The Nurse Leader Discussion

NUR435 2.1 In this article review, you will explore ethical issues and discuss their implications. Read the article, Moral Courage and the Nurse Leader download by Cole Edmonson. Step 2 Based on the article, answer the following questions in a two-page (500-word) paper: Step 1 • • • • What are the sources of ethical dilemmas for nurse leaders? How should nurse leaders handle those issues? Explain the 4As Framework recommended by the Association of Critical Care Nurses (AACN). What are the recommendations that can increase moral courage in nurse leaders? Step 3 Save and submit your assignment. When you have completed your assignment, save a copy for yourself in an easily accessible place and submit a copy to your instructor. Cite all sources in APA format. 4.1 n this writing assignment, you will complete a paper addressing an issue from the perspective of the nurse manager on a unit. Review your unit’s and/or facility’s organizational chart. You have been promoted to nurse manager of your unit. You realize that to function effectively, you must have a better understanding of your organization’s structure and, specifically, the chain of command. Find and analyze the organizational chart of the healthcare organization you are currently working for or for one that you have encountered in your nursing experience. Step 1 • • • • • • • • Step 2 In a two-page (500-word) paper, address the following points: Give a brief description of the organization of the healthcare structure used in your facility. Describe the chain of command used in your organization and identify the people you report to and those who report to you. Consider the following and discuss how the chain of command is used to implement change. Based on the organization chart, what leadership structure is used in the organization—hierarchical or flat? How does this affect implementing change? Does this organization use a shared governance model for nursing? When nurses have an idea for changing a process and they make a decision as a group, where do they go with their suggestions? (the director? the unit manager?) Explain why understanding this information is important to your success. Write your paper using APA format. Step 3 Save and submit your assignment. When you have completed your assignment, save a copy for yourself in an easily accessible place and submit a copy to your instructor. Cite all sources in APA format. Moral Courage and the Nurse Leader Cole Edmonson, MS, RN, FACHE, NEA-BC Abstract Today’s nurse leaders practice in very complex environments. This complexity leads to value conflicts and creates the potential for moral distress. Jameton’s sentinel work framed the concept of moral distress as arising when one knows the morally right thing to do, but cannot do so because of organizational constraints. In this article the author reviews sources of moral distress among nurse leaders, discusses the nurse leader’s responsibility for demonstrating and supporting moral courage, identifies threats to moral courage among nurse leaders, offers strategies to promote moral courage, and makes recommendations for the continuing development of moral courage. Citation: Edmonson, C., (Sept 30, 2010) “Moral Courage and the Nurse Leader” OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Manuscript 5. DOI: 10.3912/OJIN.Vol15No03Man05 Key words: moral courage, moral distress, moral residue, ethical conflict, value conflict, authority gradient, clinician-organization conflict, nurse leaders Today’s nurse leaders practice in very complex environments. This complexity leads to value conflicts and creates the potential for moral distress. Jameton’s (1984) sentinel work framed the concept of moral distress as arising when one knows the morally right thing to do, but cannot, due to organizational constraints. Jameton observed that moral issues are defined not by the scientific how-to’s, but by questions of ought-to’s, adding that knowing ‘how’ to provide care is different from deciding ‘what’ care to provide and ‘to whom’ we should provide care. Jameton has suggested that nursing is the moral center of healthcare and provides the true image and inspiration of ethical care and compassion. In 2002, Corley expanded on Jameton’s (1984) work to include conflict arising when nurses’ commitment to the organization and/or physician is misaligned with their duty to patients. Repenshek (2009) reported that this continuing conflict eventually leads to chronic stress for patient care providers. Moral distress can lead to burn out, ‘hardening,’ disengagement, and lack of focus on the primary work of nursing. Rashotte (2004) referred to the inability to successfully resolve moral distress as the “stories that haunt us.” These stories often describe situations related to patient advocacy, end of life, futile treatment, and role conflict based on values. Corley (2002) noted that because nurses act as moral agents in the healthcare system, the patient, nurse, and organization all benefit from nurses’ acts of moral courage. These acts have the potential to increase nurse retention, promote patient comfort, relieve patient suffering, and enhance the reputation of the organization. Although moral distress among direct-care nurses has been well explored, the experience of moral distress among nurse leaders is virtually absent in the nursing literature. The stories that haunt nurse leaders often emerge from the same situations as those that haunt direct-care nurses. It is important that nurse leaders support direct care nurses in facing these situations and address these situations in their own work by demonstrating moral courage. Sekerka, Bagozzi, and Charnigo (2009) have described the concept of ‘professional moral courage’ as a managerial competency. Although not specific to nurse leaders, their work is easily applied to the work of nurse leaders. Sekerka, Bagozzi, and Charnigo found that the leader who considers more than rules and policies, who demonstrates hardiness and determination, and who is self directed toward the good or what is right and moral routinely displays acts of moral courage. They added that education and training greatly improve a leader’s will to proceed in the face of difficult situations. Although finding, utilizing, and evaluating a specific model to decrease moral distress by bolstering moral courage in today’s nurse leaders remains elusive, nurse leaders must develop, role model, and practice moral courage as the first step to decreasing moral distress in the profession. In this article I will review sources of moral distress among nurse leaders who hold formal leadership positions within a healthcare organization, discuss the nurse leader’s responsibility for demonstrating and supporting moral courage, identify threats to moral courage among nurse leaders, offer strategies to promote moral courage, and make recommendations for the continuing development of moral courage. Sources of Moral Distress among Nurse Leaders Moral distress in nursing arises from a variety of sources. These sources may include a nurses’ reaction to the situation, continuation of the situation causing the distress, complexity of the environment in which the distress occurs, and characteristics of the nurse and the situation producing the distress. Each will be described below. Moral distress among nurses is seen in two different dimensions, described by Jameton (1984) as the initial dimension and the reactive dimension of moral distress. Initial moral distress is the distress nurses experience when they are faced with interpersonal value conflicts. It is experienced as feelings of frustration, anxiety, anger, and an inability to act as one sees fit due to organizational constraints. Reactive moral distress is the distress nurses experience when they do not act upon the initial distressing situation to bring about resolution. These acute manifestations of moral distress, if not acted upon and resolved, lead to moral residue, or the additional development over time of regret, anger, and frustration. An example may be that of nurse leaders who value excellence in care and believe the staffing standard for their unit is not appropriate to the patient population being cared for, thus interfering with quality outcomes, yet who chooses to ‘live with the standard’ instead of speaking up and actively working to change the target. These feelings of anger and frustration may be turned on themselves in the form of low self-esteem, self-hate, and job dissatisfaction, or turned on others resulting in horizontal violence directed at peers or the offending source (Corley, 2002). The Nurse Leader Discussion

Repetition of this ‘moral action paralysis’ creates what Levi, Thomas, Green, Rentmeester, and Genevia (2004) have referred to as ‘jading,’ which is the worn-out state that results from consistent and prolonged pressure to perform distressing tasks in relation to the moral position of the nurse (leader). Coles (2010) added to the observations of Levi et al. by suggesting that the cost of sustained moral distress can be absenteeism, morale issues, and poor productivity for the organization along with emotional exhaustion for direct-care nurses and nurse leaders. Moral distress permeates nursing due to the nature of the profession, especially in light of the increasing complexity of the healthcare environment that may include performance expectations, finite resources, technology advancement, aging of the population, and the competitive globalization of healthcare. The healthcare environment is characterized by emotionally charged issues for patients, families, and providers, creating fertile ground for reasonable people to disagree on the decisions as to what is ‘right’ and what is ‘morally right’ (Nathaniel, 2006). Mohr and Horton-Deutsch (2001) offered two explanations for action/inaction on the part of the nurse, namely the nurse’s dispositional status (characteristics), and the nurse’s situational status. Dispositional status represents the individual psychological characteristics of the nurse regarding personal beliefs, values, and convictions that influence the decision to act. Situational status represents the characteristics of the situation, i.e., the extent to which they meet a threshold for action to be taken by the nurse. Mohr and Horton-Deutsch contended that it is likely that neither explanation is singularly responsible for action or inaction. It is more likely that an interaction effect is occurring with cultural ideology as a context. Nurse Leader Responsibility Our nursing leaders and professional organizations have made it clear that nursing leaders are responsible for creating cultures that support acts of courage in nursing. The American Organization of Nurse Executives has advocated for the creation of healthful work environments that support moral courage by identifying nine elements/principles for nurse leaders to integrate into member organizations. Principle Five calls for leadership to be competent, credible, visible, and expert. These behaviors are seen in leaders who demonstrate moral courage. Other nursing leaders, and also professional organizations, have issued calls for leaders who are able and willing to demonstrate moral courage as described below. Corley (2002) described the ‘courage to take action’ in a morally distressing situation as verbally acting to alleviate the initial moral distress felt by nurses in morally conflicted situations. The Nurse Leader Discussion

This may be thought of as using one’s voice to express or advocate for an action to alleviate or reduce moral distress experienced by self and/or others. Buresh and Gordon (2006) shared that nurses must find their ‘voice of agency’ to act with courage, conviction, and capacity. Such courage to speak up is supported by many state nurse practice acts that require nurses to act out their professional duty as agents of patient safety, maintain professional practice boundaries, and protect patient rights. Lachman (2007) described moral courage as the individual ability and capacity to overcome fear and openly support one’s core values. Acts of moral courage occur in public and private settings within healthcare organizations that provide not only the context but also the channels for these acts to occur. Nurse leaders need to develop the ability to role model ‘speaking up.’ Ketefian (2001), in her work with the Midwest Nursing Research Society, addressed the need to develop moral reasoning as a pre-requisite to demonstrating moral courage. She also noted that there has been too much of a focus in the moral courage literature on the individual characteristics of the nurse, and not enough focus on the environment created by nurse leaders in the organization. Ketefian (1980, 2001) has identified the need to increase research that will enhance our understanding of environmental and organizational factors that impact a nurse’s ability to act in a morally courageous manner. The American Nurses Association (ANA) in the Code of Ethics for Nurses (2001) has called for nurses to act when a patient’s or nurse’s rights are violated through decisions made by others. Nurse leaders experience moral distress related to patient care much the same as do directcare peers. However, the uniqueness of the combined, and often conflicting roles of nurse and leader create additional opportunities for leaders to experience moral distress due to the added responsibility of leaders to both self and the organization. Grossman and Valiga (2009) have described this leadership challenge as one of being morally fit and also creating healthy disorder to challenge hierarchy, tradition, cultures, and norms that mitigate against healthful work environments for the purpose of providing quality care for patients. In Nursing Administration: Scope and Standards of Practice (ANA, 2009), nurse leaders are directed to define ethical frameworks for administrative practice and provide leadership in establishing an ethical culture at the bedside for the direct-care nurse, a culture that is inter-professional in nature. This standard includes a commitment to self-care for nurse leaders through stress management and connections with self and others. Threats to Moral Courage for Nurse Leaders Jameton (1984) described how the nature of nursing practice can create moral distress due to differences between actual and expected experiences. This process begins during the prelicensure education of nurses and continues throughout their professional career. These differences occur because nursing emphasizes prevention and humanizing of the individualized care provided, using high-touch, relationship-oriented care that often conflicts with the curative , standardized nature of hospital-based care that values high-tech, production-based, and efficient care. The Nurse Leader Discussion

These differences contribute to the value conflicts that plague the healthcare system. The authority gradient and the clinician-organization conflict can both contribute to these differences. Authority Gradient The authority differences in healthcare organizations that are related to differences in roles and positional power between physicians and nurses, administrators and nurses, and nurse leaders and nurses can create repression of personal values. The authority gradient (AG) is the command hierarchy of power, or the balance of power, measured in terms of steepness. The authority gradient can influence both patient care and organizational decisions by repressing those in subordinate positions, keeping them from influencing or making decisions they consider to be the most appropriate. Speaking truth to power must be encouraged and developed in nursing professionals to mitigate the negative consequences of the AG and to improve healthcare systems. Nurse leaders need to understand how this gradient affects their professional decision-making power within the organization. Strong shared governance models and positioning of nursing within the organization provide mechanisms to reduce the steepness of the authority gradient. Examples of organizational positioning of nursing include arranging for the chief nursing officer to hold membership and voting privileges on the Board of Trustees and developing nursing committees that report directly to the Board, bypassing traditional hierarchical positions that might not support initiatives proposed by nursing. The Clinician-Organization Conflict Nurse leaders desire to, and are expected to balance diverse and competing interests of patients, families, physicians, employees, and organizations while maintaining a moral environment. Nurse leaders are different from many other healthcare leaders in that they move between the clinical and administrative/organizational domains in healthcare settings. Their decisions need to be multilayered and contain increasingly scaffolded elements of risk to themselves as nurses and as leaders. Rashotte’s hermeneutic-phenomenological study (2004) suggested that acute moral distress, unresolved by moral action, creates moral residue or stories that haunt us and continually resound within us. The concepts of ‘looking back”’ or ‘moral regret,’ as described by Wurzbach (2008), emphasize the influential role of moral certainty as predecessor to and sustainer of the ability to act. Moral certainty, as defined by Wurzbach (2008) is the inner conviction to such a high degree that it is sufficient for action. In her research Wurzbach found that nurses who exhibited moral uncertainty regarding a situation and those who had very little time to plan a response were more likely to experience moral regret. The Nurse Leader Discussion

Increasing moral certainty and allowing for planning, discussion, and anticipation of outcomes may prevent moral regret and subsequent moral residue in nurse leaders. Nurse leaders are not exempt from the need to plan ahead in their work so as to find moral certainty in the decisions they make. Nurse leaders who intentionally provide for and invite open discussion of decisions from a moral perspective and who avoid last minute, rushed, and unplanned decisions have the greatest opportunity to assist others in avoiding moral regret. Email, although efficient from many perspectives, may not be the most effective way to deliver or discuss decisions with potential to contribute to moral distress. In-person and phone conversations allow for generative discussion, planning, and moral decision making through active dialogue. They allow the nurse leader to consider both the clinical and organizational demands of the situation. Nurse leaders work in inter-professional teams that often include non-clinicians having limited or no experience in providing direct patient care. These team members may have backgrounds in finance, organizational operations, and/or administration but not in clinical endeavors. Bringing the clinical perspective to the team often means educating the team on care processes by describing how specific types of care can create specific outcomes and addressing the specific ethical conditions in a given situation. To influence inter-professional teams nurse leaders must translate the work of nursing into familiar terms and paint a picture for their colleagues describing how their colleagues’ actions and/or areas of responsibility impact clinical providers and patient outcomes. Nurse leaders who obtain knowledge outside of the clinical domain and broaden their experience to include knowledge of ancillary operations and financial processes can better influence their organizational colleagues for the betterment of patient care. Nurse leaders may ‘level their playing field’ by becoming members of, and fellows in healthcare-related organizations, such as the American Coll The Nurse Leader Discussion