Good Intentions Aside: A Manager's Guide to Resolving Ethical Problems, by Laura L. Nash. Boston, Mass, Harvard Business School Press, 1993. 259 pages, softcover, $16.95.
Nurse leaders deal with ethical problems on a daily basis. The challenges are complex, the issues difficult, and the answers never simple. Given the high level of trust the American public puts in nursing, the need to step up and deal publicly with many of these issues is both an opportunity and a risk. Whether on a public/institutional or even patient to family basis, nurse leaders need a framework to manage these issues. Ethics as a discipline helps us better understand our approaches to current situations and those that are on the horizon with emerging technologies and disciplines such as genomics and personalized medicine.
Laura Nash originally wrote this book with the intention of addressing ethical conduct in the business setting. Her work captured the attention of executives and public policy makers as they considered "the moral foundations on which socially legitimate forms of capitalism rest." (Preface)
The heart of her book is in the Covenantal Ethic. If the covenant is broken, both the public and the business are hurt. The Covenantal Ethic has 3 essential components: (1) It sees value creation in its many forms as the primary objective. (2) It sees profit and other social returns as a result of other goals rather than the overriding objective. (3) It approaches business problems more in terms of relationships than tangible products (p. 20). All 3 of these aspects can be found in most contemporary approaches to management and leadership. These 3 components provide a practical guideline to decision making for managers. Nursing has always argued for patient over profit. With evidence-based practice, nursing continues to seek value creation for every interaction. And the argument of relationship-based care has a growing audience.
The example the author chooses for healthcare is centered around an elderly patient in a nursing home. The patient is sufficiently well to have a 24-hour visit outside the home. The intended visit would lift the patient's spirits. However, for this patient, the visit would require an overnight stay. Current policy at that time requires an empty bed be filled immediately. Since there was a 3-week wait for beds, the patient would have to go to a hospital bed, removing him from familiar surroundings and caregivers. Both the administrator and the physician agree the patient should have the weekend visit, but they view the ethics differently. The physician sees the whole system as unethical. The administrator and the insurance plan agree the hospital cannot afford an empty bed. Using the Covenantal Ethic framework, the author argues for letting the patient go on the visit and leaving the bed empty.
The book goes beyond the Covenantal Ethic and addresses situations with ethical concerns by leading readers/managers through a series of questions addressing their own personal sense of duty. Who might get hurt besides ourselves? Am I perpetuating a dishonest and fraudulent relationship? Whose needs am I considering in my definition of the problem? Have I tested the other person's needs directly? (p. 145). And there are many more.
If you have studied or already familiar with ethics, then you would want to add this book to your library. This book would be helpful in the following ways: (1) A classic reference text for middle to senior leader's library. It is particularly useful when you find yourself behind closed doors and need to reflect on how you want to deal with a problem. (2) A required reading text within the context of a course, probably at the graduate level though some BSN faculty may also consider. (3) One of the books for an ethics committee to use as it struggles with policy decisions. (4) A reference for case managers and/or patient advocates facing decreasing resources and increasing denials. (5) A framework for nurse leader experts in ethics and charged with helping staff nurses understand how to deal with these issues on a practical level.
Incorporating ethics in our decision making means embedding it in our practice of nursing. Applying that thinking in arguing the business case for our patients requires further knowledge of ethics as a discipline. That requires further study and one both this issue and this book help accomplish. As nurse leaders become chief operating officers and chief executive officers, this book is a must have.