S28 September-October 2016/HASTINGS CENTER REPORT
Undisputedly, the United States’ health care system is in the midst of unprecedented complexity 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 complex care across multiple care settings. Medical advances
give us the ability to send patients home more efficiently
than ever before and simultaneously create ethical questions about the balance of benefits and burdens associated 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 environments, 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 standardizing 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—shortening stays, for instance—can imperil respect for patient
readiness to assume responsibility for complex treatment
protocols. Although pressed to meet fiduciary responsibilities to the institutions in which they practice, most
clinicians remain committed to their ethical responsibilities 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 excluCreating 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
SPECIAL REPORT: Nurses at the Table: Nursing, Ethics, and Health Policy S29
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 potentially 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 paradigm grounded in compassion and sustained by a culture
of ethical practice.
What Is a Culture of Ethical Practice?
I
magine, for a moment, a health care system where patients 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 integrity. 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 moral 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 respected. The culture aligns individual and organizational values, 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 compliance 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 intimate, 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 rapidly 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 expertise is vital in designing effective care delivery models and
promoting patient outcomes. As in the U.S. Ebola experience, nurses are often the first to recognize unsafe situations. 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 contributions 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 paradigms, 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 person 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.
S30 September-October 2016/HASTINGS CENTER REPORT
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
convened by the Johns Hopkins University Berman Institute
of Bioethics and the School of Nursing, identified sustaining 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 organizations 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 ethically. 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 consultants; representation at all levels of organizational operations 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 president for patient care designed and implemented what the
hospital calls a “Collaborative Governance†communication 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 direct care roles for the purposes of sharing ethically challenging experiences in their practice; learning the language of
ethical discourse; teaching clinicians, patients, and families
about advance-care planning; and making recommendations for policies that can positively affect ethical care in
the organization. Additionally, they are charged with implementing and evaluating a clinical ethics residency for
nurses supported by the health resources services administration,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 organizations that have achieved Magnet status, granted by the
American Nurses Credentialing Center.12 As Magnet organizations, 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 organizational priorities, policies, and research agendas.13 They
acknowledge that the pathway to positive patient experience 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
Table 1.
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 mechanisms, such as ombudsmen and surveillance and reporting 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 advocate their widespread use.
5. Develop mechanisms to engage staff members in
cocreating system solutions for problems that may undermine 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 interprofessional team, patients, and families.
7. Establish nonnegotiable, no-opt-out accountability
norms for leaders, clinicians, and staff members to prevent or remediate instances of reprisal, disrespect, or
dismissal of ethical concerns.
8. Allocate resources to support interprofessional attainment 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, member organizations, community and health care networks, 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).
SPECIAL REPORT: Nurses at the Table: Nursing, Ethics, and Health Policy S31
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, particularly with regard to quality and safety and ethical concerns.
Second is a full-spectrum approach to intentionally design systems and processes that systematically shift underlying structures, norms, and policies to produce the desired
results.14 Such an approach engages all stakeholders to articulate the values that make up their moral compass; it leverages 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 prioritizes ethics as central to the organization’s mission and operations 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 accountability for ethical dialogue and action, invest in resources
to support clinical and leadership decision-making and
conflict management, and design systems to detect and address ethical issues through processes such as quality improvement, 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 collaboration, from disparity to fairness, from victimization
to principled moral agency. When the culture shifts, individual 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 create a plan to address them, using techniques and interventions such as those listed in table 1.
By aligning the values of the organization and the individuals 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 ethical commitments to produce meaningful change in their
daily practice. Collectively, nurses stand ready to collaborate 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,â€
January 2016, at http://www.aha.org/research/rc/stat-studies/fastfacts.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-summitreport.
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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express written permission. However, users may print, download, or email articles for
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