentialing Center, 2013).
13. E. Fox et al., “Integrated Ethics: Improving Ethics Quality in Health Care,” National Center for Ethics in Health Care, Veterans Health Administration, accessed August 12, 2016, at http://www. ethics.va.gov/elprimer.pdf.
14. J. F. Stichler, “Healthy, Healthful, and Healing Environments: A Nursing Imperative,” Critical Care Nursing Quarterly 32, no. 3 (2009): 176-88.
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