Josey Roane* reports the following “ethical” problem: “In my acute care facility, dangerous understaffing has become the rule rather than the exception – and by understaffing I am talking about one registered nurse for up to 15 patients. As a nurse manager, I not only have to adopt this ‘staffing plan,’ I am required to defend it to staff, patients and families. This causes me considerable anxiety – and often I am so anxious about what may be going on in my unit that I cannot sleep at night.

“I have been told repeatedly that money is very tight and that the hospital was on the verge of bankruptcy. Now, I read in the newspaper that the best-paid hospital CEOs are paid nearly $10 million a year… Perhaps if our CEO cut his salary in half, we could hire 10 more nurses! Patients would be safer, there would be fewer errors, and I could sleep at night.

“Staff are so concerned about staffing that one nurse wrote a letter to the CEO about it, and all the rest signed it. From that moment on, the CEO wanted her gone…and so when she made a very minor mistake, I was told to ‘write her up’ for making an egregious error, and to fire her immediately even though she had an excellent employment record. And I did it. What else could I have done? If I didn’t do it, someone else would have…”

Commentary

The first distinction that must be made is this: you are facing a moral problem, not an ethical one. An ethical problem exists when you face a situation in which you do not know what is the right thing to do. You were asked to do something you believe to be wrong, and you did it. I am not judging you for this, merely observing it. And that is the definition of a moral problem – doing what you think is wrong. The problem often is that there are big price tags associated with your choice.

That being said, I may be able to explain why some people feel compelled to do what they think is wrong. Subtle pressures may co-opt one incrementally over time: a condition facilitated when some of the pressures brought to bear are ethically justifiable and some are not. In such manner, work environments may cultivate moral schizophrenia. Factors in the organizational culture, especially financial pressures, conspire to turn what would seem to be clear-cut offenses into excusable departures from normal moral standards. Incrementally, what was previously unacceptable becomes first “necessary,” then “accepted,” and eventually expected.

When administration creates a survival ethos, ethical concerns often are trivialized. When this happens, managers justify actions whose moral implications run counter to their conscience based on a sense of “having had to do it.”

People make decisions within a context that consists of an inner and outer environment. A person’s inner environment is the common sense values we were all taught – honesty, integrity, fairness, respect for others, promise-keeping, etc. A person’s outer environment consists of everything else: people’s actions and reactions, role, status, timing, resources, standards, expectations and psychological distance from outcomes. In addition, being a member of the “team” also helps obscure one’s sense of right and wrong. All people, including managers, have a fundamental need to be connected and engaged, and a reciprocal need not to be separated from their group. This need is both capitalized on and intensified by the techniques used to form effective teams. Difficulties arise when one disagrees with a “team” decision, as you did with the short-staffing issue where the ethical issues are not as clear. And they are compounded if the disagreement is about an ethical issue that is clear, like being told to lie and to scapegoat an employee. The pressure to do what is expected of a team member is very real.

The only cure for your moral problem is to “undo” what you have done if you can…or to learn from it if you cannot. The question is “What price are you willing to pay for a clear conscience?” …and no one can answer it for you.

*Name changed to protect privacy

References

Curtin LL. Why good people do bad things. Nurs Manage. 1996 July;27(7):63-5.

Doctorow C. New York slashes hospital spending, but can’t touch multimillion-dollar CEO paychecks. March 16, 2011. http://boingboing.net/2011/03/16/new-york-slashes-hos.html. Accessed March 24, 2011.