Healthcare Ethics Issue Essay

find a current or fairly recent (less than 1 yr.) article in a newspaper, magazine, news website, or a nursing blog/organization/journal dealing with a health-care ethics issue. short 1 page summary of the article and why you selected the The article you did. https://journals.sagepub.com/doi/10.1177/0969733021992448

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Original Manuscript Institutional betrayal in nursing: A concept analysis Nursing Ethics 2021, Vol. 28(6) 1081–1089 ª The Author(s) 2021 Article reuse guidelines: sagepub.com/journals-permissions 10.1177/0969733021992448 journals.sagepub.com/home/nej Katherine C Brewer Chamberlain University, USA Abstract Background: Ethical relationships are important among many participants in healthcare, including the ethical relationship between nurse and employer. One aspect of organizational behavior that can impact ethical culture and moral well-being is institutional betrayal. Research aim: The purpose of this concept analysis is to develop a conceptual understanding of institutional betrayal in nursing by defining the concept and differentiating it from other forms of betrayal. Design: This analysis uses the method developed by Walker and Avant. Research context: Studies were reviewed using health literature databases with no date restrictions. Ethical considerations: Analysis was conducted using established guidelines for ethical research. Findings: Although institutional betrayal is a concept applied in the literature, there was a paucity of studies exploring the concept within nursing. Examples of the concept in the literature include violation of trust between organization (i.e. employer) and nurse, such as provision of inadequate workplace protections, ineffective or hostile management, and gaslighting of those who experience negative events. Examples of institutional betrayal have become more visible during the COVID-19 pandemic. Discussion: A conceptual definition of institutional betrayal is a deep violation of trust or confidence or violation of moral standards committed by an institution toward a nurse.

This definition incorporates experiences and issues suggested by the literature. Outcomes are likely negative, including impacts on nurse psychological and workplace well-being. This concept likely fits within a framework of ethical workplaces and has conceptual relationships with moral distress and moral resilience. Further studies can help qualitatively explore and empirically measure this concept. Conclusion: In the pursuit of improving the ethical culture of healthcare workplaces, this concept can provide meaningful insight into organizational behavior and its consequences.

Naming and describing the concept can promote conceptual clarity and equip researchers, nurses, and leaders to identify and mitigate the issue. Keywords Institutional betrayal, concept analysis, nursing, organizational ethics, COVID-19 pandemic Ethical relationships are important among many participants in healthcare, including the ethical relationship between nurse and employer. The Code of Ethics for Nurses outlines the ethical obligation of employers to provide safe workplaces for nursing practice, which in turn translates to better overall nursing care.1 An Corresponding author: Katherine C Brewer, College of Nursing, Chamberlain University, 1951 Kidwell Ave., Vienna, VA 22182, USA. Email: katherine.brewer@chamberlain.edu 1082 Nursing Ethics 28(6) understanding of what strengthens and weakens this ethical relationship can better inform the work toward creating ethical workplaces and cultures.

One aspect of organizational behavior that can weaken an ethical culture is betrayal, specifically institutional betrayal.2,3 Betrayal is a violation of trust, displayed by intentional or unintentional actions or behaviors that run afoul of expectations.4 In the case of organizations, betrayal is a violation of the ethical relationships between nurse and organization. Among nurses, psychological trust that organizations will provide for physical and psychological safety, fairness, and an ethical culture of practice is outlined in Code of Ethics for Nurses.1 Nurses develop trusting psychological relationships with their institutions and assume with confidence that the expectations for respectful ethical behavior will be met.

5 Ethical relationships and the potential for institutional betrayal might be viewed as part of the theoretical basis for moral distress, moral injury, and moral resilience.6 Moral harms are likely related to issues of professional and personal well-being. These harms are theoretically more likely to occur in high-risk situations, such as public health emergencies. The COVID-19 pandemic represents an intense, longduration public health emergency that creates risk for nurses and other healthcare providers. The emergence of stories through the news media of the physical and emotional risks faced by nurses and others, and in some cases, the lack of organizational assurance to protect from these risks, highlights the importance of understanding the relationship between institution and nurse. Failure to meet the needs of health and safety and to respect or acknowledge the risk nurses take to care for patients sick with a novel communicable virus could represent an important example of moral health hazards related to betrayal of trust.

7 The purpose of this concept analysis is to develop a conceptual understanding of institutional betrayal in nursing as a specific type of betrayal. This concept can be applied as a distinct environmental and cultural factor in nurse well-being and can promote conceptual clarity for use in research regarding ethical culture for nursing practice. Creating a standard definition for institutional betrayal can also equip researchers, nurses, and leaders to identify and mitigate the issue. Methods The concept analysis was conducted using Walker and Avant’s framework.

8 The first step was to conduct a literature search to identify uses of the concept, examples of the concept, and empirical referents. A literature review based on PRISMA guidelines was conducted.9 The literature review was conducted in June 2020. The time frame was used to allow for emerging evidence of well-being issues in the COVID-19 pandemic. The search of the literature was conducted in the CINAHL, APA PsychINFO, and Medline databases with search terms nurs* and betray*. These broad terms were used to provide a wide search for uses of the concept in the literature. Another search was conducted in PubMed using the terms betrayal and institutional betrayal. A hand search of references was also conducted for titles which appeared to be consistent with the terms. Inclusion criteria were articles from peer-reviewed journals published in English and were consistent with the conceptual of betrayal among nurses committed by an entity to which a nurse belongs (i.e. institution).

To fully explore the concept, no time limit was placed on articles to best fully explore the available literature. Results There were 121 unduplicated articles identified in the search (duplicated articles were filtered out by the database automatically and search results indicated there were about 20 duplicates). Titles and abstracts were reviewed for consistency with the inclusion criteria. Articles which were unassociated with the concept, explored betrayal of patients or community members, were not related to a healthcare, or were Brewer 1083 not focused on betrayal while providing care were excluded. The search terms with Boolean operators created a wide search, and many of the articles were not focused on the concepts specifically (e.g. the term betrayal was in the body of the article but was not the main topic).

From the search, including the hand search, 12 articles were read in full. Of the articles reviewed, only one used the term institutional betrayal to describe experiences among nurses.10 Five articles suggested betrayal within the experiences of nurses and two articles discussed betrayal as a factor of moral injury and moral distress; these seven articles were used to define the concept. The remaining articles did give clear indications of the conceptual definition or manifestations of betrayal and thus were not used. Definitions and use of the concept Betrayal is defined in the literature as a violation of trust among people through incidental or intentional actions which has lasting negative impact on relationships.11 The betrayal can diminish the dignity of the person betrayed and disrupts the ability for self-actualization.4 Betrayal trauma theory posits that harmful acts perpetrated by a known or trusted person exacerbates the negative sequelae because the person harmed feels so violated and betrayed.11 Institution is defined in the dictionary as “an established organization or corporation (such as a bank or university) especially of a public character,” a “significant practice, relationship, or organization in a society or culture,” and “something or someone firmly associated with a place or thing.”12 In nursing, the institution could include individuals (e.g. managers, co-workers), entities (e.g. the workplace administration), or even societies.

Thus, using these definitions, institutional betrayal is defined as betrayal which occurs when acts of betrayal are committed by organizations (e.g. individuals or collective systems) to which an individual belongs.2 One article was identified in which institutional betrayal was specifically named as a possible issue in nursing.10 The article uses the term institutional betrayal to describe gaslighting, where nurses who report issues in the workplace (i.e. whistleblowers) were made to feel that their complaints were insignificant or that issues in the workplace were not really happening. The resulting cognitive dissonance, which is internal confusion and doubt, among the person who is gaslighted creates a deep sense of emotional and psychological damage. Other articles described examples of betrayal within an organization without specifically defining it as institutional betrayal. Rushton6 describes betrayal between nurse and employer as several factors, including inability to provide an environment where the logistical needs of practice are met (e.g. adequate staffing), lack of autonomy and safety to make ethical decisions regarding care. Rushton6 also uses betrayal to describe organizations restraining a nurse’s ability to provide ethical, quality care. This would include an organization creating a sense of incapacity among healthcare professionals to speak out or object to unethical practices or decisions, creating external or internal constraints to ethical practice, or lacking organizational integrity. This constraint is said to create another form of betrayal—a sort of self-betrayal where the nurse betrays the patient. Dissonance can also occur when professionals are mandated to carry out organizational decisions without input or engagement; the confusion is that the clinician believes they are meant to act one way toward a patient but are mandated to act another way, whether explicitly or implicitly. Betrayal was also used to describe unsafe work environments. Cleary et al.5 describes betrayal as the inability of nurses to provide safe, quality care due to constraints of equipment or resources due to institutional constraints (e.g. policies, supply shortages, financial decision). There may also be betrayal when an institution creates barriers to ethical practice, such as policies which favor profit over humane care.6 Institutional betrayal during the COVID-19 pandemic has been suggested as an issue for those who feel trust in their employer was violated by insufficient personnel, safety precautions, and resources, particularly in care of the most vulnerable such as nursing home residents and patients with disabilities.7 1084 Nursing Ethics 28(6) Betrayal has also been used to describe the cultivation of a negative work environment.

This could stem from lack of fulfillment of expectations.13 Betrayal as a work environment issue could include an organization or its leaders engaging in deceitful communication, disregarding the needs of patients and providers, and failure to make decisions in the best interests of others.14 Organizational betrayal has been used as a term to describe work environments where organizations responded to negative workplace issues with hostility toward the victim, demonstrating a lack of concern about the issue, or creating an environment where the issue was likely to occur.15 Betrayal was used in some articles to describe a form of moral issues faced by nurses. Betrayal and actions which reduce trust and increase stress in health work environments predisposes one to moral distress, moral injury, and moral suffering.6 Moral distress is another concept that has similar constructs as betrayal, yet, differs in terms of conceptual definition. Moral distress is posited to occur when internal or external constraints limit the capacity of a healthcare provider (or other professional) to perform their obligations toward others. Moral injury is often described as betrayal of what one considers right by an act of a higher authority, or, a violation of a deeply held moral belief by one’s own actions or the actions of others in authority.16 Attributes of the phenomenon Defining attributes A conceptual definition of institutional betrayal is a deep violation of trust or confidence or violation of moral standard committed by an institution toward a nurse.

Key attributes of institutional betrayal in nursing are (1) violating of trust or confidence by implicit or explicit means, (2) occurring between nurse and an institution to which the nurse belongs or identifies with (e.g. workplace, political institution, community, or society), (3) creating perceived constraints to ethical culture and practice, (4) occurring as covert and/or overt actions or behaviors, (5) creating or compounding stress, and (6) diminishing the sense of an ethical culture. Antecedents For betrayal to occur, certain antecedents must exist. The nurse should identify with the tenets of professional nursing practice, including the ethical responsibilities of beneficence, fidelity, and nonmaleficence toward patients, other healthcare professionals, and society. Identification with ethical tenants of the work and a desire to help others is cited as a reason for participating in a potentially dangerous healthcare situation such as an infectious disease outbreak. Related to this is a sense of duty and seeking to help others in times of crisis while recognizing the risks involved to self and others (e.g. family members). An ethical duty to respond as an antecedent cultivates and enriches the emotional relationship nurses have to their practice.1 The nurse would expect the institution in which they are responding will meet its obligations for safety, protection, and support. The professional nurse recognizes the ethical obligations owed them by the institutions under whose auspices the person is providing care. Institutions is a broad term meant to encompass the systems, policies, and individuals that oversee some aspect of nursing practice, including but not limited to, healthcare employers, government officials, and even other members of society.

The recognition of the ethical obligations of organizations to healthcare professionals helps to heighten the psychological contract.13 The relationship between the institution and the professional also sets the basis for the betrayal to occur, in that the professional has some level of trust or dependence on the institution committing the betraying acts.2,17 Brewer 1085 The context of the healthcare service delivery is also a critical antecedent; this is because the high-risk scenario in which the nurse would be required to provide care heightens psychological contract that the organization will provide for their health and safety. Although institutional betrayal can occur in nonhealthcare workplaces, a high-stakes situation intensifies the perceived risk to the healthcare professional, thereby intensifying the trust for safety from the institution. Outcomes Outcomes of institutional betrayal are posited to be negative, particularly outcomes of negative workplace well-being.

Consistent with betrayal trauma theory, which posits that harm induced by a person who is known or trusted by the victim is compounded by the violation of that trust, institutional betrayal among nurses would intensify the physical or psychological damage from a stressful event.11,17 Betrayal likely intensifies the stress of providing care with increased negative effects on well-being such as sadness, depression, anger, and burnout.7 Coping with the stress is disrupted, which could impact the professional commitment. Likewise, healthcare professionals who experience institutional betrayal might even consider leaving the profession altogether.5 These issues create downstream problems for healthcare worker recruitment to response efforts and issues with retention. Empirical referents Referents serve as the evidence of the phenomenon and offer a framework for measurement in future studies. Several of the articles identified in the literature search served as empirical referents for institutional betrayal. The Institutional Betrayal Questionnaire (IBQ)3 and the Institutional Betrayal Questionnaire for Health (IBQ-H)18 were developed and used to determine the number of acts of betrayal an individual experienced in an institution after a negative event. The Institutional Betrayal Questionnaire for Medical Services (IBQ-MS) was developed to measure institutional betrayal among medical patients, using 42 items to measure three factors of institutional betrayal—healthcare experience, system response, and cognitiveaffective (perception).19 The Betrayal Trauma Scale is a validated scale to measure issues of betrayal that impact psychological health and well-being; however, it is focused on issues of sexual assault in its item framing.20

The Reina Organizational Trust Scale® is a 54-item scale used to measure levels of trust within an organization, focusing on experiences and interactions with peers and managers within an organization and measuring trust conveyed through those interactions.14 The Moral Injury Symptoms Scale–Healthcare Professional version (MISS-HP) was created to measure moral injury among healthcare providers and includes an item measuring level of agreement with the statement “I feel betrayed by other healthcare professionals whom I once trusted.”21 Single questions have also been used to determine betrayal.13 Case studies A final element of Walker and Avant’s model for concept analysis is to provide case studies. These examples illustrate the elements of the concept in recognizable scenarios. For this concept analysis, the case studies were constructed using nurses providing care during the COVID-19 pandemic. Healthcare Ethics Issue Essay

These cases consolidate the proposed attributes of betrayal and use the COVID-19 pandemic as a key exemplar of the antecedents, particularly the expectation of the nurse that the institution will protect them and provide for safety and assurance. The model case also introduces the potential for the community/society in which a nurse lives to take the form of the institution. 1086 Nursing Ethics 28(6) Model case J.G. is a registered nurse working on a medical intensive care unit (ICU) in New York City during the COVID-19 pandemic. At the hospital where J.G. works, the emergency department is being inundated with critically ill patients. Almost every patient on the unit is intubated and experiencing acute respiratory distress syndrome. Mortality on the unit is high, and J.G. and the other nurses experience some tragic patient care scenarios. There is little communication about the hospital’s response plan and the unit is running low on personal protective equipment. The hospital administration sends an email that the units need to reuse all equipment on multiple shifts because more equipment is not being ordered due to limitations in financial resources and ongoing supply issues. There appears to be an intense politicization of the pandemic. J.G. watches TV news conferences where government officials blame the healthcare workers for the protective equipment shortages and claim the workers are stealing supplies from the hospitals to sell them. Healthcare Ethics Issue Essay

Some government officials downplay the severity of the pandemic, including dismissing the importance of public health measures such as selfquarantine and facial coverings. To J.G., their intent seems to be glossing over the severity of the issue and trying to convince people that what they are seeing and experiencing is not real and that the virus will just disappear. Several health officials have resigned or been fired due to intense political pressure or blatant disregard for their public health expertise by politicians. Social media users appear to promote these statements, and soon there are rallies and visual instances of community members purposefully violating the public health ordinances in New York and other cities, claiming the pandemic is “overblown.”

All of this makes J.G. feel, betrayed, dejected, and angry. Contrary case A.C. is a nurse working in a critical access hospital in a small town. A.C. and a fellow nurse are working with a physician who is overseeing the government’s response to the COVID-19 pandemic. A.C. is a health professional with years of dedicated service to public health and feels a strong commitment to helping the community. During the pandemic, A.C. has to make some very difficult decisions and assist the governor with regulations around health and commerce. A.C. has little data to work with at first and the level of unknowns around the virus are intense. A.C. works in partnership with the governor to make decisions and set policy. The governor verbally supports A.C. and the others in news conferences and in internal meetings. A.C. advocates for increased funding for the public health departments that are conducting much of the dayto-day work. The governor supports these requests and is honest with A.C. when things are not going to be funded and gives clear rationales. A.C. feels valued, highly supported, and not under political pressure to quit or resign. Borderline case L.D. is a nurse working as a medic during the COVID-19 pandemic. L.D. has conducted a number of ambulance rescues involving severely ill COVID-19 patients, and transports from nursing homes with patients suffering from COVID-19-related pneumonia. L.D. experiences a number of patients expiring during the rescue. As a member of the county-managed rescue squad, L.D. and colleagues have a very close working relationship with the government agency supplying equipment and training. Healthcare Ethics Issue Essay

The agency is frequently sending messages and communication committing to the health and safety of the responders. L.D.’s squad commander is briefed frequently by the county emergency management office and is a part of the hospital preparedness roundtable. As the COVID-19 pandemic becomes more intense, L.D. starts to notice the communications from the county appear to slow. The squad commander is invited to fewer Brewer 1087 meetings and decisions seem to be made more and more haphazardly. L.D. hears from a colleague on the county’s emergency management staff that the immense amount of work resulting from the pandemic is taxing the system, and the managers feel somewhat incapable of keeping up. L.D. perceives that the county managers and the squad leaders are trying their best to provide support for the responders, but the overwhelming taxation on the system (e.g. supplies, finances, personnel) is making it very difficult. L.D. feels confused and frustrated. Healthcare Ethics Issue Essay

Discussion The concept introduced in this article could provide a better understanding of how nurses and other healthcare professionals’ negative experiences could factor into the overall conceptual model of moral health and well-being. The concept likely fits into the overall ethical culture of healthcare in which professionals feel supported in their work. The analysis can be used in future studies by applying this concept within a model describing how the experiences of nurses and other healthcare professionals (e.g. physicians, social workers) providing care directly or indirectly in these types of events might experience psychological harm from the organizational systems within which they are practicing. It could also be used to explain behaviors related to future participation in health emergency responses, and/or intention to remain in the profession itself. Institutional betrayal likely fits into the conceptual model of moral distress. Institutional betrayal could be a component of moral distress, especially if the actions of the institution resulted in the external constraints experienced by the professional (e.g. not providing enough supplies for adequate patient care, thus resulting in the professional being forced to provide inferior care). Moral distress is a phenomenon where a person who has ethical and moral obligations to others as part of their work can experience a sense of great emotional disturbance when they, either by their own actions or the limitations imposed on them by others, cannot fulfill their obligation. Healthcare Ethics Issue Essay

Sources of moral distress could include culture of fear where clinicians fear reporting unethical practices due to fear of retaliation.22 Thus, aggressive or hostile leadership as betrayal can contribute to the issue of moral distress. There are several concepts noted that could be related to institutional betrayal, but which differ. Institutional betrayal among healthcare professionals differs from self-betrayal or interpersonal betrayal with regard to the perpetrator. Healthcare Ethics Issue Essay

Self-betrayal includes issues where a clinician feels they were not able to give their all, either from internal or external constraints, resulting in a sense they betrayed their patients.6 Institutional betrayal likely differs from moral injury. Moral injury is often described in the context of military service, where one’s duty or prescribed orders to carry out actions, such as killing others, violate one’s own inherent morality. Betrayal-based issues of moral injury have also been suggested to be severe, such as war-zone atrocities.16 Moral injury has also been used to describe the outcome of one’s own actions which violate ethical values and strongly held beliefs, as opposed to the actions of others, which then instills a sense of shame and guilt. Healthcare Ethics Issue Essay

It is also suggested that betrayal is a source of injury among other immoral acts of omission or commission on the part of the individual or the institution. Institutional betrayal might be differentiated from moral injury in that the organization’s violation of established trust is an injurious event, whereas moral injury is the outcome of those events. Further work is warranted to define and differentiate institutional betrayal and moral injury. Institutional betrayal is also likely different from moral adversity, where a manager or other person with hierarchical powers in an organization is mandated to enforce what they perceive as immoral or unethical. For example, a manager who is required to direct healthcare professionals to make due with inferior personal protective equipment by higher administrators, and who subsequently feels a deep sense of guilt or remorse at having to enact such a procedure, is potentially experiencing moral adversity as opposed to committing institutional betrayal. Managers and other individual leaders may be in untenable positions and 1088 Nursing Ethics 28(6) feel a sense of guilt or despair with regard to the staff they manage or supervise, which could potentially make them victims of institutional betrayal while being seen as part of the institution itself.

However, this phenomenon requires further exploration and study. Future mixed-methods studies could incorporate both quantitative and qualitative exploration of betrayal as a facet of moral health. Future quantitative studies could incorporate this concept into research studies of the experiences of nurses and expand to other healthcare professional populations, such as physicians and social workers. These studies could include psychometric testing for instruments to measure betrayal and exploring relationships of betrayal with moral distress and moral resilience. Healthcare Ethics Issue Essay

Future qualitative research can explore the process by which healthcare professionals cope with the negative experiences in providing care with a lens toward understanding how one experiences betrayal. Incorporation of the concept in future research studies can assist with a more robust understanding of moral distress within other healthcare professions which have ethical relationships with their institutions (e.g. medicine). Although this article focuses on betrayal within nursing, it does so because of the theoretical ethical relationships between nurse and institution. A broader approach can enhance the understanding of the concept and provide evidence toward development of interventions to assist healthcare professionals. This might include incorporation of counseling strategies used to treat patients who have experienced betrayal trauma.

Importantly, the use of this concept can help provide clarity around the specific actions organizations are committing which are violating trust of healthcare professionals so that these actions can be eliminated and enact a more wholesome ethical culture.6 Limitations Although this concept analysis was conducted with a focus on a sound methodological approach, there are possible limitations. The search terms used were purposefully broad to conduct a wide-ranging literature review; however, articles may still not have been shown in the results. Conclusion Institutional betrayal among healthcare among nurses is defined as intense disappointment resulting from violation of trust between nurse and institution in which the nurse is practicing. The concept describes how institutions, whether government agencies, individual managers, or society in general, can betray the confidence of those who are providing care and, in some cases, risking their own health and safety to help others. Healthcare Ethics Issue Essay

The theorized outcome of this concept is a negative effect on the healthcare professional’s psychological health and health behaviors, such as intention to continue to work in the institution or to continue in nursing at all. The development of this concept might contribute a research concept to studies of the experiences of healthcare professionals and toward strengthening the moral resilience of those nurses and their communities. Acknowledgements I would like to thank Lesly Kelly, PhD, RN, for her review of the draft. Conflict of interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Healthcare Ethics Issue Essay

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. Brewer 1089 ORCID iD Katherine C Brewer https://orcid.org/0000-0003-1822-972X References 1. American Nurses Association. Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association, 2015. 2. Smith CP and Freyd JJ. Institutional betrayal. Am Psychol 2014; 69(6): 575–587. 3. Smith CP and Freyd JJ. Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. J Trauma Stress 2013; 26(1): 119–124. 4. Parse RR. Human dignity: a human becoming ethical phenomenon. Nurs Sci Q 2010; 23(3): 257–262. 5. Cleary M, Wilson S and Jackson D. Betrayal in nursing: recognizing the need for authentic and trusting relationships. Issues Ment Health Nurs 2018; 39(5): 447–449. 6. Rushton CH. Moral resilience: transforming moral suffering in health care.

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