Mar 01, 2009
By Janet (Jan) Storch, RN, PhD , Patricia (Paddy) Rodney, RN, Phd , Bernadette Pauly, RN, PhD , Thomas Reilly Fulton, RN, MSC , Lynn Stevenson, RN, Phd , Lorelei Newton, RN, BSN , Kara Schick Makaroff, RN, MN
Enhancing Ethical Climates in Nursing Work Environments
The Canadian health-care system is under pressure, created in good part by limited fiscal resources in the face of increasing demand. The economic and organizational challenges arising from fiscal shortfalls along with values that reflect a business approach to health care have placed a great deal of strain on workplaces where health-care providers practise.
These pressures also have an impact on the well-being of individuals, families and communities and on the well-being of direct care providers and their managers (Hamric, 2002; Hardingham, 2004; Varcoe & Rodney, 2009). In other words, these pressures have important ethical dimensions.
In the current era of providing health care under pressure, considerable strain has been placed on nurses’ workplaces. Underneath the economic and organizational challenges prevalent in health-care delivery today are important values that shape the ethical climate in workplaces and affect the well-being of nurses, managers, patients and families. In this article, the authors report on the outcomes of Leadership for Ethical Policy and Practice, a three-year participatory action research study involving nurses, managers and other health-care team members in organizations throughout British Columbia. By using an ethics lens to look at problems, participants brought ethical concerns out into the open and were able to gain new insights and identify strategies for action to improve the ethical climate. Nurse leader support was essential for initiating and sustaining projects at six practice sites.
Critical to nurses’ performance is the presence of a positive ethical climate — “the implicit and explicit values that drive health-care delivery and shape the workplaces in which care is delivered” (Rodney, Hartrick Doane, Storch, & Varcoe, 2006, p. 24). Even though studies conducted over several years in diverse areas of nursing practice have shown that nurses face serious ethical challenges, researchers and policy-makers who study the work environment rarely use an ethics lens to look at workplace problems. Examining the values at work in healthcare organizations reveals the nature of the ethical climate and therefore adds an important dimension to this research.
Since 1999, our academic research team has been studying ethics in nursing practice. In this article, we report on a major study — the team’s third — addressing the ethical climate of health-care settings. Our previous studies led us to conclude that nurses in direct care know more about nursing ethics than they realize; that we could assist them in recognizing that knowledge; and that by engaging in dialogue about ethics with colleagues, nurses are able to decrease their moral distress and, as a team, find ways to improve their ethical environment (MacRae, 2008). We also found that the support of nurse managers and senior executives (chief nursing officers or their equivalents) is critical if ethical climates are to be enhanced and moral communities are to be developed. We believe that such collaboration leads to greater attention to ethical practice and improves the quality of nursing care delivered to individuals, families and communities.
The research team jointly developed a proposal with several chief nursing officers (CNOs) in B.C. and invited all CNOs in the province, along with two national nurse leaders, to participate in Leadership for Ethical Policy and Practice (see box). The aim of this three-year participatory action research study was to strengthen ethical practice in health care by opening up places and spaces for nurses and others to discuss ethical practice and ethical issues (Rodney et al., 2006). We wanted to show that CNOs, front-line nurses and other health-care providers working together can create moral communities.
The CNOs worked with academic investigators, and with their own staff, to develop ethics projects in practice sites in their respective region or organization. Initiating a project meant that nurses and other health-care providers began to meet on a regular basis to discuss and address whatever ethical matters arose. In these sessions, they could problem solve and find ways to overcome or reduce the barriers to the delivery of safe, compassionate, competent and ethical care called for in the Code of Ethics for Registered Nurses (Canadian Nurses Association, 2008). Each site identified and implemented strategies for action, but, in all cases, the involvement of a CNO (or her or his designate) was needed to sustain projects. At the end of the study, six projects were active; two additional sites planned to begin projects following restructuring in their organizations.
WHAT WE LEARNED
Often, getting participants to recognize the ethical dimensions of a situation was a necessary first step. For example, nurses at one site were frustrated that some physicians who were new to the hospital were not willing to wear identity badges. These nurses quickly dismissed the matter as “not being about ethics,” while complaining that they couldn’t be sure that the person requesting the patient’s chart should receive it. In addition, they noted that patients were confused: Was the person they spoke with a doctor? And if so, which doctor was it? Once the researcher drew the nurses’ attention to how ethical practice involves honouring values of confidentiality, safety and respect — which wasn’t what the physicians they spoke of were doing — they began to recognize the ethical issues in their everyday practice (Storch, 2004).
As an example of a typical project, registered nurses and licensed practical nurses were invited by their CNO and managers to meet to learn more about the study. They chose to be involved in a site project and subsequently met to discuss some of the situations in their work environment that they perceived as interfering with their ability to practise ethically. Their list of concerns included the move to full scope of practice in acute care for LPNs, their anxiety about maintaining their own levels of competence in all areas of practice, and their reluctance to call physicians at night. With time and opportunity for reflection, other matters surfaced — safety and competence, teamwork, expectations of colleagues, respect, the needs of patients/clients — that enabled the nurses to see how using an ethics lens could help clarify problems and provide a different perspective on them. Beginning actions to improve the climate in which they worked included clarifying role expectations, developing ways to increase levels of competence and establishing interprofessional guidelines for their unique circumstances.
Other issues common to most of the projects — and particularly pronounced when nurses encountered conflict about end-of-life issues — were the less than ideal working relationships with physicians and the lack of respect in nurses’ treatment of one another. When such problems were viewed through an ethics lens, groups gained new insights about the effects on patients and were able to develop strategies for dealing with the problems. At one site, for example, staff held meetings to address role conflicts in their interdisciplinary team.
In each year of the study, the research team organized a conference or a workshop for participants from across the various regions to allow them to meet and hear about other projects underway. These events contributed to a sense of enthusiasm and hope. Comments on event evaluation forms noted the ripple effect of projects, the empowering outcomes of discussions with CNOs and the value of feeling connected to a process.
The support of formal nurse leaders was a key component of each site project. The research team learned (again) that like participatory action research itself, improving a workplace’s ethical climate takes time, persistence and ongoing commitment. Immediate deliverables were not always possible, and progress was often not readily apparent within the three-year time frame. In some settings, a team was able to achieve the goal of involving other health professionals at the outset or later on in the project. An important finding, noted on evaluation forms and in comments from participants, was that the projects gave nurses hope that their work environments could be changed.
The fact that knowledge transfer occurred while the research was going on meant that many participants felt transformed by their ability to see the ethical components of situations. At one site, once long-standing conflicts between physicians and nurses came to be viewed through an ethics lens, workshops to improve interprofessional communication were instituted.
Our findings show that action is needed to develop guidelines and put them into place, with support from formal nurse leaders, to create positive ethical climates and promote ethical practice. One of the outcomes of the study was a set of guidelines (see page 24) that we believe can be adapted for use in a variety of settings — locally, nationally and internationally — to shape the ethical dimensions of nurses’ workplaces. Together with our colleagues in nursing and other disciplines, we are looking for ways to take next steps toward the goal of implementing these guidelines in practice settings across Canada.
WHAT WE LEARNED
- Nurses and other health-care providers welcome the opportunity to discuss ethical concerns and perspectives.
- The key ingredients for successful ethics projects are the interest shown by nurses working in direct care and their trust in one another, formal leadership support, access to resources (including time) and the ability of all participants to acknowledge even small changes.
- Champions are crucial to the ongoing effectiveness of projects.
- Most projects begin with conversations with an outside facilitator, who can help group members feel safe to speak out, followed by group decisions about further learning and action. As staff become more confident in taking the lead, they will not need outside facilitation.Ethics projects provide opportunities to debrief and to act on short-term and long-term goals. Progress should be evaluated regularly.
- Approaches must be tailored to the unique histories and clinical challenges of each workplace.
- As projects develop, unique strategies emerge for enhancing ethical practice, with the potential to improve care. Reports of renewed commitment to work, better relationships with colleagues and more reflective ethical decisionmaking are common.Health-care providers from other disciplines have identified similar ethical concerns and are beginning to join nurses in these projects, welcoming the opportunities for dialogue and action they provide.
- Understanding the meaning of and accurately measuring moral distress and ethical climate are complex endeavours.
WHAT YOU CAN DO
- Ethical action starts with having hope that work environments can be changed. Support each other to challenge statements that normalize poor practice (e.g., “that’s just the way it is,” “we can’t afford to do better,” “it’s the patient’s own fault”).
- Start with planning meetings that bring together interested nurses and other health-care providers at all levels. Some of these individuals will want to help steer the project. (Membership of the steering group will likely fluctuate a bit over time.)
- Identify a leader in your work group who can champion the project. It is helpful if this person’s position includes responsibilities for some of the actions you will be undertaking. Clinical nurse specialists, professional practice leaders, managers and nurse educators have made great champions.
- Throughout, work consciously to equalize power dynamics. Everyone ought to have a voice, and the number of degrees or professional status someone has doesn’t make that person more right than another. Pay attention to colleagues whose voices might otherwise get lost (e.g., care aides, students).
- Start to seek support for your ideas from others who can help — management/administration, related groups (e.g., ethics committees, patient safety committees, risk management groups) and external resources (e.g., academic researchers, professional association representatives, union representatives).
- Have a beginning discussion at a staff meeting. Follow up by inviting all staff to identify ethical concerns; you might want to post sheets of paper in the coffee room for this purpose. Next, prioritize the items and meet to discuss how to begin addressing them. A workshop or retreat for staff is another way to share concerns about ethical practice in a safe and nonjudgmental way. Identify themes (e.g., communication challenges, end-of-life issues, workplace environment issues); action groups to address those themes; and areas of strength/past successes to help to energize the group. Having this event professionally facilitated and away from the practice area is helpful.
- Work out short-term and long-term goals with your practice colleagues. Some immediate deliverables are helpful, because improving ethical practice overall can take years. Our team worked with one group who were able to make an immediate structural change so that nurses could have a place to chart in an increasingly crowded environment. The group also took on a longer range project to improve interdisciplinary communication.
- Expect some skepticism from colleagues. They will (quite rightly) say, “We tried this before, and nothing improved.” Be honest about progress and challenges, communicate regularly about what you are doing and be prepared to re-evaluate and regroup based on feedback.
- Build in regular evaluation periods to reflect on what you have done so far, what has worked and what needs to change. Invite new colleagues to join your steering group to support those who have been at it for a while.
- Share what you have learned with nurse leaders and nursing colleagues as well as managers and administrators: present at conferences and write newsletter articles and formal journal articles. It is incredibly energizing to see that it is not just your work group facing these challenges, that your suggestions have value and can be enhanced by listening to others and that what you are doing is important.
- Consider seeking funding to turn your project into a formal research study. Practice colleagues have told us that it is validating to have their concerns and actions addressed through research. Keep in mind that generating a research study will require partnerships with academic colleagues and that research grant proposals take significant time and energy.
- Maintain hope. Don’t underestimate what you can do individually and collectively!
- Recognize the importance of ethics to the provision of high-quality health care.
- Support efforts to strengthen ethical practice in health care.
Chief executive officers
- Ensure that strengthening ethical practice in health care is part of your organization’s values and commitments as evidenced by allocation of resources for this purpose.
- Foster opportunities for nurses and all health-care providers to participate in the creation of positive ethical climates through identifying areas of ethical concern and generating directions for action.
- Create opportunities for interdisciplinary dialogue about ethics in health care, recognizing its positive impact on patient care.
Chief nursing officers
- Promote the development of opportunities for ethics education and debriefing, i.e., ensure there is a place and moral space where everyone can speak freely and openly to address ethical concerns.
- Identify a forum and a consistent ethical framework for discussions on ethical situations.
- Keep up to date on the evidence related to ethical climates/healthy workplaces and advance initiatives to establish and sustain the attributes of a healthy workplace with a positive ethical climate.
Canadian Nurses Association/Provincial and territorial colleges and associations
- Recognize ethics as foundational to health care.
- Recognize diverse value systems in health care that influence nurses’ ability to provide safe, compassionate, competent and ethical care.
- Develop strategies to support the development of practice environments that permit full and consistent implementation of CNA’s Code of Ethics for Registered Nurses.
Canadian Institutes of Health Research/Canadian Health Services Research Foundation/Canadian College of Health Service Executives
- Foster knowledge translation of research findings, including qualitative and quantitative studies of work environments.
- Develop strategies to support the potential of ethics to change the quality of care provided to patients/clients and their families.
- Develop funding opportunities for research focusing on ethics in health care, including studies that examine outcomes for patients.
Leadership for Ethical Policy and Practice
Co-Principal Investigators: Janet (Jan) Storch, RN, PhD; Patricia (Paddy) Rodney, RN, PhD.
Co-Investigators: Colleen Varcoe, RN, PhD; Bernadette Pauly, RN, PhD; Rosalie Starzomski, RN, PhD; Lynn Stevenson, RN, PhD; Lynette Best, RN, MSN; Heather Mass, RN, MSc; Thomas Reilly Fulton, RN, MSc; Barbara Mildon, RN, MN; Fiona Bees, RN, MSN; Anne Chisholm, RN, MN; Sandra MacDonald-Rencz, RN, MScN; Amy McCutcheon, RN, PhD; Judith Shamian, RN, PhD; Charlotte Thompson, RN, BScN, MSN, MA.
Research Associates: Kara Schick Makaroff, RN, MN; Lorelei Newton, RN, BSN.
Acknowledgment: Funding for Leadership for Ethical Policy and Practice was provided by the Canadian Health Services Research Foundation and Health Canada’s Office of Nursing Policy and First Nations and Inuit Health Branch and through the offices of CNOs (or their equivalents) in B.C.’s health regions.
This project was supported by many colleagues in nursing and in other professions. The authors acknowledge the essential contributions of CNOs and other regional nurse leaders; site-specific project nurse and physician leaders; nurse leaders from the First Nations and Inuit Health Branch, B.C., Health Canada and the Victorian Order of Nurses; and numerous graduate and undergraduate students from the University of Victoria and University of British Columbia schools of nursing. We thank staff nurses who participated in the three-year Ethics in Action study for their work as advisers for Leadership for Ethical Policy and Practice. Special thanks to staff nurses Susan MacRae, Michelle Lafrenière and Heather Dickinson, who served as advisers to CNOs and nursing peers.
Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON.
Hamric, A.B. (2002). Bridging the gap between ethics and clinical practice. Nursing Outlook, 50(5), 176-178.
Hardingham, L.B. (2004). Integrity and moral residue: Nurses as participants in a moral community. Nursing Philosophy, 5(2), 127-134.
MacRae, S. (2008). Ethics in everyday nursing practice. Nursing BC, 40(1), 9-13.
Rodney, P., Hartrick Doane, G., Storch, J., & Varcoe, C. (2006). Toward a safer moral climate. Canadian Nurse, 102(8), 24-27.
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