ACUTE AND CRITICAL CARE NURSES provide care that is intellectually challenging and often physically demanding in surroundings that are increasingly complex and characterized by ethical concerns and dilemmas. The American Association of Critical-Care Nurses' (AACN's) Standards for Establishing and Sustaining Healthy Work Environment state that these nurses "repeatedly voice grave concern and moral distress about the deterioration of healthcare environments in the United States."1(p10) As complex adaptive systems, these environments may include, at any given time, teams of nurses, physicians, social workers, chaplains, case managers, and administrators. While these teams generally include someone in these various roles, the actual individuals serving in the roles may change daily, an additional challenge.
Chen et al2 adapted the Institute of Medicine's3 definition of the hospital as a complex adaptive system to acute and critical care units. These authors (Chen et al2) observe that a complex adaptive system is one in which a collection of individuals interact together in situations of tremendous uncertainty and frequently in the face of professional or social disagreement about patient/family care, processes, and outcomes. Nurses' ability to identify and resolve concerns in such situations as part of a collaborative ethical climate is a significant retention factor and a hallmark of a healthy workplace. As defined by Olson,4 an ethical climate is one in which practices and conditions promote discussion and resolution of decisions with ethical content.
The purpose of this article is to describe a pluralist ethical framework that evolved from the formation of a healthy workplace and that may be integrated to sustain an ethical climate. Discussion of development of a healthy workplace employing participatory action research (PAR) will be followed by a description of ethical theories supporting the framework and their relevance to creating and sustaining a healthy workplace and ethical practice environment. Finally, specific application examples of the ethical framework from nursing units' staff PAR studies will be presented.
DEVELOPING A HEALTHY WORKPLACE THROUGH PAR
Greenwood and Levin5 describe PAR as facilitating groups to develop shared goals and promote positive change through action. To further inform the Parsons6 healthy workplace intervention, a theoretical framework was designed, incorporating the key concepts of shared leadership, participatory change management, and empowerment based upon Magnet Hospital findings. The specific methodology utilized to implement PAR and facilitate nursing units' staff to create a healthy workplace is a future search conference (FSC).
An FSC is a sequential facilitated group process during which a desired future and strategies to achieve it are identified.7,8 This sequential FSC process includes a review of the unit's past and present and envisioning a desired future for a healthy workplace. Fundamental to this change process is that the participants design and implement their own plan. They "own" it and are, therefore, committed to it. Researchers and participants utilize review and reflection in their work together to evaluate the plans and actions accomplished.
A conference setting away from the hospital work environment is utilized for the first FSC. The sequential group process includes the following in the Parsons6 FSC:
1. The group identifies objectives for the conference.
2. The group develops ground rules for working together.
3. The group develops a shared history and discusses it extensively to understand where their unit has been.
4. The group analyzes the present status and decides what to keep, eliminate, or create.
5. The groups envision a shared desirable future.
6. A Mind Map of their desired future is developed.
7. The "gestalt" of a unit's desired future is represented in their Mind Map in a visual and colorful poster presentation.9
8. The groups decide top 3 priority goals for the coming year through multivoting.
9. Participants' self-select to the action planning group and topic of their choice.
10. Each team reports draft action plans to receive feedback and revise plans accordingly.
11. A communication plan for all unit staff is developed including follow-up team cocaptains and plans for meetings throughout the year.
For continued support and development, booster conferences and 1-year group follow-up conferences are held. Given the complexities in today's healthcare delivery system and multitude of competing variables, a comprehensive ethical framework titled "Empowered Caring: An Ethical Framework for Participatory Action Research" was developed to guide the work.
PLURALIST ETHICAL FRAMEWORK
In healthcare, ethics and ethical issues are usually conceptualized as principles and standards of practice associated with our responsibilities toward patients and family members. Codes of ethics for all major health professions, including nursing, address provider/recipient issues and incorporate the familiar principles of beneficence, nonmaleficence, justice, and respect for autonomy.10 Several codes, including that of the American Nurses Association, specifically mandate that providers work collaboratively in the interest of improving patient care.11
Nurses are familiar with consideration and application of the principles to resolve ethical issues in patient care. However, they may be less accustomed to their implications for intra- and interprofessional teamwork and developing/sustaining a healthy workplace and ethical climate. While incorporation of ethical principles is vital to these undertakings, they are not enough. Indeed, the AACN addresses this in the following statement from the Standards for Establishing and Sustaining Healthy Work Environment1 titled "Our Ethic of Care":
AACN's mission, vision, and values are rooted in an ethic of care that acknowledges the interrelatedness and interdependence of individuals, systems, and society. An ethic of care respects individual uniqueness, personal relationships, and the dynamic nature of life. Essential to an ethic of care are compassion, collaboration, accountability, and trust. Within the context of interrelationships of individuals and circumstances, the traditional ethical principles of respect for persons, beneficence, and justice provide a basis for deliberation and decision-making.1(p42)
The PAR methodology described above is considered a "new paradigm" approach, in that it is research done with and for people rather than on people. Because the issues that arise during this process are myriad and complex, a pluralist ethical framework, grounded in principles and informed by an ethic of virtue and care, evolved and developed. It is also proposed that this framework can be used to foster and sustain an ethical climate in acute and critical care settings.
FUNDAMENTAL ETHICAL PRINCIPLES
The fundamental principles of beneficence, nonmaleficence, justice, and respect for autonomy form the foundation of Western healthcare ethics, practice, and research. Originating from utilitarian and Kantian theories and codified by Beauchamp and Childress10 in their influential "Principles of Biomedical Ethics," they also "prescribe and justify nursing actions."12 Rules of behavior addressing patient-related issues such as confidentiality, informed consent, and veracity are derived from these principles, which constitute the base of the framework depicted in Figure 1. The collaborative, relational nature of developing a healthy workplace using PAR, however, and resolving issues that arose during the process required a more comprehensive ethical model. In viewing the relational nature of PAR as a covenant between participants and researchers, Hilsen states: "Instead of doing good to serve my own needs [horizontal ellipsis] the focus of my research should be on the best interests of the other [horizontal ellipsis] as that is the worthwhile human purpose inspiring the project."13(pp27-28) As can be seen from this quote and in Figure 1, emphasis is placed on individual character and action, which are congruent with an ethic of virtue and care.
As noted in the AACN statement above, we are obligated to treat patients, family members, nursing peers, and members of other disciplines with respect and justice and to expect the same in return. These principles are also necessary but not sufficient to promote and sustain an ethical environment. Although beneficence and nonmaleficence are relevant, the latter obligation "to do no harm" takes precedence. To this end, an ethical environment is one in which providers are assured that they can deliver safe care consistent with standards, adequate staffing, and competent team members. Justice, as a fundamental ethical principle, incorporates aspects of truthfulness and respect for others. The issue of mandatory overtime relates to discussions of justice and has additional implications for sustaining a healthy, ethical practice environment.14
Based on Victor and Cullen's15 model that identifies 9 different climate types derived from 3 overarching ethical theories, a benevolent ethical climate supports all staff members and encourages teamwork and shared decision making. Research suggests that acute and critical care units with benevolent ethical climates may have better clinical outcomes, improved patient/family satisfaction, decreased mortality, and less nurse turnover.16-19 While incorporating fundamental ethical principles, a benevolent climate is also reflective of an ethic of virtue and care.20
VIRTUE ETHICS
Unlike principle-based ethics, virtue ethics does not consist of fundamental rules and cannot be applied in a decision-making algorithm. Nevertheless, it provides a powerful pragmatic framework for acute and critical care nurses, other members of the interprofessional team, individual units, and the organization as a whole. Indeed, Caza et al21 found that those organizations with high scores on virtue assessments outperformed those with lower scores in several areas, including employee satisfaction and retention. A modern version of Aristotelian ethics, virtue ethics has regained prominence in the 21st century because of MacIntyre's work,22After Virtue, among others. Several nurse authors have also explored the relevance and need for virtue ethics because it acknowledges the significance of moral character and recognizes the role of emotions and experiences in moral judgment.23,24 As Day observes:
Perhaps the most important difference between virtue and care ethics and Kantian and utilitarian ethics is that whereas Kant and utilitarian philosophers ask, "What should I do?" (acute) and critical care nurses ask, "What kind of nurse should I be?"25(p182)
Virtue ethics involves a consistent, habitual pattern of perception, affective response, and action. Consequently, acting in an ethical manner according to a set of principles or rules becomes insufficient; one must be disposed to act habitually in that manner when providing care, with peers, and in life. The Greek notion of virtue or arete as excellence in relation to a learned skill or acquired character traits differs from disparaging connotations of the concept. As Austin notes, "Rather than being a device for uptight persons trying to seem 'holier than thou,' virtue is a significant aspect of an ethical life."26(p55)
The larger community-citizens, patients, interprofessional team members, and nursing peers expect and are entitled to more than simply knowledge and competence. They expect good character. Virtues associated with good character in nursing have evolved over time from those such as cleanliness and self-sacrifice to include several depicted in the framework (Fig 1) and considered essential to the process of developing a healthy workplace and benevolent ethical climate: compassion, fidelity, veracity, and prudence.
Compassion is recognized as the cornerstone of healthcare providers' practice, a critical trait necessary to the delivery of morally good care.23,27 Similar to all virtues, compassion integrates perception, affective response, and action; it is the latter that differentiates compassion from the seemingly similar but passive concepts of sympathy and empathy.12 We can readily identify the need for compassion in patient/family care; however, it also has relevance to the formation of a healthy workplace and benevolent ethical climate. Social justice, which underpins the PAR approach used in the HWI, has a strong connection to the virtue of compassion.28 In this context, compassion is not so much about what we choose to do for people but what we choose to do together with them in an effort to share their burden and enable them to maintain their independence and dignity.
Practicing compassion with other members of the acute and critical care team may also contribute to sustaining an ethical practice environment, because it is a component of moral sensitivity. Moral sensitivity is requisite to recognition that an ethical dilemma exists. Without moral sensitivity and compassion, members of the healthcare team may not be able to see that a problem exists or may unknowingly tolerate ethically objectionable acts/conditions. This recognition also involves the ability to appreciate the perspectives of others, including team members, by acknowledging their values, beliefs, and obligations. Compassion and moral sensitivity include awareness of the various courses of action and how each may affect all members concerned, the patient, family members, and others on the interprofessional team.29
In the HWI, fidelity, or acting faithfully, required the ethical behavior of bearing witness and describing experiences as expressed by the nurse participants. It is truthfulness but more than just telling the truth; it relates to understanding, contemplating, and communicating the nurses' experiences in creating a healthy workplace. Within the context of sustaining a benevolent ethical climate, fidelity is also defined as the obligation to remain faithful to one's commitments. Such commitments relate to responsibilities within fiduciary relationships beyond that of patient-provider to address those with nursing peers, interprofessional team members, and the unit itself. These commitments include demonstrating loyalty, active concern for the well-being of others, and giving credit where credit is due.
Empowering participants in the HWI (PAR project) with the means to take systematic action to address problems in developing a healthy workplace requires persistent fortitude from all involved in the project. As a virtue, the notion of fortitude in the framework expands Aristotle's interpretation of heroic courage to include Aquinas' ideas of endurance, patience, and moral strength.30 In this way, it can be understood to mean more than a low sensitivity to fear, which can be considered an admirable, yet temporary, psychological characteristic.
In practice, fortitude or courage becomes a virtue only when it serves others.31 Sustaining an ethical climate requires moral fortitude or the ability to follow through with a morally justified course of action. It involves the strength to withstand situational pressures and maintain a commitment to do the right thing.32 Research suggests that organizations with a collective moral fortitude or strength are more resilient, productive, and inspire greater public confidence.33 While nurses and other members of the interprofessional team may know the right thing to do, they are often hampered by policies, hierarchical power that inhibits action, time limitations, and legal constraints, resulting in moral distress.18,34 Improving communication and collaboration among interprofessional team members may decrease moral distress in acute and critical care settings and contribute to creating collective moral fortitude and an ethical practice environment.34 Baggs35 proposes several concrete suggestions to improve interdisciplinary communication and collaboration: joint practice committees, joint intensive care unit leadership, scheduled joint patient bedside rounds and interdisciplinary meetings, and interprofessional orientation.
Understood as practical wisdom, prudence is the capstone or metavirtue because it is the one that must govern the others.36,37 As the most complex virtue, prudence involves rational elements blended with humane considerations. While derogatory connotations of the term suggest timidity and unwillingness to take risks (ie, "prude"), in the classical sense prudence means good judgment with attention to possible risks or hazards. Prudence makes it possible to deliberate on what is good or bad in situations and through such deliberations, to act correctly. Acute and critical care nurses frequently encounter competing calls to multiple principles and virtues such as justice, compassion, and fidelity when caring for patients and families and when working with other team members. As a learned skill, prudence enables the nurse to take into account the complex nature of such situations, weigh the benefits and harms, and make careful, reasoned judgments.38
The virtue of prudence also has relevance for developing and sustaining a healthy workplace that may be challenged by reduced staffing, increasing patient acuity, and limited resources. As a moral community, interprofessional team members may not be able to provide all the services and care that they would like to in such circumstances. Practicing prudence facilitates the distribution of limited time and resources in the most fair and appropriate manner.37
ETHICS OF CARE
Several authors suggest that care is a virtue and can thus be subsumed under virtue ethics.39,40 It is proposed, however, that collaboration rather than a submersion provides a more comprehensive ethical framework for developing and sustaining a healthy workplace in conjunction with underlying ethical principles. Originating with the writings of Carol Gilligan41 and Nel Noddings,42 an ethic of care is congruent with nursing and PAR because it emphasizes their inherent relational nature rather than abstract rules. Thus, in PAR, nurse participants are not considered examples of universal categories who must be protected by application of abstract principles, such as nonmaleficence. Rather, as seen in Figure 1, they are accepted and respected as unique individuals located in situations that require interventions based on care, support, and sensitivity to context. Care ethics is also considered feminist because it acknowledges the absence of women's voices in traditional ethical theories.12,43 A feminist ethics of care is consistent with the core ideals of PAR, achieving social justice, personal empowerment, and organizational transformation.
In nursing, Jean Watson's44,45 seminal work on human caring is used by several organizations in seeking or sustaining Magnet status because it serves as a guide to change nursing practice and sustains a healthy, healing workplace. Watson46 argues that the dominant business model prevalent in healthcare today with its focus on beds, disease, and attaining the latest technology ultimately provides short-term solutions to patient care needs and the nursing shortage. She maintains that nurse leaders and hospital administrators share in the responsibility of creating a caring, healthy workplace and an ethical practice environment. An ethical practice environment mandates that attention be paid to the systems of care, supports, and resources to address moral distress, caregiver burden, burnout, and workplace violence. To accomplish this transformation, Watson46 suggests several strategies for nurse leaders and administrators that are similar to those in the framework such as developing skills of caring behaviors and caring presence in relationships with individuals and groups within the organization.
An ethic of care is relevant to organizational ethics in general47 and to acute and critical care units in particular.48 Caring behaviors may include active listening, respecting others, and demonstrating compassion, as described above. As an extension of ethical behavior, ethical comportment is more inclusive and is described in business ethics as
[horizontal ellipsis] behavior that includes one's intentions, efforts, feelings, and thoughts, and occurs within individuals, between individuals, and within organizations [horizontal ellipsis] and may come directly from the heart, soul, or spirit as well as mind, and does not exclusively involve rational, linear, or intellectual processes.47(p109)
And in nursing ethics as:
[horizontal ellipsis] socially embedded practical knowledge that is rational, even though it is not based on rational calculation (i.e., theories). (It) cannot be formalized. Because it is socially embedded, ethical comportment requires engagement in a situation and a sense of membership in the relevant social group.48(p77)
White47 observes that practicing ethical comportment requires 4 elements: attentiveness, responsibility, competence, and responsiveness. Attentiveness is recognition of the need to be cared about and the ability to be totally present for another, including patient, family member, and those on the interdisciplinary team. Assuming responsibility for others again involves compassion and recognition that all persons are connected to all other persons. To act competently is to act within in one's capabilities. To be responsive or open is to allow relationships of trust to form and thrive.
Acute and critical care nurses, members of the interdisciplinary team, nurse leaders, and administrators all have opportunities to enact caring behaviors. To comport oneself in an ethical manner or to practice ethical comportment is to be intentional about this caring, thus, supporting and sustaining a healthy workplace and ethical practice environment.
APPLICATION OF THE ETHICAL FRAMEWORK
The framework is perhaps best understood through brief examples from nursing units' staff PAR studies. All members of a nursing unit's care team participate in their healthy workplace intervention. They normally identify their unit conference as a unit retreat. The purpose of each PAR study is for the unit staff and manager and senior nursing officer, vice president or chief nursing officer, to work together to determine their own future and take action to support their desired future. An FSC is utilized and the nursing staff develop a shared history, current status, and vision for their unit. The group members decide the top priorities and develop action plans to implement them.
From the initiation of the intervention to its conclusion PAR is a facilitated research process. It requires vigilance to facilitate the group toward its own objectives. PAR researchers must function ethically at each step of an FSC described in the first section of this article and attune themselves to the group's goals and dreams. It comes alive as "empowered caring" for each person and unit to meet them "where they are," and facilitate their work to fulfill their own desired future.
At the beginning, participants must be appropriately informed about the process, their role in it, and potential to develop the desired future of their unit. The researchers must be honest about the boundaries of decision making in an organization. For example, a unit staff must know that they can discuss any concern for their unit and patient care. However, plans impacting the hospital budget or policy must be recommendations and are not decided at the unit level. These are examples of traditional ethical concepts such as beneficence, respect for autonomy, and veracity or telling the truth about the opportunity, processes, and boundaries.
Ground rules also support the facilitated process by managing behaviors to assure confidentiality of information deemed confidential and to prevent harm, or nonmaleficence, to any participant through the use of words. All opinions are valued as well as differences. Researchers assure the participants that "they are not afraid of conflict"-in that only by understanding different opinions can common ground be found by the group members.
Essential to achieving a vision for a desired future and plans to implement it is the creation of a respectful environment of trust and acceptance. In units with a troubled chaotic past or present, researchers must make it safe to share stories of serious patient care problems, incidents, and concerns. Compassion and prudence contribute to making it safe to reveal their reality and to address change. Fortitude is needed to stay present with the group during a difficult discussion and facilitate and guide them to their own way forward. Fidelity, being faithful, to each staff's story, issues, concerns, and dreams is fundamental to trust and the PAR process. The application of these ethical concepts is empowered caring in action.
Prudence is required in the just-in-time teaching and learning process when groups have established their vision for the future and make decisions for priorities. An action planning format and process are taught and the group is coached to develop plans for their top priorities. During this part of the research process, participants are learning how to develop a specific action plan and implement it fully in the work world. At follow-up staff meetings and booster conferences, each action planning team reports to the entire community on the status of their accomplishments throughout the year. Participants have the opportunity to learn and practice skills for implementation and follow-through during the entire healthy workplace intervention.
The nursing workplace in acute care hospitals is continually impacted by multiple demands, competing agendas, and very complex patient care. Empowering the staff, who are experts on their own workplace, is essential to develop a healthy, positive, and engaged workforce. A pluralistic ethical framework provides guidance for facilitators and leaders to promote the creation of these environments.
SUMMARY
A healthy workplace intervention framework was described to guide the PAR with individual nursing units. PAR, as a method, does research with and for people rather than on people and therefore, requires articulation of an ethical framework that is more inclusive and thus pluralist in nature. The framework, empowered caring, is based on traditional biomedical ethics and is guided by care ethics and virtue-based ethics. Examples of ethical issues in working with nursing units' staffs in acute care hospitals are described.
REFERENCES