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Nurs Outlook 63 (2015) 377e378


From the Editor

Nurse leaders can shape ethical cultures

Marion E. Broome, PhD, RN, FAAN

In 1984, Madonna sang about “Living in a Material World”. At the time I had just defended my dissertation, was busy with creating a professional ‘place’ for myself, growing a young family, and was very certain that I had chosen a profession in which money and material goods for the important work I did as a nurse were immaterial. At that time, I was also pretty clueless about health care financing and how that influenced decisions about care access, options, continuity or quality. Frankly, I wasn’t alone - one would been hard pressed to find scholarly articles or studies on the topic. Of course I am now a bit older, and hopefully, wiser. I now know that committed, effective nurses are never paid what they deserve. And that it is more often than not ‘all about the money’ when it comes to many of the challenges we are facing in healthcare.access to cutting edge treatments, scope of practice, quality, etc. And too much of the dialogue around these challenges fails the ethical litmus test- is this in the best interest of the patients we care for? One must ask if as a profession, in our conversations with each other and our colleagues across health care, do we stay focused on how we and they can 1) improve access, 2) improve quality and 3) reduce costs- or do we allow ourselves to set up boundaries and silos. As a leader I am all to clear about how critically important it is to me, and those I work with, to be in an ethically grounded work culture in which conversations can be honest, transparent and focused on the real reasons we are all doing what we do. But creating, and sustaining, ethical work cultures is no easy feat. Despite by my personal belief that I conduct myself and make ethically sound decisions at work, I am not by training,

an ethicist. Nor are most nurse leaders. So what do we have to guide us in the quest for creating and sustaining ethical cultures? Fortunately during the past 12 months two key documents have been created that provide clear pathways and guidance for all nurses (American Nurses Association, 2015; Nursing Ethics Summit Report, 2014). Last August, 50 nurse ethicists spent 2 ½ days together at a summit “Nursing Ethics for the 21st Century” sponsored by the School of Nursing and the Berman Institute of Bioethics at Johns Hopkins University. Importantly 15 strategic partners, powerful and important nursing associations, also joined us as we discussed what the priorities for action to create a ‘Blueprint for the Future’ should be. The summit report describes the assumptions held by the participants related to the challenges we know nurses face daily in practice, the role of the ANA Code of Ethics as a document for the profession that provides guiding principles for nurses individually and collectively, how nurses suffer moral distress when ethical challenges are not addressed and efforts we can engage in to improve ethical climates in nursing practice, education and research to improve outcomes for patients, families and communities. The executive summary of the summit follows this editorial and the full report “A Blueprint for 21st Century Nursing Ethics” can be found at (www.bioethicsinstitute.org/nursingethics). The question for AAN and CANS members is not how do each of us live out our own ethical values but how we, as leaders use our experience and wisdom to create ethical cultures in which all nurses can practice to the fullest extent possible. Ethical cultures are critically important to nurses in direct care delivery or leading health care delivery systems, nurses in education shaping the next generation of nurses, and nurses conducting research and translating knowledge. So what does it mean to create an ‘ethical ethos’ in our own workplaces? Through fearless leadership. In her new book, Fearless Leadership, Carey Lohrenz, (a naval aviator) describes three fundamental characteristics of leaders: integrity, persistence and courage (Lohrenz, 2015). Nurses are well known for their integrity and persistence-those are part of our DNA (Lohrenz, 2015). Courage through bold actions in the face of tense, fearful and morally distressing situations


Nurs Outlook 63 (2015) 377e378

is not always as evident. Yet these are tough times in the arenas in which nurses work- health care, higher education, competitive high paced research environments. Once more, as resources are constrained and choices made about where investments should be made it is only nurse leaders who can speak for nurses on the front line, those in the community caring for the most vulnerable patients experiencing challenge after challenge accessing quality care, and students balancing high tuition and decreasing clinical placement opportunities extending their time to degree. Each and every one of us should be comfortable with all aspects of our advocacy role..but many times speaking for is not as easy as speaking about. Advocacy opportunities are numerous and include (but are not limited to) listening to perspectives such as ‘we must continue to raise tuition to gain better salaries for nurse educators’, ‘a higher nurse to patient ratios require we be more efficient’, ‘IRB approved the proposal so we must not make any changes’, etc. But we must not stop at listening.it is the ethical leader’s role to speak for nurses, their contributions to outcomes and demonstrate how critical (not value added) an ethical environment is if nurses are to make the contributions to solving our health care and health education challenges they are capable of. In order to achieve the three objectives of the Triple Aim (improved access, quality care and lower cost) nurses must be able to work in environments in which they can use their education and experience without unnecessary restrictions, others must be provided resources to assist them to address situations as part of a team that are causing moral distress and must be able to deliver care without undue stress and strain due to unsafe patient care ratios and unsafe environments. This will mean nurse leaders in those environments must be unrelenting in giving voice to nurses’ concerns about the context in which care is given, and in which students learn. This places additional burden on those nurse leaders, who are always outnumbered in higher

leadership circles in any organization. But now, thanks to 50 ethical experts and their strategic partner organizations coming together to dialogue and strategize there is a comprehensive set of contemporary, timely recommendations and ‘best practices’ to draw on to chart their course of advocacy.


American Nurses Association (ANA). (2015). Code for Ethics for Nurses with Interpretive Statements. Washington, DC. Lohrenz, C. (2015). Fearless Leadership: High Performance Lessons from the Flight Deck. Austin, Texas: Greenleaf Book Group. Nursing Ethics Summit Report. (2014). http://www.bioethicsinstitute. org/nursing-ethics-summit-report/blueprint-for-the-future.

Author Description Marion E. Broome is the Editor-in-Chief of Nursing Outlook.

Marion E. Broome, PhD, RN, FAAN Corresponding author: Marion E. Broome Dean and Vice Chancellor for Nursing Affairs Duke University School of Nursing Associate Vice President for Academic Affairs Duke University Health System School of Nursing Duke University DUMC 3322, 307 Trent Dr. Durham, NC 27710. E-mail address: [email protected] 0029-6554/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.06.004

Nurse leaders can shape ethical cultures.

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