Ethics/Integrity and Trust
What has happened to educational preparation in ethics today? More than 50 years ago, as a nursing student, I was required to take a medical ethics course with all healthcare students. A recent survey by USA Today indicated that despite corporate scandals, only 28% of workers receive ethics training. In the 80s, establishment of ethics committees in hospitals became an essential component of accreditation standards for the Joint Commission on Accreditation of Healthcare Organizations. These committees served as vehicles for difficult decision making in regard to the care of specific patients.
These committees usually included an administrative representative from the hospital, a physician, a social worker, a psychiatrist, a registered nurse (especially a staff nurse who cared for the patient whose case was being discussed), an ethicist, and always the attending physician for the patient whose case was being reviewed. The American Hospital Association had a national committee to recommend standards for all hospitals and the Hastings Institute served as a regular resource for guiding challenging patient care issues, such as whether to start tube feeding on a terminal cancer patient or not. Should the wife be told that her husband was dying of AIDS when the patient requested that she should not know what his terminal illness was? He had an alternative lifestyle that she was unaware of. Such cases brought before the ethics committee that I was co chair of, required all participants to have a high level of integrity and trust in these very confidential patient care situations.
In 1995, the Joint Commission on Accreditation of Healthcare Organizations introduced an organizational ethics standard titled "Patient Rights and Organizational Ethics." This was intended to provide an assurance that the integrity of clinical decision making was protected from financial pressure. Organizational ethics is the intentional use of values to guide decision making in the organization. But what about personal ethics? Ethics is a part of our everyday lives. We make decisions on the basis of our values and moral code. And oftentimes there is no black and white answer, but resolution of problems represents a shade of gray. As a nurse journalist, I am reminded of integrity in writing and try to conscientiously represent the truth. And that is a big order for anyone.
Fortunately, for Nursing Administration Quarterly, we have a leading ethics expert on the editorial board in Leah H. Curtin, DSc(Hon), RN, FAAN, Editor-in-Chief, Journal Clinical Systems Management. She is a clinical professor of nursing at the University of Cincinnati College of Nursing. A graduate of the Good Samaritan Hospital School of Nursing and the University of Cincinnati, Leah earned a master of arts in philosophy with a major in medical ethics from the Athenaeum of Ohio. She was awarded an honorary doctorate by the State University of New York in 1990 and by the Medical College of Ohio in 2002 for her humanitarian services. In 1996, Leah was scholar-in-residence at University of Ballarat in Victoria, Australia. She is author of almost 300 articles and 400 editorials as well as 8 books. Sunflowers in the Sand: Stories From Children of War was researched in the Balkans and received a positive review in The New York Times Sunday Book Review and has raised nearly $100,000 for the care and treatment of children damaged by war.
Joining Leah as coeditor for this issue is Marilyn Rantz, PhD, RN, FAAN, NHA, professor, Sinclair School of Nursing, University of Missouri - Columbia. Her exemplary dedication to care of the elderly has led her to several outstanding research grants: Technology to Support Aging in Place at Tiger Place, Administration on Aging; A New Measure of Nursing Home Care Quality, NINR-NIH; Multilevel Intervention to Improve Quality in Nursing Homes, NINR-NIH; and several others. She is widely published and has a remarkable practice record in administration of nursing homes as well as academic positions. She received the American Journal of Nursing Book of the Year Award for The New Nursing Homes: A 20-Minute Way to Find Great Long-Term Care. Marilyn epitomizes the conscience of caring for the elderly with integrity and trust as the trust in America's healthcare system is declining.
Ethics is the moral code or values we use to conduct our lives at home, in our community, and in whatever we do at work or play. Golf involves ethics, as honesty in scorekeeping is a part of the game. We only fool ourselves if we forget to count a stroke. The game of life is based on our decision making, individually and as organizations, and what values and principles guide these decisions. If an organizational decision affecting the quality of patient care is a compromise in our values and beliefs, then we are the ones who have neglected our own ethics and values. For example, when I was a chief nursing officer at a very prestigious medical center, the financial reimbursement laws were changing. There was a man in his 80s who had a hernia repair and was supposed to go home on the same day of surgery with no one there to care for him. There had been no home care arranged and I fought with administration to allow him a night stay in the hospital, without reimbursement. Needless to say, finance won out and I personally accompanied him to his apartment to see that he would be all right. He was so appreciative. Follow-up home care was arranged, and I left that position as there were too many other compromises unfavorable to quality nursing practice.
Some of the questions guiding me are
- Do I have all the information necessary to make a decision?
- What do I need to know?
- What are my ethical concerns?
- Are there professional codes that I should use? (The Nightingale pledge still serves well as does the American Nurses Association Code for Nurses.)
- Is there a way to consider other perspectives and diverse ideas such as an ethics committee?
- Who are the stakeholders-nurses, doctors, patients, family members, financial officers, lawyers?
- How would I feel if I or a family member was the patient?
- What are the consequences of my action or inaction?
- Is there a long-term effect as in the Schiavo case?
- Am I consistently minimizing harm?
- Can I help create an environment conducive to true professional practice upholding all professional practice codes?
Nursing administrators are in a unique position, no matter at what hierarchical step in the ladder of organizational impact, to be strong, visible leaders for what is right and consistent in supporting the values and mission of any healthcare organization: patient and family centered care. Do what is right for the patient and his or her family, what is right for the nurses you lead, and most important, what is right for you and it will be right for the organization.
Barbara J. Brown, EdD, RN, CNAA, FAAN, FNAP
Editor-in-chief, Nursing Administration Quarterly