Legal / Ethics

Creating ethical environments in nursing

A nurse fails to implement treatments for a patient, yet documents that she provided such care.
Administrators pressure nursing faculty members to falsify student grades.
A nursing leader urges a nurse-researcher to engage in scientific misconduct so as to improve the odds of obtaining funding.
An administrator intimidates staff nurses into showing administrators they’re willing to do as directed—even though the direction is unethical.
As morally wrong as these situations seem, they do arise—and create ethical conflicts in nursing practice, academia, and research settings. The nursing shortage, financial constraints, healthcare consolidation, and ineffective leadership have intensified such ethical dilemmas.
Now more than ever, health­care and academic leaders must demonstrate consistently high professional and ethical standards. They must foster environments that ensure individual ethical behavior and practices while providing high-quality, cost-effective health care and education.

What exactly is an ethical environment?
An ethical environment is one in which:
• individuals are aware of the work they perform and understand how the work environment influences their ability to raise questions about ethical concerns
• individuals are aware of an ethical culture
• institutional policies and procedures address ethical principles
• purposeful discussions of ethics take place
• identifiable behavioral expectations are provided.
To create and sustain an ethical environment, leaders must emphasize and demonstrate ethical principles, such as doing good and having respect for others—and must continually act as catalysts for creating and upholding such an environment.

Effect of an ethical environment on job satisfaction, retention, and patient outcomes
Research shows that nurses who have a mechanism for discussing workplace ethics are more likely to be satisfied with their jobs and to recommend their employer to other nurses seeking jobs. Also, nurses whose leaders acknowledge ethical concerns and support them in these concerns perceive their ethical environments as much more positive. And those who perceive their environment as ethical are more likely to report wrongdoing without fear of reprisal. What’s more, nurses view an ethical environment as the most important factor in helping them perform their jobs in a way they believe provides the greatest benefit to patients.

The role leaders play
Strong leadership is essential to producing and sustaining an ethical environment. As individuals, each nurse is subject to countless influences, including other people and environments. When leaders expect and consistently demonstrate the highest professional and personal standards of conduct and ethical behaviors, individuals can realize their greatest potential. Conversely, when standards are unclear and questionable behaviors are tolerated or even encouraged, individuals may find themselves questioning profoundly held values.
For this reason, leaders must remain on guard constantly to ensure an ethical environment. Once standards are set, even the slightest divergence can be troublesome. Ethical violations send the message that behaviors previously deemed improper may now be acceptable. If one individual demonstrates dishonest or untrustworthy behavior or fails to comply with rules and regulations, others may conclude that such behavior is now acceptable—especially if that person is a top performer or respected leader. Unless leaders take appropriate action to address unethical behaviors, the system designed to define ethical conduct and promote an ethical environment will collapse.

How leaders can promote an ethical environment
Leaders in healthcare organizations can promote an ethical environment by:
• including ethical standards of behavior and practice (such as the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements) in job descriptions
• defining the scope of professional responsibilities for participation in ethical situations—for example, by identifying what’s expected of nurses who observe unethical behaviors
• encouraging and supporting open expression of ethical concerns—for instance, by using ethics committees and nursing ethics consultants when nurses confront ethical dilemmas
• making ethics resources (such as an ethics committee) available for open discussion of ethical concerns without fear of retribution
• establishing an anonymous mechanism that safeguards employees who wish to raise ethical concerns.

Maintaining ethical vigilance
In 2006, nurses topped the list of trusted professionals in Gallup’s annual survey of public perceptions of honesty and ethics. Not only are we the single largest group of healthcare personnel; we also make up a large percentage of professionals in academic and research settings. Only by practicing ethically at all times can we ensure that the highest ethical standards are upheld continually.


Selected references
American College of Healthcare Executives. Creating an ethical environment for employees. Available at: www.ache.org/policy/environ.cfm. Accessed August 8, 2007.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Available at: www.nursingworld.org/ethics/ecode.htm. Accessed August 8, 2007.
Cialdini R. Creating an ethical environment. Available at: www.insideinfluence.com/year03/06/Leader-To-Leader-2003.pdf. Accessed August 8, 2007.
McDaniel C, Veledar E, LeConte S, Peltier S, Maciuba A. Ethical environment, healthcare work, and patient outcomes. Am J Bioeth. 2006;6(5):17-29.

Colonel John S. Murray, PhD, RN, CPNP, CS, FAAN, is a Consultant to the U.S. Air Force Surgeon General for Research; Director of Strategic Planning in the Office of Integration, National Capital Area Military Health System; and President of the Federal Nurses Association.

The views expressed in this article are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the federal government.

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